Wednesday morning I came into work and took report on a patient in airborne isolation r/o TB, a laundry list of co-morbidities, mild respiratory distress, vitals not to bad in the moment but I'm sure you can see where this is going.... yup straight to RSI hell with a chaotic attending and a hot shot resident.Long story short, as the RT was preparing her equipment, I was preparing mine, setting my monitor parameters, etc, etc. The resident walks in to the room with a spiked and primed bottle of propofol and clearly says 'here ya go, it's already for you', and hangs it on an IV pole. I clarify the starting dose with him and he gives me a verbal order for 30 Âµg/kg/min. Attending walks in the room. Then I clarify what RSI drugs he wants; 20mg Etomidate and 120mg of succ.Fast forward, the patient is intubated, Sp02 is crap, abg is crap, blood pressure has been crap prior to me assuming care but the current trend for 2 hours has been adequate with resuscitation efforts, pt is waking up within seconds post securing the tube, RT is suctioning and simultaneously, I pipe up and start a conversation about starting the propofol at a lower dose than the resident had ordered and adding an analgesic, fentanyl, to accommodate propofol (which as we all know propofol has hypotensive side effects and no analgesic properties). My rationale being that I can keep the prop at a fairly low rate, keep the blood pressure adequate and the patient can be more comfortable and less likely to wake up with PTSD.Attending shuts my idea down and states that propofol has analgesic properties and she'd rather use Versed and fentanyl bc versed does not have a profound effect on blood pressure as propofol... lol...wait it gets better...so keep in mind that now is not the time to educate a physician and what not because the patient is fighting the vent and circling the drain respiratory wise and I've got to move this patient out of isolation and into the Critical Care area of the ER; according to infectious disease it's OK to do that because now the patient is a 'closed circuit' ... I know I know ... ***, right. Back to RT suctioning... The attending requests her to stop suctioning so we can cycle blood pressure and get an accurate reading before we start the propofol bc this man needs sedation now and we need him calm and I have the propofol hanging in front of me, and a verbal order from the resident and a discussion with the attending about changing sedation gtts and it's obviously not in the best interest to leave the pt put in an order for a titration gtt that I didn't even get details for or wait for the doc to do it and then call pharmacy and have them validate it so I can get it out and blah blah blah...So the nurse I give bedside report (who should be helping me bc she has no pts) to can bridge the gtt to the new sedation orders. in my mind this keeps the patient safe and the tube is less likely to come out, exposing the dept, plus I have 3 other neglected patients ...I need to hand off this one and now ... so b/p is 125/88, sp02 is 86%, attending sees the b/p and walks out. The understanding is that this is an adequate blood pressure to start the propofol, so I start the propofol at 10 mcg/kg/min instead of 30; I followed pharm protocol bc frankly 30 is to much to start with this guy...anyway I titrate by 5mcg q 5 to 20mcg and everyone is ready in the assigned area, patients is chill, last bp is 110/70-ish and we go, fentanyl is overridable in the pyxis, versed is not ..let's get that fent going ... and hand off is complete.Now I'm charting and the charge tell me to save it and come talk to him now.. I comply, the director is there waiting .. the conversation starts with, 'did you hang propofol without an order?' 2 docs say you did and there are writing you up bc the pt decompensated and is now on 5 mcg of levophed, (5 people!!!)and the prop is still hanging and now at 40!!! Resident dictates he never gave any orders for propofol... when I asked the nurse that took over for me how long it took her to bridge him off the propofol, she said she didn't because propofol is used so often that she didn't bother looking at the orders and just continued to use it...Resident is lying!!!! And I'm blown away at all of it!!!Bring on the question and comments please!!!