NMA851

Wow NOT totally electronic? We do have paper charting for us to complete on the PC's but we also have computers in EVERY PT room. No matter where we go or what room we are in, EVERYTHING follows us (or we follow it) :):). Furthermore, we have to SCAN SCAN AND SCAN just about every little flippin' thing we do - including the PT's armband which must be done before you can as much as access anything. There's alot more about these technologies I could talk about but I do not want to trample on your thread so to speak - or get "off topic"! When it comes to getting orders/requesting orders, all I have to do is email the MD, for lack of better words, who responds with electronic instructions and signatures via his handheld. It's like a Blackberry basically. The one I carry will send me the response and populates into the PT record. Then I can go about my business. Until there is a response though, nothing can be done - and there is no "verbal" authorizations anymore either - it's ALL done this way or no way. Honestly - I have nothing but GOOD things to say about the way this works - the margins for errors, at least as far as charting/orders/paperwork is concerned, has been SIGNIFICANTLY reduced. There are several checks/balances that I mentioned above with the scanning of EVERYTHING. If a particular med strength is unavailable and I can draw a partial, we're able to do that, waste the rest if necessary, and because I used a different strength, it sends an Exception to the MD letting him/her know the time, date, etc. etc. as to why I did what I did. Whenever I scan the med, it pops up a message stating wrong strength is the ordered strength unavailable? You answer yes, I get a prompt of "do you wish to substitute?", I answer yes, and voila - off I go. Then the systm is smart enough to recognize if an error is about to be made, i.e. it's impossible to substitute in order to get the ordered dosage. This has MANY more good points than bad - about the only BAD (more irritating than anything) is the amount of scanning of EVERYTHING. A bag of saline? Really? A blanket? Tissues? What syringe? I can't wait until they make us start scanning everytime we put a pair of gloves on, flush the toilet, or better yet, whenever we walk into a PT's room!! Hope you at least SMILE with this part :):). I do not understand why they would want "runners" when that seems to be a bit cumbersome at times however HIPPA really is a touchy subject. EVERYONE wants to error on the side of caution and I understand that. However, I don't see an issue with "paper" charts/logs/books being right there by the patient but in a LOCKED drawer. There's the HIPPA protection at least!! Once you're up & running fully electronic, trust me your life will be MUCH easier as far as the dreaded paperwork. Take it easy, NMA

We all make mistakes - what IS IMPORTANT is your statement of "I made such a mess of my life"... You ADMIT your errors - which is a heck of alot more than most people do. The beginnings of a "new start" are obviously hard, stressful, painful, and scary. A VERY good friend and colleague I've known since HS was recently in trouble for an addiction issue that even I, as one of her closest friends, NEVER even knew about. I don't know if this is your situation or not, however I got involved in the matter as I was signing off on waste/destroys when she was diverting. While I was never found at fault nor had ANY problem with myself in this, the fact that my "witnessing" the remains of a syringe of 'whatever' going down the drain was only water/saline/etc. instead of the actual narcotic. Why would I ever doubt her - she has been in my life forever. Little did I know, EVERY time she was 'wasting', whoever witnessed it never knew the wiser. For me to hear "Wasting 2MG Dilaudid" and seeing it go into the sink never made me think twice; that is, until the god-forbid Pyxis counts started going haywire... First started w/vials of 15ML saline being off, especially whenever there are no MAR's to support it, then moved all the way up to the narcs... The final straw was whenever too much waste of narcs started showing up and then 3 days later, while shifting a PT, 3 vials of Morphine fell out of her pocket and broke on the floor...... No way of hiding that... Nevertheless, be HONEST and be OPEN. Do whatever it is they are asking, stick to it, and get into the SNAP if you haven't already. No matter what it is, these programs are out here to HELP any one of us for any variety of problems. IT happens - and what the Board wants to see is admission, a plan-of-action, and proof you're doing what you're agreeing to. i don't know the whole story as you can tell but chances are, you'll be on a probationary status until completion of the sanction(s). Just remember - HONESTY, WILLINGNESS, SUCCESS!! I may not know you but as you see with my story above, I've seen first-hand what it can do to a person and his/her career. My friend and colleague got her act together, followed her 3-year RMA (recovery management agreement), did her urine screens, attended therapy, etc. etc. for THREE YEARS and not ONCE had an issue. Even when she was unable to pay for the screens, she was proactive about it and wrote the Board/ISNAP to advise them. They WILL WORK WITH YOU - ONLY IF YOU ARE SHOWING THEM YOU'RE WILLING TO!!!! Once she completed everything, she went to the petition for modification of probation, and due to her successful completion, the probation was removed and she was fully active. She was able to still work while on probation, but had a TON of restrictions and reportings, but nevertheless and as I said earlier, this WILL WORK IF YOU ARE READY, WILLING, AND COMMITTED TO THE PROGRAM(S). You're certainly in my prayers/thoughts :) NMA

First, I am new to this forum and I am VERY happy to be part of a group of my peers who can talk amongst ourselves. We all need a place to 'get it out of our systems' as well as seek some advice/opinions. Please bear with me as I "learn the ropes" here. :):):) I'm noticing an increasing rate of PT's experiencing ICU psychosis "syndrome" lately in my CCU. I put "syndrome" in quotes for a reason as a few of us (for OT reasons) have picked up a few night shifts to avoid OT. Furthermore, there have been quite a few rotation changes and 'general' changes supposedly for the "good of the PT care" :). We all know what this means - $$ saving attempts.... Anyway, the situations with psychosis are on the rise lately without much explanation. Until the handful of us days started picking up the nights, we would not have seen the difference in protocols. Last night in particular, after briefings and reading charts/MAR's/etc., the 4 PT's I took over were charted as confused/disoriented, refused oral meds, incoherent, etc. I found this odd given 2 of the 4 PT's have been mine on days for at least 2 weeks; and I had yet to see any real noticeable deterioration in function, particularly psych function. I'll just stick with these 2 particular PT's for the sake of this discussion as well. Anyway, their MAR's showed quite a few IVP's of Ativan, some up to 8MG's, Halidol, etc. These are PT's that, while there are PRN's for Ativan, have NEVER needed more than 4MG/day thus far. Further in the charts I see one of my PT's ended up in 4-points and missing restraint logs. I brought this to the attention of my CN who simply advised "It was evidently necessary"... OK - well, that does not answer my inquiries - especially whenever the 2 PT's never got to these extents and such a rapid deterioration, in a 12 hour period, had me pretty disturbed and in fact worried. Upon further investigation, MAR showed DC'd oral's, IV only ordered. Then I see the pain meds used on BOTH patients was IVP Fentanyl, 25MCG, then both started on infusions of 5MCG/hr with NO titration over the course of the shift. It's almost like they were "left to deal with it".... PT "A" was on Oxycontin 80MG Q12H with 15MG IR's Q4-6PRN; PT "B" was on Morphine CR 100MG Q12H with 30MG IR's Q6H. IMO, I believe this caused a precipitated withdrawal due to the changes in medications without PROPER consideration of the conversion factors nor consideration of titration of the Fentanyl. Once the CR's started wearing off, withdrawals had to set in as I've seen this before. I may not have double-digit years under my belt, however ANYONE who is on a high-dose chronic opioid therapy should ALWAYS have this be the #1 consideration after ensuring vitals are stable. This, too, was the case (both PTs stable). I did not like the CN's response so I paged the MD. Was told there is NO connection between withdrawals and the psychosis despite me KNOWING these 2 PT's for their entire duration of stay thus far. I further believe the withdrawals were masked a bit by (go figure) increased need of Ativan IVP's. I had two pretty coherent PT's that were now completely in la-la land with a different MD this week as well as a different CN - ALL of which did not seem to find any merit behind my theory. The other RN's with me agreed - particularly the seasoned ones - but since the PT's were now unable to take any meds PO, the choices were [now] IV/IVP.... Quite irritating to say the least - not to mention 2 PT's unable to voice their pain levels or anything else for that matter. I finally was able to consult with another MD who agreed to titrate to effect; after 6 hours, and I capped the infusion 150MCG/hr as the PT began to become lucid. PT "B" had a different MD at the time who denied my requested titration. PT "B" remained FAR from coherent, completely combative, and physically/chemically restrained. I am attempting to provide as much background as possible to gain some opinions as to this withdrawal theory throwing the PT's into the dreaded ICU psychosis states - especially to the points of needing 4-points?? NOT good... Of course, being one of the lesser-experienced, who am I to question. I counter that statement with our licenses are on the line everyday we walk through those doors so EVERY decision we make is one that must be in the best interest of the PT as well as following orders. Given PT "A"'s response once titration became an effective dose, I cannot understand why PT "B" could not have the same. Finally, PT "A" was DC'd off Fentanyl once he was able to resume PO meds - original meds at that - and the episode was overwith.... The final VERY ODD situation that occurred with a colleague the day before the 2 PT's went into these states was my request to witness multiple wastes on the exact same meds that these 2 PT's were taking PO.. She alleged they both refused ANY meds PO - but didn't set off any 'bells' given if they refused PO, they were already dispensed, they had to be wasted. Given withdrawal (especially with a long-acting) would take at least 12 hours to set in, I'm now speculating that the "waste" may not have truly been destroyed... I HATE to go down that road, but many pieces of the puzzle(s) are starting to fit if you get my drift... This WILL be the FIRST TIME I will be dealing with a problem of this nature, i.e. diversion, however I am unsure of how to proceed at this stage. Please feel free to ask ANY questions or clarifications; I'm new to this forum, I'm hoping this is a good start in a new place, and will return the favor as I am able down the road!!! Thank you to all in advance for your opinions/advice in these situations. I truly apologize for the length of this once again but I appreciate it more than I can say!! NMA

I certainly understand the "dealer" syndrome... Especially when we're utilizing CII's at relatively high doses. While I do not know this PT's entire history, my first question would be if your PT already has an opioid tolerance. The next question would be what was the MD's titration period (25MG to 50MG to 100MG) over 24/48/72H periods or the same day? IMHO, we all know that patient comfort is a priority; again, not knowing all the specifics, if your PT is scaling in the upper ranges until the higher doses were administered, all you were doing was your job to attain effective pain management. I'm not a big fan of Demerol and rarely used. I personally do not believe it is an effective medication & prefer the many other choices - unless there is an allergy situation or other mitigating circumstance. While this may appear to be a high dosage, consider the efficacy. For example, 4MG Dilaudid & throwing 25% cross-tol would be around (give/take) 200MG of Demerol. Don't get yourself in that state-of-mind where you 'dislike' your job. I know it's easier said than done as I've been there myself - the "second-guessing" stuff that is. Nevertheless, it is our jobs, and unless my PT's are known abusers, I stand by my obligation to keep the PT comfortable as best as I can. Further, the MD is the one ultimately signing off on the orders & MAR. You've got yourself covered :):).