The Bucking Bronco in Room 116

[TriciaCorn, MSN]

When the census is low in theCVICU, we take turns floating to other ICUs and the CV Stepdown Unit. One weekend it is my turn and off I go to the 4^th floor. I knew I was in trouble during bedside report. The patient is sitting in the recliner in the far corner of his hospital room. His blue jeans and t-shirt are crumpled on the floor under the window and his hospital gown is only half on. His girlfriend is perched on the edge of the bed, slightly out of breath with a tight grin pasted on her face. She bounces a little on the mattress as she twirls her hair. The patient's eyes dart continuously from me to the day shift nurse and then to his girlfriend as if sizing us up. It is obvious that we had interrupted a heated conversation.

The patient's girlfriend tells us that the patient wants to leave. I look up at him,but he simply sits there, glaring. Unusual affect on this guy, I think. The day shift nurse explains in detail all the reasons that he needs stay; positive troponins, heart cath in the morning, hypertension, and no prescription coverage. The girlfriend, who seems to be doing all the talking says, "He really wants a cigarette, just one." The day shift nurse and myself counteroffer with a nicotine patch. The patient just sits there, glaring.

The girlfriend follows us out into the hallway and explains that John* drinks a lot at home with his father, upwards of several cases of beer a day. I contact the physician and request a CIWA protocol. The first few hours of the shift pass by without too much issue and hypotension in another patient's room keeps me occupied. Around 10 pm the girlfriend comes out, she says the patient is anxious and sweating profusely. I go to the Pyxis and get out the Phenobarbital and Ativan. I give the prescribed doses of both medications. Little did I know how many more times I would administer these medications over the next 8 hours.

Over the next hour, the patient goes into full alcohol withdrawal, but none of the medications relieve or reduce any of his symptoms. By 11 pm he is trying to pry the windows open and attempting to barricade himself in his room. We call a Code BERT, which brings in security officers, the house supervisor, numerous floor staff, and the physician on call. We attempt to hold him, but he breaks loose and bites his girlfriend in the face. He scratches, claws, spits, and hits anyone who gets in striking range. The doctor orders restraints, but he bucks in the bed deliberately attempting to break his own wrists. It is at this point that we switch to leather restraints and have staff members take turns holding him down, this goes on for 4 hours.

We call the doctor for the 8^th time around 430 am to request again that the patient be moved to ICU where he can be more adequately sedated. The doctor asks us to administer the Ativan and Phenobarbital one more time. I refuse, at this point, the physician has already ordered and I have administered well over the dosing limits of both drugs. I tell the doctor that the drugs are not working, we are in danger of overdosing the patient and compromising his respiratory drive, the situation is not safe. We finally move him to the ICU by shift change. Once he arrives, the staff there immediately sedate him and intubate him. Within 20 minutes of his transfer he is finally silent and unmoving.

It's 6:50 am and I have not seen any of my patients since 10 pm the night before. I am sick to my stomach and shaking from exhaustion at what I have been through and worry for the patients that I have not laid eyes on in hours. The other nurses had taken my team for me and ensured the care of those patients for the night. In retrospect, I should have found this to be a silver lining in an otherwise horrific experience. Instead, it was the beginning of the end for me as a bedside nurse.

I was exhausted, depleted of all empathy and compassion for anyone, including myself. I felt as if I had been through hand to hand combat in a war zone. We had 5 security guards, 4 CNAs, 6RNs, my charge nurse, the house supervisor, and 2 staff members from the staffing pool who had to stay in this patient's room all night. One of the RNs hurt her back and had to go out on workman's comp for 2 weeks. A CNA had two fingers on her right hand broken and was taken to the ER for treatment. 6 of the staff members present in the room that night called out for the rest of the week. I questioned administration throughout the night about why we were allowing this situation to continue and never received an adequate explanation.

As nurses, it is important for us to recognize these pivotal moments in our careers as they are happening. Otherwise, the trajectory of our desired career path becomes skewed by the random acts of unfairness that we are bound to witness during our work. A nurse needs to self-assess on a regular basis to fend off burn out. I wish I had stood up for myself and my patient and insisted that the patient be moved much earlier in the shift. Several staff members were harmed that night and the patient could have died as a result of the enormous amount of drugs administered without respiratory support. It was a mistake and I learned a lot from the experience.

*name changed

[anon456, BSN, RN]

My heart goes out to you. I think that eventually most of us will experience a situation where we have to choose between our deeply-trained desire to follow doctor orders, and to put our jobs on the line in order to save our patient and/or our license. This is very empowering-- but extremely stressful and traumatic. Your experience sounds horrible and never should have escalated to that point. I hope the hospital had a debriefing not only to examine what could have been done better to prevent it escalating to that point, but to emotionally support those who were there.

I have been a nurse for 7 years now, and I've had a few times when I had the milestone experience of being the ultimate advocate for my license and patient over doctor orders. Here are some of them:

-- I was given report on a pediatric patient who was currently in ER. I knew this patient well, he was very fragile in the best of times, and per this report he sounded terrible. I decided to go to ER to assess him before taking report and accepting him as my patient on my floor (I was charge that night). Our floor was stepdown ICU at a 3:1 ratio, and I was not sure we could provide the best care for him in his current state. My assessment made me very concerned. It was both my knowledge of this patient, and a gut feeling. I refused to take him. I told them he needed to go to ICU instead. The ICU said they didn't have room for him and I said, well then he will be safe to stay in ED until there is room. I got yelled at by the ICU nurse manager, the ER doc, and again by the ICU doc. I stood my ground. He was taken to ICU an hour later. I went to check up on him a couple hours later and he had been sedated and put on some high-stakes drips. I was told that later after my shift ended he coded. He survived it and went on to live many more years. But I'm so so glad I stood my ground.

-- More recently I was the only nurse of a small hospice unit with two CNA's and 4 patients. Not a bad day, right? But one patient required 3 people to care for, as they were very obese, and required frequent hygiene cares. During those times of changing this patient, we had to listen for call lights of the other patients. It was manageable though, being a small unit. THEN I was sent us this patient who was very combative and disoriented and threatening to bite, hit, smear bodily fluids everywhere, and run out the door. I asked for a sitter for this patient until we got him more sedated and calmed down. I was told there were none available, too bad. THEN I was being sent yet another patient and I said no way, I will not take report or accept another patient until we get a sitter for the disruptive one, or until he calms down and is safe. I was told I was being insubordinate but I stood my ground anyway. Well . . funny thing . . they were able to magically come up with a sitter, after all. And all ended well. When the manager heard about it the next day she said I did good. :-)

-- A patient was looking very bad and I kept calling the MD and was being blown off and even made to feel bothersome for informing him of my concerns. After talking with my charge nurse, who was equally as concerned, we agreed to call for a Staff Assist, which is right below Code Blue-- it gets the ICU docs to come and assess within minutes. They took one look at the patient and he got transferred to ICU.

[JKL33]

This was simple ETOH WD?? Hmmm on that.

However, the lesson you learned will serve you well from this point forward.

[trvlngrn22]

Curious, what did you use for CIWA protocol? Not knowing yours and not liking mine in particular, let me say a few things. I usually explain to the pt,as soon as I get protocol,that I have learned that he drinks fairly regularly. I do not say alcoholic or say that it is too much. I do say no matter how much, a body can get used to it and can make them uncomfortable or even seriously ill. I explain I have a list of questions and that we score often too make it easier to see how he's doing. So do the first, score and treat. At the first it sounds like he could have used a dose immediately. Now, here's what I do differently. Many protocols will say for a low dose to retreat in 4 to 8 hours. But when do you ever give a med and recheck that much later? So in an hour, recheck score and if same or higher call MD to remediate. Then again. I ask MD for clarification order that I can use to treat pt hourly if needed.

ETOH withdrawal pts can usually tolerate huge amounts of meds. And by not making an issue of his addiction and just pointing out that my job is to make his stay easier, to protect his heart, and to be honest make my job easier. Most pts respond well to this and will usually call me when the symptoms get worse. The key is to treat them often and with as much as needed so your pt isn't found trying to open a window or otherwise losing it. And remember the scale is somewhat subjective. If 1 more point is the difference in 1 mg or 2, he may need the 2 mg more and couldn't the severity of something be a little worse than you gave him credit for.

Another consideration is asking the doc if he will just order some beer for him. A few beers would calm him down and be less stressful than withdrawing. If his cath is clean he can just go home the next day. I assume he's not in for ETOH treatment. Believe me, I've gone down both routes with pts.

Usually. I see pts like yours when they are undertreated. I work in ICU and I see it from previous shifts, the floors,or even ED.

To my amazement, our protocol doesn't reflect the above repeated treatment. A sister hospital had a similar one with the exception of a small notation that an acute withdrawal may need to be treated every hour, but gave no means to do that. Of course if your diligent and score early, you'll maybe give them 0.5 mg. But why on earth are we expected to check them again in 4 hours. It surely gets worse before it gets better. So I score hourly until I get them in a good place.

[subee, MSN, CRNA]

This guy was going to wind up intubated..period. Yep. Needed to go to ICU for Propofol drip. Dosing limits don't mean much in these situations because it can take a frightening amount of meds. But this was a terrible experience for all involved and I know how these all nighters can diminish you. I just hope that this nightmare can cause an institutional change re: recognizing the acuity if this situation. A friend of mine recently lost her son due to DT's in an ICU where he got good care but the previously undiagnosed cardiomyopathy caused his death. Sorry this happened to the OP.

[trvlngrn22]

Dosing limits do matter. Not all pts with bad withdrawals need to be intubated. And early on, before it became a crisis, what you call a "frightening amount" of meds is needed. Like I said, the point is to prevent an exacerbation of symptoms. But when we shy away from treatment because of our discomfort and not the pts needs, we do not help and sometimes harm the pt. In my experience, we have given haldol 5 mg for 24 hours (240 mg total). The pt did not need intubated, he needed meds for his acute psychosis. (and was extremely pleasant when his psychosis passed) Or my last ETOH that needed and got Ativan 4mg every 20 to 30 minutes for a couple of hours before she calmed down, again not intubated. Or one that just got a shot of whiskey every couple of hours or a beer or two with meals. What is frightening is the amount of alcohol that people can drink and still function. Sometimes you have to try and not match it but come a lot closer than you think with meds.

[monkey205]

I remember working ICU and one of my patients had esophageal varies. MD standing order was to transfuse PT every time H&H dropped under his orders. I transfused her twice and when she needed third time I called MD to come in now as he was to do Blakemore procedure in am - he refused, stating to just keep transfusing her. Mind you, every time they got blood, they vomited - I called my supervisor, the residents and covering MDs, nobody would do anything. The patient wound up coding and passing away at change of shift - MD finally came in during code but too late. I gave my notice that day! One of my worst memories ever!

[TriciaCorn, MSN]

I know right!! Paradoxical reactions are rare, but when they happen it can be a real mind twister!

[TriciaCorn, MSN]

Wow, I can certainly understand how that would be a real career changer. Unbelievable situation to go through and I am sure that your respect for those that you worked suffered as well. It makes it so hard to trust them the next time something goes wrong. Glad you have moved on!!!