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.