canadian_RN

Hello all, I'm an RN here in Canada (gee, did my name give it away? :chuckle ). A couple of weeks ago I found out that my Aunt (mid 50s) who lives in a very small rural town in a couple of provinces over, has bone cancer. Now the details of whether this is mets or whether it's primary bone CA, I don't know. I am in contact w/ my cousins (her sons) and they are understandably upset because this has all been very sudden and I'm trying not to push them too much for details or come across as a "know it all nurse." From what I can gather, she'd been hospitalized 2 months ago, briefly, for a bout w/ kidney stones. It was during that stay that they did an ultrasound and found nodules on her liver - but this wasn't further investigated (don't even ask me why). She began having generalized pain and a CT scan was done of the lungs showing some type of mass. Due to some gong-show type mix-up, she never had a biopsy of this. She ended up having a bone scan which, from what I gather, revealed cancer to arm, leg bones and spine. They did a CT of brain but nothing abnormal there. I would suspect, due to the fact that primary bone CA is so very rare, that she's got cancer somewhere and it spread to the bones.....but nevertheless, she's in a lot of pain. Her small town doc, who likely has little to no experience dealing w/ cancer, has given the family a prognosis of her having only a 2% chance of survival.....yet, they're giving her regular transfusions (packed cells, I believe) and they're still planning to send the poor woman by ambulance to the city 5 hrs away this week, for a lung biopsy. She's undergoing NO treatment of any kind but there is a possibility that they'd send her for radiation but the doc says there's no point doing that until they "know what kind of cells they're dealing with." I don't get this because it's proven she has cancer in her bones and it's proven that radiation can help to decrease the destruction of bone caused by cancer cells, which can thereby help to decrease the pain. Well, there's a lot I don't understand about her case. I used to work with a lot of palliative patients and we were meticulous and thorough when it came to adequate pain management....but in my aunt's case, she's in agony 24/7. She's getting 10mg of Morphine via subcu buttefly, every 2 hours. It's snowing her pretty good but it's not managing the pain well. This is heartbreaking to me - I know that bone cancer is very painful but this isn't the 1800s......there's better pain management regimes available. The comment my cousin made today is that they don't want to up her morphine because it would be too much for her (she's not a large woman) - I suggested they give her a bolus and then give less every hour instead of more every 2 hrs. Keep in mind, this is a small hospital and their palliative area is just new. I've asked him to talk to the Doc about trying Dilaudid or even a Fentanyl patch. She's too groggy to swallow adequately so po meds are not an option. She's receiving nothing but the morphine. It's been several years since I worked acute/palliative so might be out of the loop in terms of the more common pain med protocols but does anyone have any basic suggestions? I've begged my cousin to have the family doc consult with a pain specialist but I think cousin and family are afraid to offend the family doc. It's a bad situation but my poor aunt is suffering immensely. Do you think some IV steroids would help? Or any other injectable or IV med that would complement the use of narcotics? I've tried to tell my cousin that each person is different and for some, Morphine might work well but for others it might not, it just varies and the doc should be finding what works for HER. When my cousins try to speak up on her behalf, the nurses (from what I'm told) just look at them blankly and make comments like, "She's terminal, there's nothing else we can do." But to me this is just a crock. Okay, so they can't obviously cure her.......but surely they can manage her pain BETTER. She is constantly moaning and the family is beside themself, watching her suffer. She's so doped up on morphine but it's obviously not helping a lot......she's too groggy to even take a sip of water or talk. Would some IV steroids help any? It's been 10 yrs since I cared for palliative patients and I'm sure pain management has improved a lot over that time, so I'm not sure what to advise them. I feel helpless - if there was something I could suggest they talk to the doctor about.......NOBODY should have to suffer, nobody.

Let's see, years ago I worked with an RN who had many years experience, she often worked as an evening supervisor as well. She worked nights, I was working days. After I got out of report, I did my usual round to check on everyone and check IVs, etc. I came across a patient who came in periodically with kidney stones. I noticed he was sleeping. This was a young guy, late 30s or early 40s. I realized he wasn't sleeping, he was have unconscious! His resps were about 8. He was on a morphine drip. I checked the bag, noticed it was a 100cc minibag versus the usual 250cc bag we'd use for morph drips. I quickly shut off the morphine and ran saline, paged the doc stat (who was luckily doing morning rounds). The guy was transferred to ICU STAT. He was overdosed. Instead of putting 50mg into a 250 bag of N/S she put 50mg into a 100cc bag. I wrote her up, but did anything happen? Nope. She continued to nurse AND be a periodic nursing supervisor. Years before that, I caught a new RN drawing up Potassium Chloride to use for doing a heparin lok flush. She was mistaking the small vial of N/S for KCL. She was one scary chick. And yes, I wrote her up. She didn't last long. Caught one other scary RN once.....we had a patient come up from Emerg, admitted to our unit. He had a DVT and came up on a Heparin drip. His Emerg orders stated he was to have a loading dose of heparin s/c. He'd have received this in Emerg prior to starting the drip. When he got to the floor, I saw her going into his room with a syringe. When she came out, I asked her what she'd given him, she lied and said she'd given him nothing. I didn't believe her. I went in and made small talk with him...he mentioned a nurse had just been in there to give him a shot to his arm (s/c). She still denied it. There was nothing else injectable she could have given him, nothing else was ordered that was injectable. When I was a nursing student, I was doing my practicum on a med/surg unit. I was helping do morning care with an LPN..she was a really mean, grouch cow. She got up this lady (brain mets) onto the toilet. Later I heard this poor old lady had fallen off the toilet and hit her head. This wench just left her on the toilet - not secured at all, no access to a call bell...she should have never been left unattended. I was always astounded and mortified, too, to see RNs give a bolus of saline to unclog an IV line or hep/saline lok. They'd get out a big 10cc syringe, fill it w/ N/S and attach it to the hub and put major pressure to flush the cannula.....um, hello? if there's a clot on the end of the cannula congratulations, you just dislodged it. I'd even seen docs do this, too. sheesh. I remember one nurse who forgot to prime her iv tubing and the young patient got a hole line of air from the tubing, ended up in ICU w/ an air embolus. She was fired. I wrote up a couple of physicians, also. Had a case once where I was working nights...had a lady in her 50s who began having chest pain, vitals weren't good, color was awful....I called down to EMERG and wanted the on-call doc up to my unit STAT. He was too busy on the phone making personal calls. He didn't show up until I'd paged him 3 times........she was then promptly transferred to ICU. I think he lost his license to practice a few years later as he was charged with double billing. A real pillar of integrity and compassion, that one. Also had another incident where I had a 17 yr old patient w/ Mono. A week earlier in our small town, a girl in his class had mono but was misdiagnosed as having the flu....she ended up dying at school of a ruptured spleen. Needless to say, all the teens in town were devastated and very scared. So this young guy rings the bell in the middle of the night complaining of abdominal pain..to the area of his spleen. He's in tears, afraid he's going to die, too. I call downstairs for the ON-CALL doc. Well where is he? He's left the building..he went home. He lived a half hour out of town. I was livid. If you're oncall, you damn well better be available *NOW*.....so I call him up at home, wake him up, he says he'll be there right away. I'm trying to calm down this young guy.....he's very restless, very scared, what can I do, not much.........we wait. 30 min goes by, no doc. 40 min, no doc. I call his home again. GUESS WHAT? He fell back asleep. I was not impressed. I completed an incident report and reported him to the chief of medicine. Although I'm sure nothing happened as a result. He finally did come in..bully for him.

Hello all, I'm an RN here in Canada (gee, did my name give it away? :chuckle ). A couple of weeks ago I found out that my Aunt (mid 50s) who lives in a very small rural town in a couple of provinces over, has bone cancer. Now the details of whether this is mets or whether it's primary bone CA, I don't know. I am in contact w/ my cousins (her sons) and they are understandably upset because this has all been very sudden and I'm trying not to push them too much for details or come across as a "know it all nurse." From what I can gather, she'd been hospitalized 2 months ago, briefly, for a bout w/ kidney stones. It was during that stay that they did an ultrasound and found nodules on her liver - but this wasn't further investigated (don't even ask me why). She began having generalized pain and a CT scan was done of the lungs showing some type of mass. Due to some gong-show type mix-up, she never had a biopsy of this. She ended up having a bone scan which, from what I gather, revealed cancer to arm, leg bones and spine. They did a CT of brain but nothing abnormal there. I would suspect, due to the fact that primary bone CA is so very rare, that she's got cancer somewhere and it spread to the bones.....but nevertheless, she's in a lot of pain. Her small town doc, who likely has little to no experience dealing w/ cancer, has given the family a prognosis of her having only a 2% chance of survival.....yet, they're giving her regular transfusions (packed cells, I believe) and they're still planning to send the poor woman by ambulance to the city 5 hrs away this week, for a lung biopsy. She's undergoing NO treatment of any kind but there is a possibility that they'd send her for radiation but the doc says there's no point doing that until they "know what kind of cells they're dealing with." I don't get this because it's proven she has cancer in her bones and it's proven that radiation can help to decrease the destruction of bone caused by cancer cells, which can thereby help to decrease the pain. Well, there's a lot I don't understand about her case. I used to work with a lot of palliative patients and we were meticulous and thorough when it came to adequate pain management....but in my aunt's case, she's in agony 24/7. She's getting 10mg of Morphine via subcu buttefly, every 2 hours. It's snowing her pretty good but it's not managing the pain well. This is heartbreaking to me - I know that bone cancer is very painful but this isn't the 1800s......there's better pain management regimes available. The comment my cousin made today is that they don't want to up her morphine because it would be too much for her (she's not a large woman) - I suggested they give her a bolus and then give less every hour instead of more every 2 hrs. Keep in mind, this is a small hospital and their palliative area is just new. I've asked him to talk to the Doc about trying Dilaudid or even a Fentanyl patch. She's too groggy to swallow adequately so po meds are not an option. She's receiving nothing but the morphine. It's been several years since I worked acute/palliative so might be out of the loop in terms of the more common pain med protocols but does anyone have any basic suggestions? I've begged my cousin to have the family doc consult with a pain specialist but I think cousin and family are afraid to offend the family doc. It's a bad situation but my poor aunt is suffering immensely. Do you think some IV steroids would help? Or any other injectable or IV med that would complement the use of narcotics? I've tried to tell my cousin that each person is different and for some, Morphine might work well but for others it might not, it just varies and the doc should be finding what works for HER. Thanks in advance for your input. Lisa

That's a good question! I don't work acute care any more but when I did, I know we had a large chart in our med room that listed meds that COULD be given IV push. Of course we had to also follow our hospital's Pharmacy and Therapeutics' policy as to which ones could be given and under what circumstances Eg) some could only be given if a doc was present, some could only be given IVP in an emergency situation, some could only be given that route with a specific doctor's order that it be given that way, etc. Guess I didn't really answer your question, though, sorry. If you work in a hospital, contact your Pharmacy Dept there, they should be able to give you a general list of meds that shouldn't EVER be given this way, at least I'd think so.