Zachary2011

Our hospital, insulin gtss goto the units only... ie ICU/CCU/CVICU..... however I think depending on the circumstances they should be able to goto the floors or at least to PCU of which is considered critical care, however they dont take care of any critical pts. ... I never understood that..... I do think q 1 hours accu checks is too much for the floor nurses they are busy enough...... it all depends if they are DKA, whats there anion gap, how symptomatic are they....... if I have time I prefer to watch them in the ER after their boluses, and k and get the suger down enough to start the D5 with the gtt, hopefully their anion gap is much more narrow or even normal and then they can be sent to somewhere other then the units. However at this time the units complain the pt. is too stable even if on insulin gtt for them to accept, and the other floors say they are too unstable or they wouldnt be on an insulin gtt........... but I believe for the most part our gtts goto the units.

Most the docs I know differ the versed dose for each individual pt., the usual things as in weight, age, extent and type of injury...... many times they will give 2-4mg, monitor the pt and if needed give more.........also I completey understand the diprivan being the big gun as compared to versed being a little 22. I was just curious as to which you would prefer to administer for reductions. As I mentioned on earlier posts, I have learned a lot from these posts and will never personally give diprivan to a pt. not intubated. Is there even a better drug of choice then versed........ at times if the docs think they can do the reduction with just valium and morphine or demerol they do that...... I prefer that for pt. safety also ,if at all possible. If this question is for a whole different post I apologize,,,, I just thought who better to ask then the people whoms post Ive been reading. All seem like they could give me some helpful info. on this subject. Thanx again

I agree w/ Tazzi, Some people just cant handle betablockers, just as some cant handle calcium channel blockers........... However I think you did the right thing regardless of what response the pt. had.......... Ive seen pt.s go into complete heart block after getting a beta blocker......

Hi again, I just want to say I have learned a lot from this discussion, and myself will no longer give diprivan personally, however I am sure it will remain the drug of choice for reductions in the ERs I work at.............. My only question is, we are all talking about aspiration, apnea, etc. other s/s , these same complications occur with versed, in fact just lucky Im sure but the only time I have had to bag a pt. post reduction was on versed.... we always consider last meal and fluids...... then the part about calling anesthesia........ oh my..... that wont happen..... at least where I work it takes an act of God to get them to do a blood patch........I understand they are busy........ but our ER docs in my opinion def. have the skills to manage these pts. , of course now I say if you want the diprivan pushed...... you push it.......... anyway I guess the real question was ,dont these same complications occur with versed......... are they just more likely with diprivan? How much more likely? If you worked in the ER what would you rather give for reductions and why? Thank you for all your help!!

I agree w/ CEN35, many times its actually a blessing I would think that some of the pts. that code do not make it.. Its all about quality of life........ The children on the other hand is horrible....... we just had a 10 day old die about 2 weeks ago and those are the ones that get to you......... also when a code comes in by the medics and you know them.......... as many of you know your friends and family just dont look like themselves when they come in intubated, coding , or critically ill. When that happens it tears your heart out. But you keep going ....... I strongly believe ER care sets the tone for the pts. future recovery and the fact is no one can do it better then we can (ER Team) given the situation and circumstances that we work in, so with that said most deaths I believe is God calling for them and no matter what we do we cant change that calling.

You can inject a small amount or air with all IM injections so that the air aids in pushing the med deeper into the muscle so less if any is lost when you remove the needle. As far as measuring whats in the needle, I hope one would change the needle from the one used to draw up to the one used for injection, and as someone posted the needles do hold meds..... ie; if you use a blunt to draw up morphine, say 2 mg which is 0.2 ccs then you pull back on the syringe after discarding the vial you will get about 1/2 cc or more of morphine that was in the blunt. making your dose almost 3 mg instead of 2 mg....... just change the needles from the one used to draw up the med to the one used for injection. Either way with the excpetion of pediatrics I wouldn't be to concerned.

i just want to thank everyone for all the information, i can say now i will no longer push diprivan on a non-intubated pt. except for rsi ( we rarely use diprivan for rsi except sometimes for burn pts) i will continue to hang the gtts post intubation and draw my line there. i had no idea legally i was on such thin ice, so much literature by lww and even ena supported the use of diprivan for cs. i have certain rules i go by as a nurse, 1) pt safety, 2) tx pts with the best care and with all my heart 3) being my pts. advocate,, i love my job and honestly feel nursing chose me, i treat all who come in through the door as i would want to be treated. i do think there is still a chance that diprivan may become the drug of choice for difficult reductions and for cs, but untill the laws clearly state and i am educated extensively with a certificate allowing me to administer it i will never do it again. also if i had to goto crna school to push it on a non-intubated pt. i think ill just keep asking the docs. for morpine, valium, versed, or whatever else................. thank you all rns, crnas(of whom i really appreciate you all sharing some of your knowledge with me). again. thank you

[ I don't understand why these RN feels like that need to be pushing the envelope with their licenses, it's not like they are getting paid more money for that service. It is all too risky for me. I would rather leave it up to the trained aesthesis. Just my opinion. In the ERs I work at, 1 in Fort Worth and one farther south, The ER Docs want Diprivan to be drug of choice for all CS, and this POST I have been really trying to pay close attention to and learn from. We give Diprivan fairly frequently for reductions., cardiac conversions ...etc......... I made it a point to ask the Medical Director if I should be worried about its administration. He said you have a far less monitoring time post drug dose then w/ versed and morphine of which is what we usedto use........ 8 mins as opposed to 2-6 hours of drug effect. He said all else is same, have ambu bag, intubation box, at bedside and monitor vitals just as you would w/ versed. Please , if anyone can tell me why I should be concerned............... now keep in mind I am not a CRNA, I am an RN and I am aware of dosing, side fx, poss. complications,and I am very comfortable with handling complications should the arise etc. however much of the CRNA knowledge, ie; chemical make-up, exact physiology etc. is over my head. I would just like to be able to tell our docs why I shouldnt give diprivan when they all seem okay with our nurses doing that. Thanx for any help

I am not an LVN anymore, graduated ADN and now working on BSN, Sorry I just never updated my profile. I was also unaware that this was strictly a CRNA post, my bad.

Wow, Ouch, Sorry for the post........ No I dont know of LPNs pushing Diprivan, only RNs, heres a few examples of where I am coming from........ A friend of mine is a Gastro Doc and they used to use Fentanyl and Versed for colonoscopy procedures. Now they use only diprivan...........versed's duration is anywhere from 2-6 hrs., and diprivan's duration is 3-5 mins. so if complications where to occur ie: hypotension, apnea, bradycardia, the time from of managing these complications would be much shorter, Granted you can give romazicon for versed reversal. For example when we would do a reduction we used to give morphine and versed and monitor and sent the pts. home hours later. Now that we use diprivan we can send the pt. home 30 mins. post reduction. Recovery time for diprivan is 8 mins., 20 mins if given with an opiod. They pt. should be monitored equally the same with SpO2, Heart, BP, RR, and resp. equip. at bedside. Sorry if I dont see the diferences in monitoring and actions, and that I see the pros of diprivan related to the shorter half life. Please educate me on this, I have no problem being told why I am wrong and the reasons behind it. But please dont be rude and condenscending. Sorry I even expressed my opinion or view.... but really please let me know why my view is wrong, I would appreciate it.

Do you give versed as an RN, well if so, diprivan is no different, Has pretty much same effects with a much shorter half life. And as with versed you need to have an Ambu bag, and Resp Box at hand for possible BVM and intubation if unable to BVM effectively. We give Diprivan all the time in our ER also for reductions and such and use the gtts for post intubation sedation. Just need your ER doc there for airway managment. I guess I dont understand the big deal w/ diprivan and some nurses not thinking it should be in there job description. Nothing to be too concerned about, so easily titrated even by IV push, onset is like 30 sec.s and pt. is back to baseline LOC in 15 min.s Its a wonderful med and so much safer then Versed .

I am so sorry you are discouraged and the support you needed was lacking. But......... I work in a very busy busy ER, and many times we work short...... Do I think a new Grad should start their career there... No I dont, By being as busy as we already are its near impossible to give a new nurse the time and attention they deserve.... I hate that its that way but it is. Now I also worked at other ERs in Texas not near as demanding, and in that case a new Grad would probably learn and have the support they needed. It just depends on so many factors, pt. rollover, managers, staffing, acuity, etc. I honestly think a new nurse should gain exp. at least for one year in another dept. other then ER, ER is fast paced, so the nurses themselves need to be fast. Hang in there, give yourself 1 year on a medical or tele, then go back down to the ER and I bet you will own that ED within 6 months. Take Care

As all have mentioned different hospitals have different ways of calling codes, ........ first thing is be sure and assess the pt. and not just the monitor before calling a code. Also be certain the pt. is not a DNR before calling a code. Every floor should have at least 1 crash cart and you should start CPR right away and bag the pt. right away. By thyis time their should be help for you and even before a Doc shows up he should be on a monitor and if V-Fib or V-Tach(pulseless) shock the pt. Give Epi right away and possibly Atropine (unless has had a heart transplant, then Atropine does no good), if pt is diabetic give 1 amp of D50. This is all ACLS protocol , and by protocol you can do any of these life saving measures without a Dr. at bedside. I work in an ER and many times we dont call the codes , we have all we need there...... now Pharmacy responds to all codes called overhead which is wonderful, no reason to even break open the crash cart. Just a hint, if you feel no radial pulse they still may have a pulse, on avg. you need a systolic of at least 90 for a radial, and 60 for a femoral. But please start cpr asap, there has been so many times I respond to a code on the floors and there 4 or 5 nurses standing around the pt. as if just waiting on someone to say okay boys and girls you can start CPR and ACLS now.

I apologize if I sounded harsh towards anyone. The point is I have great respect for most Medics and for most ER nurses.

Its a shame how some people are speaking about the other profession on here, "Try intubating on a hill with coyotes and bears chasing you on skateboards"...................... We as nurses speak to the pts. family when one passes, yes even the 10 day old babies, in fact I would say 90% of our pedi codes are brought in by mom and dad and not the Ambulance. If you want to work in the hospital and want more respons. goto school, get you liscence, hell the way some are talking get your MD cause evidently you are all that and more already , and I am speaking about a few posts on here........ sounds to me like your above all the rest but unlucky for you noone else knows that. I was an EMT for 8 yrs. before I got my RN I have been on both sides of the fence......... and the one thing I hear from most EMTs that get there liscence....... "I had no idea"..... and I am sure nurses would say much of the same with a few shifts on the truck......

I also am an EMT inter and now an RN, In the ER,,,,,,,,,,,, Heres some differences......... As an EMT, there BP goes low you bolus, regardless of pt illness, IE: CHF......and you just cont. with transport...... as a nurse you have many options one is educated on...... ie: Dopamine, Levophed,and the calculation of these gtts. etc. As an EMT you place Nonrebreathers on all pts. with low SpO2, In ER, if they have COPD or known to be a C02 retainer you take off the nonrebreather, .... You give Ntg SL for chest pain, in the ER we will do same but also heparin, morphine, and ASAP EKG, for if they are having a Right Ventricular Infarct nitro is usually contraindicated, and hope the cath lab is available or perhaps give throbolytics. As an EMT you do just what the original post stated, you keep them alive for transport........... I am not saying thats a bad thing, for I have a lot of respect for my past job. and many times the pt. is asymptomatic by the time they hit the ER and many times in part to the care the EMTs provided. Also in a busy ER as a nurse you do often treat as you feel is needed , its not as if a DR. is there to watch over you or write an order for your every move. You often determine which pts. get to a room while others wait in the waiting room (the pts. you dont see as an EMT), and if this sounds simple enough just wait untill you have your first code in the ER waiting room. You learn to read lab values, not just surveys but Enzymes, ABG's, lactate levels, etc. You learn to identify the warm stages of sepsis and treatright away so when the go into the cold stage they dont crash. I greatly agree EMTs are way underpaid, and we are all in this together, for the greater good of the pt. I also know of many EMTs who believe they have been demoted by working in an ER.................... but the fact is ,just doing vitals sign , helping to clean up a pt, getting them a blanket, is the basics of nursing care, and if someone believes they are above that, they have no business in the ER. People are EMTs and ride the trucks because they love it, and if thats what you love......... do that, and I thank you for doing that.

Let me tell you my view on write ups, First anyone can write up anyone else (at least at the hospital I work) regardless of the situation or person. It seems anyone can say and write down anything they want to about another person. Some nurses are just more then happy to write everyone and everything up, These nurses have no business being in the profession. We are all in this together and unless you know of someone doing something intentionally to a pt. , family member, or another employee please dont get happy with that pen and paper. Most nurses I have seen do this are out for revenge, or possibly because now they may have to get up and do something. They ***** cause they dont have enough time ,yet they will spend 2 hours writing someone up instead of taking care of there pt.s. I have never written someone up in my life and if something happens to a point I feel the situation needs to be addressed I will come talk w/ you, and/or your supervisor. I work in an ER one of top 3 busiest in Texas, and some floor nurses, really only 2 nurses, get all bent out of shape when they get a pt. from the ER so they look for every reason in the world to write that ER nurse up. I simply reply to them............. You work in a hospital, you are going to get pts., if you can't handle that leave. Or they want you to wait untill next shift or 3 hours later to bring that pt. up........... well I am sorry but we cant tell the ambulances, helicopters, and pt.s from the streets to hold that MI for a few hours, or to not get shot in the chest untill Nurse B%$#H has time to accept you upstairs.

First off, you can refuse pts before report is given, however if you refuse after taking report, its pt. abandonment. Even still if you feel its unsafe , while on your shift call safe harbor. This will help protect your liscence and they in turn will follow up with your hospital to look into the working conditions, usually nurses call safe harbor related to unsafe nurse pt. ratios and/or acuity level. Your manager or administration will have no grounds for retaliation if you call safe harbor, its there to protect nurses.

I work in a busy busy ER, before this I have worked on PCU/ICU/CCU, and as Im sure many of you Nurses know when you get a pt. demanding TX before diagnostics or even after diagnostics it can be frustrating. It's people telling you how to do your job. I agree no one knows their body better themselves but its never proper to demand treatments or interventions as a healthcare person. There are ways to suggest and be diplomatic about what you want and then their are the ones that are demanding. Now when it comes to your child I completely understand, but instead of saying No Dr. he has to have this, say Dr. you know what worked well for him before, or Dr. you know he had trouble with that before. I see many Nurses as Pts. and even Physicians, and for the most part if you let them know the TX path your taking and the results of all diagnostics they are extremely happy. Nurses do not deserve special care, nor do physcians, (I do agree children do), I treat all of my pts. the same, as if they were family..........and sometimes family disagree. Just because you hav RN,MSN, or MD on your name badge is irrelavent to me. And as many of you ER nurses know when they are in the ER they basically post their badges on their forhead, so all can see that this some how makes them VIP. I understand there are bad nurses out there just like in any profession, so its always good to have some one that can understand and translate the medical interventions (hows and whys) to your family if they are being treated. But on the other hand a good nurse will do that for their pt.

Thanks for the information but we do draw from peripheral sites often, I work in an ER and many times redraw from IV sites for labs, ie: cardiac markers, cardiac enzymes, redraw of potassium following treatment of hyperkalemia, hourly surveys for DKA while on D5 and insulin gtts..etc. When I was in ICU we also would draw from peripheral sites if able, granted there are times when you can only get the draw upon first insertion but if located in the AC you can many times draw from them daily. Of course through all this I discard the waste and obviously never draw from a gtt or fluid site or draw from a site above med administration. Thanx all, Zachary

Question, Why not draw from a midline, a midline is the same catheter as a picc, usually a picc is attempted and if unable to thread through, the cath is clipped and the infusion team settles for a midline. As long as appropriate waste is discarded this would be the same as drawing and wasting from a peripheral site, of course blood cultures should be avoided from a picc or midline and should always be drawn from a new access site. If you know why some people are mentioning not to draw from a picc please let me know the rational for it. Thanks All, Zachary

No need to split the injection up unless its a pedi pt., It should be mixed with 1 % lidocaine, no need for a dr.s order, if you look at the insert on the vial it will tell you to mix w/ 2.3 ccs of lido. Same with Ancef and many antibiotics that are given IM. What you did was fine also, its nice you have concern for the pts. discomfort but he will be fine, as long as the sciatic nerve wasnt struck. Just remember mix with lidocaine and give in one injection.

First just a thought on another entry re: couldnt find a stehoscope, why would a nurse not have one, and then why would it be hard to find on a floor? I hope you now leave it around your neck or in your pocket. I work in an ER and have worked on many floors prior. I am on a code team for our hospital and it just blows my mind how many floors and staff get flustered and dont seem to know what to do during a code situation. I cant count the times I have gone to the floor when a code was called and chest compressions havent even been started, sometimes still no crashcart or zoll hooked to pt. , some nurses say they are waiting on the DR. , well people ACLS is a protocol not a Dr.s order. CPR is essential to maintain blood and oxygen supply for the hopes of revival or survival. Place those defib pads on and shock as needed, IE: V-Fib, Pulseless V-Tach. Give that EPI and do CPR to circulate, bag w/ 100% oxygen untill resp. or the ER Dr can intubate if needed. Give that Atropine as needed. You do not need a Dr. there to save a life, he will get there to pronounce death or for orders outside of ACLS ie: Sodium Bicarb, and in the case of lethal Arrythmiasm, Amiodarone etc. I hope I dont sound to firm in this note, but CPR and shocks must be started and given ASAP, the pts. life is at risk, and this pt. could be you or a loved one someday and how would you feel if the pt. was found down at 0800 and CPR wasnt started untill 0807. ............... I do understand that if they arent monitored their can be some time before they are found, but if you do find just follow that ACLS protocol, and sleep well knowing you did everything you could do and just maybe saved a life.

I vein basically feels like a rubber band flattened out, its usually spongy with some give, of course before you stick palpate and make sure there is no pulse esp. in the AC area. Some veins do feel hard but if thats all you got you can usually pass through it. Also the alcohol pad waorks well also the thumping , (although the books say not to do this), if you rub briskly with an alcohol pad, it will not only help the vein be more visible but it also numbs the skin a little and the stick is more tolerable for the pt. Before the stick always use a fresh alcohol wipe and go over the site just one time. Being in the ER we get a lot of low BPs, and dehydrated people that the veins arent visible, you will get the knack for feeling them, one day it will all just click for you. Also I do a lot of sticks in the AC because its much more comforatable for the pt, and since we draw all the blood , its usually a bigger vein that makes redraws from the heplock much more reliable so that we dont have to stick them again. I know the floors complain about it but they dont do the blood draws and dont have to stick everyone that comes in through the door. I do however, if I think they will be admitted always start out distally at the hand. Good luck in all you do.

LVN and LPN are the exact same liscense, ones vocational and ones practical, it just depends the state your in on which title you have, I believe texas is the only state that calls an LPN an LVN.......... no difference in the two at all.