Need help with transcutaneous pacemaker incident

[Dierdron]

I'm currently under fire from my ICU manager because I administered "Ativan 4mg IV Now" as ordered by the physician, to a patient who was delerious, restrained at wrists to bed, and had a transcutaneous pacemaker delivering 80 shocks/minute (the transvenous pacemaker was not working due to not being advanced far enough.) An earlier 1mg dose did nothing for the fellow. The only effect of the 4mg dose was therapeutic----the patient slept for 3.5 hours before again waking up, pulling at restraints and required more sedation.

The manager's position is I should have questioned the size of the dose. It does not matter to her that I gave the 4mg slowly over 6 minutes (three times slower than the Nursing 2003 drug handbook allows).

My position is this was an appropriate and safe order. I'm looking for either supportive literature or even better, an expert witness. I have grieved this through my union. We believe administration is targeting me due to my position on the bargaining team (we are currently negotiating a new contract.) The case is now going to arbitration and we are about to file an Unfair Labor Practice against the hospital.

[Dierdron]

My plan for the presentation of the caution I used will be:

1. Checked order with senior ICU RN (who agreed to appropriatness)

2. Patient's weight 89 Kg (very muscular/robust 90 year old) (Nursing 2003 Drug Handbook lists upper dosing levels at 0.05mg/kg up to 4mg may be needed. 89x0.05=4.45mg

3. Administered 3 times slower than literature allows

4. Patient continued to pull at restraints until very end of drug administration (titrated)

5. Patient on 5 wire ecg monitor and continuous SAO2 (described to lay arbitrator as: monitors keeping track of every breath patient takes and second by second blood oxygen level; would alarm if levels of either dropped too much). RN always within visual sight of patient. Patient remained hypertensive and tachypneic throughout night

6. Will discuss risk vs. benefits of administration. (risk of patient working through/around restraints and pulling off pacer wires if not enough sedation administered.) Patients undergoing this level of noxious stimuli for hours are more likely to need the highest doses of anxiolytics.

7. Flumazinil/Romazicon 30 feet from patient in OmniCell drug dispensing machine.

8. Ambu-bag 2 feet behind patient's head at all times.

Thanks for the suggestions. Any other suggestions are welcome.

[nowplayingEDRN]

The only other fly in the soup that I see is that you did not document in your note that you gave the medication over the time frame you mentioned. I was always taught if you did not document it, you did not do it. You also mention the ambu bag but where was your airway roll up for ET tubes and laryngoscopes?? You would need those if you had to whip out that ambu bag. You documented where the reversal agent was and that is good and lit supporting the dosage and administration...good again.

I wish you the bes of luck and hang tough. Please keep us posted.

As an after thought out transcutaneous pacing SOP calls for the use of versed with MSo4 fot the patient for pain controll and conscious sedation for the procedure.

[earthgirl56]

If they put the eye on you ,better save your licence and leave,don't wait to be fired or,reported to BRN

With the experience you have ,you"ll get job anywhere

I had a friend who belonged to the barganing team,and after 30 years of work,managment found the way to fire her and reported her to BRN

[dianah, ASN]

As this thread is over six years old, further posts will likely not be relevant to the OP. :)

Will leave in view but close for now.

Thanks to all who have posted!