thoughts on only Paralytic while intubated....

MassED, BSN, RN · Aug 5, 2008

I have seen this done twice, on patients with enough multiple chemicals on board PTA that further sedating them became a nasty game of chase the BP vs. sufficient sedation to not fight the vent.
I'm not defending the practice.

that's a good point, and possibly what this doc was operating with.... though his BP was around 190/120 most of the time... perhaps the ER doc wanted the intensivist to sort it out without adding too much....

MassED, BSN, RN · Aug 5, 2008

NEVER NEVER NEVER give a paralytic without sedation FIRST!!!! EVER! That's a cardinal rule.
In my 8 years in the ED, I've never given any paralytic without sedation first. As a nurse, this is something you flat out refuse to do and you raise a big stink if any doc wants you to.
There are times when you're struggling to keep the BP up, and you may have to try some different things to maintain the BP and keep them sedated, but there's always something that works.
As far as documenting that you notified the doc or were refused orders for sedation, that's not really going to save yourself either, because in a court, the first thing the lawyer would be asking you is why you didn't go up the chain of command and be an advocate for your patient, knowing how cruel administering a paralytic without sedation is....ALWAYS involve your charge/supervisor in this situation...

the charge nurse was the one who went and got the doc the first time, when I couldn't leave the room to get the doc. So I'm getting the impression that is all he was willing to provide to her at the time also.

MassED, BSN, RN · Aug 5, 2008

This is a pretty serious problem. If a patient was awake during this experience and found out that they were paralyzed without sedation or analgesia, they would have a very good civil case against the hospital or providers involved.
There are special situations where giving a paralytic without sedation or analgesia is indicated. For example, if you are attempting to intubate a crash airway and encounter problems such as trismus, you can give a bolus of sux without sedation. Remember, a crash airway is defined as an unresponsive patient who is near death. This is not your typical RSI scenario. Nor does this apply to the patient who is already intubated.

I do not know exactly as he presented to the ER. Was he breathing at all? Was he cyanotic? How about arrival VS - NOTHING documented!!!!!!!!!!!!!! The EMS notes were not painting a good picture and when I arrived into the room, assuming care of this poor guy, the papers weren't filled out (the trauma sheet) and that nurse had GONE HOME. THe one who gave me "report" (if you would call it that) had nothing to say but "he's a John Doe, came in unresponsive, found on floor at home by boyfriend." So exactly how he presented to the ER doc, I don't know, just prior to the doc intubating him... grrrrr - makes me mad that there was such a lack of clinical care between nurses. I didn't get any clear picture on the ER docs dictation either...

God forbid a nurse pop in and help with this particular case. Not to mention, my assignment was switched so when I came to this particular side, the nurse who covered (while the primary nurse ducked out) and gave me a mini report was the one who switched and put my name assigned to this guy - I was taking on HER ASSIGNMENT. Not that I mind caring for the sickest patient, but it was a crappy thing to do to take it upon herself to switch, then not to assist in any way or even provide some semblance of a report to me. She was THERE, I came from another section of the ER and was ambushed.... BUT - I learned a lot by taking care of this guy.

MassED, BSN, RN · Aug 5, 2008

I am so sorry to hear that this happened to a patient. I am a nursing student and from a patient standpoint this is not ethical. Patients that are intubated are highly anxious, probably unable to breathe, and paranoid something is going to happen. There is a lot I need to learn and understand about nursing, and what to do in this situation.

this was a learning moment for me as well.

MAISY, RN-ER, BSN, RN · Aug 5, 2008

If someone is tubed in our ER, it's almost always succs and etomidate. Then, ativan and propofol drip....if our anesthesia intubates it will be propofol push and then drip. It just depends....no one would ever be intubated or remain that way with a paralytic....we titrate to effect. I truly believe it's inhumane to have anyone aware while unable to breathe for themselves!

I can't even imagine! I can't stand waking up with my face buried in a pillow gasping for air, depending on a machine or bagger...HORRIFYING!

Woody, thanks for your insight....so sorry you had that happen to you!

Maisy

MassED, BSN, RN · Aug 5, 2008

Honestly OP, it sounds like the physician was punishing the patient for using drugs. It's an awful thing but I've unfortunately seen it happen a few times.

or... perhaps when he saw the urine tox that he felt like providing additional meds would worsen his condition? Beyond the paralytics?? The docs documentation didn't have anything in there regarding any of this... I read over it before I left.

TiredMD · Aug 5, 2008

This is the kind of crap that makes me want to quit clinical medicine and work full-time as an expert plaintiff's witness.

GilaRRT · Aug 5, 2008

or... perhaps when he saw the urine tox that he felt like providing additional meds would worsen his condition? Beyond the paralytics?? The docs documentation didn't have anything in there regarding any of this... I read over it before I left.

I am not sure why he would want to use that excuse. We have analgesic medications that will not alter hemodynamics. Fentanyl, for example. In addition, medications such as ketamine could also be considered. Or, we could use fentanyl and perhaps careful doses of midazolam while watching the hemodynamic status. In addition, pressors could be added if we need to use higher doses of diprivan. Several options exist.

The punishment point is something to consider. However, if we do something harmful to our patient, then we have to deal with the law. I guess you could argue that no harm would come from this act; however, I look at it like this: Even if you are a heartless bast***, you should be able to realize that pain alone can be physiologically harmful in addition to any psychological issues. Instrumentation of the airway, intubation, and mechanical ventilation can be very painful. Remember, positive pressure ventilation works exactly opposite to normal physiologic respiration. If we are in pain, our sympathetic nervous system is highly active. This will cause increased heart rate, increased myocardial oxygen consumption and demand, and increased tissue oxygen demand. Not something you want to occur with a critically ill patient. Remember, if we have to intubate somebody in the ER, they are most likely critical.

I always remember the first time I intubated in the OR. The anesthesiologist had me review the BIS monitor printout after we finished the case. The intubation actually "stimulated" the patient more than performing the surgical incision.

back2bRN · Aug 5, 2008

I am reminded of a story a colleague told me while I was working in the OR. She had a procedure in the facility where she worked as an OR RN. She was paralysed first, tubed and then sedated. She told me it was the worst experience she had ever had. The fear of not being able to breathe coupled with the knowledge of what was going to happen next and hope that they wouldn't forget to sedate her. Needless to say, I would do my level best to sedate my pt. Going up the chain as needed plus documenting exact quotes. There is no reason to be barbaric. I work ER now and out P&P is to sedate and then paralyse.

MassED, BSN, RN · Aug 5, 2008

I am reminded of a story a colleague told me while I was working in the OR. She had a procedure in the facility where she worked as an OR RN. She was paralysed first, tubed and then sedated. She told me it was the worst experience she had ever had. The fear of not being able to breathe coupled with the knowledge of what was going to happen next and hope that they wouldn't forget to sedate her. Needless to say, I would do my level best to sedate my pt. Going up the chain as needed plus documenting exact quotes. There is no reason to be barbaric. I work ER now and out P&P is to sedate and then paralyse.

I had never experienced working with any doc in the ER who has only paralyzed - prior to this doc.

Vito Andolini · Aug 10, 2008

I agree with everyone else - how cruel! I often find that docs will only order sedation for vented patients; at times, I have to ask them for a paralytic. But I've never had it the other way around. Of course, in the ED your main focus is to stabalize the patient and get them up to ICU ASAP. You usually don't have the time play around with titrating optimal sedation settings, but to not even attempt to GIVE sedation? That's awful.
You should see if there's a P&P regarding this issue. I would have charted "Pt appears uncomfortable, biting ETT, movement noted. Writer notified Dr. Jones regarding pt's appearance and need for sedation; no orders received from Dr. Jones."

I don't want to insult you but the writing is useless. Also, it could be used against all of you and the hospital legally. You yourself can see that it is useless, as it did nothing to get the patient sedation.

What is really needed is to go over the doc's head to the Chief of Service. Now. When this is happening. The doctor is ignorant or cruel or inexperienced and scared. The doctor needs education and direction. Now. The patient is suffering now.

The OP needs to involve the ER Nursing Director, Medical Director, Ethics Committee, Risk Management, Administrators, everyone she can think of to stop this cruel practice at once.

yiyayiya · Mar 20, 2012

I am just wondering how common and cruel the practice is of using only paralytics while a person is intubated in the ER. I took care of a guy last night that we gave Norcuron 10 mg which wore off in 30 minutes each time... and the doc never ordered anything else, despite my asking.... they don't use Diprivan where I work, which I find odd... only in the units.
So, my question being... how common do ER nurses see this occur? Wouldn't this make for a horror story for the patient, once extubated, being paralyzed and aware??? Yikes... my poor guy. I kept talking to him - I saw tears... really made me mad.

Doesnt surprise me. The medical profession regularily make mistakes or have a total disregard for patients if it suits their ends (financial, ease of doing their job, etc) That is why I will never go to a doctor / hospital unless I am unable to prevent it and even then I have an extensive AD in effect. I make sure I know what these people do to me.