Saturday, May 08, 2010

Dirty Little Secrets of Nursing, Part One: Wasting it in the tubing.

Dude was 330 if he was an ounce, and not all of it was fat. Chita had been wrestling with him for an hour, during which he'd broken two sets of restraints and cold-cocked a respiratory therapist, sending him spinning into the wall.

An agitated, violent patient with vascular dementia is no fun, even if they're not big enough to hurt you. Somebody big enough to hurt you, as this guy was, can break your bones or his own without even realizing it.

Something had to be done. Chita left three of us holding down his arms and legs (I drew the short straw and ended up riding his shins like they were a bucking bronco) while she called the doc. She came back with an order for half a milligram of Ativan IV.

Half a milligram of Ativan will put *me* down, but will do buck-shit-nothing for a patient his size, strength, and craziness. I got the job of retrieving the drug and administering it.

Ativan comes in two-milligram-to-a-cc ampules, and is thick. It's viscous. It's surprisingly hard to push IV, even with fluids going.

It's also, as it turns out, quite difficult to measure accurately when all you have is a ten-cc syringe and the patient it's intended for is screaming and cursing and punching.

"Chita...." I said, not sure of how to phrase it, "uh...that Ativan? I think I measured it wrong."

Chita began to laugh. She doubled over, giggling, then gave me a high-five. "Dear," she said, "We call that wasting it in the tubing."

Everybody does it. Nobody will admit it. People will probably howl now that I've said it out loud: that clinical judgement, exercised by the RN, sometimes means that gosh, it's awfully hard to cut that Valium in half. Y'know, sometimes the whole damn thing just...dissolves in the water before you can rescue it.

It's like my friend James The Towering Inferno said once, "I gave him two Vicodin at midnight-thirty, for boredom."

Let's be straight: I'm not talking about administering rogue medications for the purpose of killing a patient (though a disheartening number of nurses seem to do that, these days). I'm not talking about giving paralytics to patients who aren't vented. Nor am I suggesting that nurses routinely give larger-than-ordered doses of medicines to patients in order to keep them quiet (although I have seen that happen myself, and have gotten into scrums over it with the nurse in question).

Sometimes, though, it really is the better part of valor to knock somebody down for ten minutes or a couple of hours. I've had doctors tell me plainly to give "a generous milligram" of something prior to a procedure, or heard them say, "Half a milligram, one, two--use your best judgement. I'll write to cover it."

Is it ethical? Only if you're more of an ethics contortionist than I am. Is it practical? Sometimes, yes: if a patient is violent or so anxious that they're having trouble, say, breathing, then a generous milligram of something can be useful. Is it widespread? Hell, yeah. Do we admit to it? Hell, no. Is it safe? There's a question, for sure.

The only--*only*--time I'll "waste in the tubing" or "forget to halve a pill" is if the patient has multiple good IV accesses, is truly in extremis, and I know that the dose I'm administering will, in the end, be safer than the dose ordered. If the person doesn't have an IV, or I don't know their tolerance, it's down-the-line, by-the-book time, and I'll use non-drug methods to deal with whatever problem they have. Safety first means it's easier to put ice on my black eye than it is to bag the guy who gave it to me.

I've overdosed patients three times: twice, the patient was being violent. This last was the second of the two violent people; the first bit a tech quite badly and kicked me in the gut. Once, the patient was so anxious, so freaked-out, that nothing would touch her except ten milligrams of Valium. Each time it worked, and each time I felt like I was doing something really, really bad.

Even so, we do it all the time. A patient reports a pain level that, according to orders, justifies one Lortab, but we give him two, because we know it'll work better and longer than just one. A patient has a particular sort of headache with which we're familliar, and we give Fioricet rather than Lortab, because experience has taught us it'll work better, even though Fioricet is ordered as a secondary if Lortab doesn't work. We crank oxygen up a bit (oxygen is a drug, remember) in order to calm the patient who swears she can't breathe. We give a tiny bit extra Dilaudid to the person who's got chronic pain and who takes massive drugs to control it.

It's one of nursing's dirty little secrets. Done right, it can be beneficial to the patient and safer than the alternative. Done wrong, it ends up a story on this blog and a black mark on my record after I yell at another nurse for obtunding a patient.

Don't tell anybody, but sometimes we waste in the tubing. It's our little secret.

22 comments:

me said...

BTDT.

Haldol, Diprivan (Propofol), Ativan, MSo4 for air hunger...

SO hard to measure those accurately sometimes...

nurseXY said...

There is much more gray area in nursing than I supposed as an outsider.

0.5mg for a violent 150kg patient? May as well waved the vial under his nose...

Maha said...

Great post! In my experience I've found that some patients just respond better to a particular dose that the doctor may not be willing to order just because they maybe new. I find this especially true for the cancer patients who are used to taking a HUGE amount of narcotic pain relievers at home - 0.5 mg IV dilaudid will NOT touch them. It usually ends up being 'wasted' in the tube and my fellow nurses and I will cosign the 'waste'. Like you said, I would never EVER teach that to a nursing student because judgment, caution and experience all play a role in 'wasting in the tube'.

Anonymous said...

Oh my Jo, you are a brave girl.

Stella said...

I have heard it called a "nursing dose" or "wasting it in the patient".

I once got report from a green nurse who had a WILD and CONFUSED patient. She is telling me he is ordered 0.25mg ativan q4hrs. I jokinging commented regarding a healthy dose. She looked at me and stated in her best holier than thou look, "I NEVER give nursing doses". I asked her how long she had been a nurse. Her answer 6 months...my reply, "you will..."

'Drea said...

I love the phrase *ethics contortionist...*

messymimi said...

When the alternative is he will hurt more people, and not get the help he needs, you are doing right.

I hope the respiratory guy is okay.

Da Blog said...

haha, great post. At work we call it the 'Debbie Dose', after a long time no nonsense nurse here.

While one of the neurologist attendings was doing an EEG on a patient, she ordered a total 3mg Ativan over about 10 minutes. He was sleeping, but by no means in danger of arresting. An order given of 0.5mg for a very agitated pt just makes me sigh.

Rachedy said...

Oh, all those times somebody bumped my arm and the entire 2mg went in? You mean that wasn't an accident?

Heidi said...

Ha. We've got a particularly wild patient right now for whom they keep ordering 0.5 mg Ativan PO. Yeah, PO. It's working reeeeal well.

Albinoblackbear said...

Ahhh! I'd never heard it called "wasting it in the tubing" before. Brilliant.

The last time I did that was with a CP patient who had pancreatitis and was unable to communicate her extreme pain (except in her vital signs and lab work). The MD was ordering pussy doses for what many refer to as 'the most painful medical condition one can have'. And I cannot handle watching people writhe in pain.

I always feel guilty after doing this an inevitably tell the doc or ask for the order (of something I've already done).

After working in acute psyche I was always amazed at what wee doses ER docs gave to psyche patients who presented bouncing off the walls.
Whenever I got those sub-therapeutic amounts I'd just say "how about I make him a cup of chamomile tea instead?"

:P

Great post.

A NURSE said...

Hahahaha! Ya,you are right - I am howling right now because I NEVER give generous doses....! ;)
Many times, with a patient obviously writhing in true discomfort I have actually said to the doc....WHAT? ONLY 50 mg of Demerol? Are you nuts? That'll NEVER work. We HAVE to give at LEAST 100.....and then he/she writes the order. Not as fun, but just as effective. :)

A NURSE said...

Problem with "oopsing" the med is, MDs start thinking that the low dose actually works....when in fact they don't.... ;)

Anonymous said...

Back in my school days in the mid 70's, scopolamine already was pretty much passe for ladies in labor. It often caused horrible agitation and delirium, in addition to amnesia and sedation it was ordered for. One doctor continued to order it in large doses. The old timers in L&D told the students working that "we will give half of what is ordered." I never saw the silence broken.

Penny said...

Friend K, on one occasion, pretended she had gotten an order from the physician for some kind of really hellishly strong yet very short acting sedative so that she could coax a hellishly claustrophobic pt into the MRI. (Dear Dr. Dumbass, Your patient was a POW in Vietnam. You didn't think that maybe he might have some issues with small, noisy spaces? Really?) She drew sterile saline into a syringe and right before popping it into the pt's IV, told him he would very quickly nod off, yet he would be perfectly alert within just minutes. This made life way nicer for the pt, and also did not require a lengthy pause while waiting to hear back from the pt's doctor, which would have completely shafted the schedule of the MRI center, not to mention the schedules of the many, many other pts in the waiting room.

Knocked him out like a brick to the head. As soon as she got him out of the MRI, he was alert and calm.

Ethical? *shrug* Got no problem with it, personally.

Anonymous said...

I am fortunate to work with some experienced intensivists who often leave it up to the nurses judgement..we ask for ativan and they let us dose as needed....I could never work in a teaching facility...; I feel for all of you who do!

Anonymous said...

I am fortunate to work with some experienced intensivists who often leave it up to the nurses judgement..we ask for ativan and they let us dose as needed....I could never work in a teaching facility...; I feel for all of you who do!

newbienurse said...

Bit of an eye opener at first when you a new nurse fresh out of the idealistic nursing schools! I remember as a student seeing my patient unexpectedly die, he was in alot of distress, having a panic attack as he died. It was all over in a matter of minutes but I remember afterwards thinking about a nurse who gave him some subcut morphine during the ordeal. I am pretty sure he didn't have subcut morphine charted so it was a bit of a shock to see a nurse give it. All the rules about medications but at the end of the day I guess the nurse was trying to make his last moments a little bit more peaceful. Rules need to be bent sometimes

Anonymous said...

you could always add Haldol and Benadryl to that Ativan... they may sleep the entire day and part of the next ha.........

Anonymous said...

I had a cancer patient who I gave 2 mg of IV ativan to, when the ordered dose was 1 mg IV. The family had stated that the patient was agitated and had asked for something that would help her be less restless. A few hours later, a family member told me again that the patient was restless and asked whether she could have something again, so I gave her the prn morphine that was on her profile. The lady ended up dying the next morning, and I felt horrible for not monitoring her respirations well enough and still beat myself up about it to this day. The doctors had spoken about placing her on hospice that day depending on what her labs looked like. I had no intentions of harming the patient, and was trying to make her more comfortable, but I constantly worry whether I should have avoided the nursing dose of ativan.

Jo said...

Hey, Anon. . .

Yours is a tough situation. You gave somebody more meds than were ordered, then she died.

Please remember that correllation is not causality. It's possible--even probable--that she would've died fairly soon anyhow. Nursing ethics stress that there is no reason to withhold pain medication from a dying person, even if the administration of that medication hastens death. So, if you look at it from that angle, there's no guilt for you.

I'd also consider what may have happened after you passed her care on to another nurse. Did she get more morphine? More lorazepam?

It sounds like your problem with the whole situation is your lack of assessment after you gave her morphine. That was a mistake, but it's not one you have to repeat. Keep it in mind, learn from the experience, and quit beating yourself up.

We all do things we wonder about--nurses, doctors, electricians, traffic cops. The best we can do is take our lessons from our possible or actual screw-ups and keep on going.

*Personally,* I'm okay with what you did, given what you've told me. You are, of course, the only one who knows all the details of the situation. Formal nursing ethics-wise, I don't know how things would pan out, but I doubt anybody would focus on drugs used to calm pain and agitation.

Jo said...

Anonyboo, email me. johannebertha at gmail etcetera, if you would. Kisses.