Verbal order-Denied by resident

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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 µg/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!!!

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How would you handle being accused and written up for allegedly hanging a propofol drip on a patient s/p intubation without an order when the resident hands you a primed bottle and says 'here ya go it's all ready for ya', in front of RT and with a verbalized clarification of start dose ??

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When you realized there was no order did you call the MD to get an order put in? Or could you put it in as a verbal? Yes, you were wrong if you just hung it with no attempt to get an order or put on in. How was the next shift to know that you had a verbal?

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This all transpired in 20 min, I was charting the RSI events and expected resident to enter detailed gtt titration orders. I was interrupted to talk to my director about the accusations that clearly are him covering his ass from the attending disapproval

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I read it and you are still wrong. Attending wanted versed. Not propofol. Resident got the prop ready. As an icu nurse, I would have been upset getting that whole mess dumped in my lap expecting me too go off your report. I would have called the attending or resident to get orders. I'm sure they would have went off knowing you hung propofol while versed was wanted. What thecattebding wants trumps any resident.

It doesn't matter that you had 3 other patients. Clarification on current orders needed to bectahen care of. Especially since you got conflicting orders.

I know when you have a patient that needs sedated at that moment, it's a pain, but you had different things thrown at you and you took what was easy and right in front of you.

Anytime you put Levo on a patient, it's not a good thing. I will say you fentanyl needed to be started before propofol. Treat pain before sedation.

And, I could understand if that patient was going to be under care for another hour or so. But you left the ER and dropped this whole mess on the icu with no orders or clarification of orders and wanted to wipe your hands clean of it.

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I transferred the patient to the trauma nurse.. I was assigned to basic er pts... the critical pts go to a designated area.. and he attending knew we were starting the propofol.. we talked about bridging and yes the Fent was necessary I agree... the pt was decompensating . I feel like I was he only RN and we were bagging the pt and restraining him that the propofol was needed to calm him down safely:(

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Side note : I mention noting about ICU.. this is all in the ER with my colleagues...

And I do appreciate the comments and opinions...thank you ..

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Specializes in Critical Care.

That's a weird situation all around. Personally, if the resident had hand delivered me the propofol and then was claiming there's no reason to think it was ordered, I go get the pyxis medication history of the propofol and ask why it says he removed propofol for this patient if it wasn't to be used.

From reading your post, I'm not really clear what the final sedation/analgesia plan was supposed to be, and you're correct that propofol has no analgesic effects. If the patient requires a wiff of BP support when properly sedated then that's how it goes, pain and/or panic is not an acceptable pressor.

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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...

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

So this is confusing. Are you sure the attending wasn't still stuck on the versed/fent idea after the adequate blood pressure was obtained? Did she change her mind again after she said she'd rather use versed/fentanyl?

About the only thing you can do is write both of them up using the incident reporting system, including the fact that they both "denied having ordered the medication after the propofol gtt was initiated." And I wouldn't care if I got pulled away from the bedside to get reamed out about this, I would still enter the VO into the EMR, if indeed it was given and not just assumed. This kind of game-playing is what makes it very tempting to not do anything they say until there is an order in the EMR, critical situation or not. Rock and hard place.

But it kind of sounds like there is some misunderstanding here.

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The final sedation was suppose to be bridged over to versed and fentanyl..I didn't want to bag an agitated pt across the hall who, in my opinion, should have never left isolation for r/o TB. But I only did what I thought was in the best interest of the patient with the tools I had in that moment .. the prop onset time is quicker then fent and the pt was struggling as we were too, in protecting him from self extubation... and subsequently exposing everyone.... and then respiratory arrest followed by reintubation and a real incident report that would be legitimate for poor prioritization, pt safety and questionable thought processes.. ..what I don't get is why the receiving nurse didn't follow through with the written orders that were actually in the computer..her response is ...'because we always use propofol so I didn't even look at the orders' ... after I told her at bedside the changes discussed with attending ... 1-1hr 15 min went by and she hadn't looked at the orders .. only titrated up on the prop to 40 and the pt became hypotensive so she alerted MDs and then they freaked out ...

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I did enter it as a late entry and charted the time it was initiated ...

the attending quote was " stop sx he pt so we can get an accurate bp before the propofol.. I didn't mind getting pulled away I'm just so shocked hat if this is how the resident is going to start off his medical practice ... then I don't want to work with him

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Got the print out from the Pyxis btw :)

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