I work in and ER that has seperate peds and adults, but I work mostly on the adult side. Recently, we had a child in the peds ER that the resident wanted dobutamine gtt on. He went back and forth on whether or not he wanted it for about an hour and then they decided that they were transferring the patient anyway and they didnt start it. From what I have seen at other hospitals and from what I do with adult patients (our policy) is that you do not start vasopressors on peripheral lines. This child was about a year old, was sitting up in mothers lap, arm bent with a 24g, IMO this is a situation that is really likely to infiltrate. They did not put an arm board and would not start a central line. One of the other nurses told me today that the peds cardiology attending was pissed at me over this, and that he told her so. Well, he never even said ONE WORD to me. Her response was well, didnt you hear him talking in the background? Well actually no, I was busy triaging about 5 patients in a row, and I only spoke with the resident, who only does peds, does not have much experience in PICU. IMO, he doesnt have much business ordering meds like that if he doesnt even know WHAT IT IS or how to give it. On the adult side, the MICU people manage those patients and medicine the patients that arent so sick. If he had something to say then he should have said it to me. Her response is "well they do it all the time in PICU". Fine, but they are not responsible for 15 patients at a time and are able to watch the site more often and avoid infiltrating that IV. At night we are responsible for all the patients that are there, any admissions, and triaging. There are only 2 nurses that night, and there were 20 patients in the peds ER including this child, as well as non-stop ambulences and sign in triages.
My argument was:
I do not run vasopressors in a peripheral line except in an extreme emergency. If this was that situation, than the child should not be sitting up on mom's lap in the chair. Her response was you let the child do what is comfortable. IMO you cant have it both ways. If the child is that sick they should be laying in the bed, or he is well enough to sit up, play and eat. I know how fast an IV can infiltrate in a small child. By the time you realize it half of the upper arm is flooded. Who do you think that lawsuit is going to blame when that happens when the child loses his arm? That's right the nurse.
2) Just because he says that they "do it all the time" doesnt make it right. I could not find a written policy anywhere that spells out the administration of these types of drugs in peripheral IV's in pediatric patients. I am sure that it is approved for code/near code situations, but I know there is no way that it could be approved for long term use. Besides, this kid was going to be transported to another hospital. If that line blows en route, do you think that thier staff are going to take the blame for that? No way jose! I wish I could find some literature on this situation, I looked online and didnt come up with anything. What would be even better is finding literature on lawsuits in this situation.
3) She said that kids dont look very sick until the very end. This kid was newly diagnosed that night, how long do you think he has been going around like this? I am sure not one day. IMO if this kid was so critically ill, than he should have been lying in the crib, attached to the monitor. While he is sitting in moms lap cooing, and taking a bottle, the movement throwing the monitor off, this is hardly good management. She says that if the kid is crying it can make the condition worse so you let them stay with the mom. When I did my rotation in PICU, if the kid was that sick and not able to stay calm by other means that would allow them to monitor them, they were sedated. I dont mean snow the kid, but a little benadryl would have done no harm and not brought down the b/p.
I am sorry about the long question and the rant, but I cant believe this BS that they are trying to pull now. Besides that fact that the attending LIED and said that he spoke to me which he never did, unless you call bitching and yelling out loud 20 feet away from me talking to me! Then he tried to say that well I told the resident. Well that is fine and dandy, but you never told me. All in all the kid turned out OK after all, and they never did start that drip. Thank you all in advance for reading my rant, and appreciate the input you have/what you would do when a situation like this comes up in the future. Thank you again :icon_hug:
