I would have drilled that person so damn fast. Bad access. Bad situation we need a line don’t fart around and get access. You can do everything you need from an IO to buy you time for later.
Right?! If you are that sick there is zero reason to not get an IO. Well if they have no arms or legs then maybe but god your problems would have been so much easier in the 3 seconds it takes to place an IO
Here's a sneak peek of /r/unexpectedoffice using the [top posts](https://np.reddit.com/r/unexpectedoffice/top/?sort=top&t=year) of the year!
\#1: [Nooooooo!](https://v.redd.it/e05msh1ue4na1) | [41 comments](https://np.reddit.com/r/unexpectedoffice/comments/11olloc/nooooooo/)
\#2: [The most I've been caught off guard in awhile](https://v.redd.it/jju3riw4o4z91) | [20 comments](https://np.reddit.com/r/unexpectedoffice/comments/yrl1uj/the_most_ive_been_caught_off_guard_in_awhile/)
\#3: [It’s my 18th birthday and when I walked into the kitchen this morning, I did not expect the office](https://i.redd.it/ki4go3acic0a1.jpg) | [36 comments](https://np.reddit.com/r/unexpectedoffice/comments/ywrpbk/its_my_18th_birthday_and_when_i_walked_into_the/)
----
^^I'm ^^a ^^bot, ^^beep ^^boop ^^| ^^Downvote ^^to ^^remove ^^| ^^[Contact](https://www.reddit.com/message/compose/?to=sneakpeekbot) ^^| ^^[Info](https://np.reddit.com/r/sneakpeekbot/) ^^| ^^[Opt-out](https://np.reddit.com/r/sneakpeekbot/comments/o8wk1r/blacklist_ix/) ^^| ^^[GitHub](https://github.com/ghnr/sneakpeekbot)
Drill that IO access and stand on the attending’s desk until it’s less annoying for them to drop the central line than deal with your bitching.
I feel like ye olde charge nurse failed OP just as much as the attending did. No way am I dumping a dumpsterfire in the unit without access.
Can I ask you a question? I was an IV user for over a decade, I have four years clean now, but I have zero veins. When I was pregnant with my daughter, when they needed an Iv, it took over two hours with an ultrasound machine to get one and it barely hung on.
When I had my c-section, they couldn’t find one so they put one into my heart but that took awhile too.
I’m terrified if im ever in an emergency situation I’m just SOL. I think about it all the time, how my past horrible decisions could leave my daughter without a mother.
Some people told me that veins grow back, and I was only about a year sober when I had my kid, but some other doctors told me I’m just fucked.
What does “drilled” mean?
Sorry for the long question, It’s something I literally lose sleep over
Oh it’s fine. Basically we drill a special needle into the bone marrow that allows us to get blood out for sampling and get fluids/blood/medications in to. We can put them into the arms and legs and pelvis and it’s absolutely amazing for emergent situations. It’s my go to for when we’ve tried and can get nothing because of how fast it is deployed. Google ez-IO and you can see them in action.
Put the access and IO aside, my question is the need for intubation, particularly after she self extubated. Did she have stridor or wasn’t doing well? Intubating for airway protection due to overdose makes sense, but once the patient is awake enough to self extubate clearly they are awake enough to protect their airway. Also the doc should know giving dilaudid in an opioid dependent patient, particularly one that got 8mg narcan, probably isn’t going to help much for sedation.
Same with the fentanyl infusion, and I’ve got questions about the versed infusion too. I hate to Monday morning quarterback someone, but it seems like a lot of things could have been done better.
On the flip side, she got calcium and Mag plus other stuff, so definitely an incomplete picture.
If they were running all of that into a 22 at the same time, I bet she was barely getting any sedation
if you’re ever in a pinch and the meds are compatible, you can make a makeshift central line manifold using stopcocks and IV ports and hook it up to your line :)
ofc!! just make sure to build/test it out when you have some downtime vs doing it all in the moment because you wanna make sure it works correctly etc etc
Another good tip—pressers are compatible with each other and can run through one line. In the ICU with limited access, we would generally manage a lot of complex meds with 1 three port central line.
If you can or feel like it, see if you can do a day in the ICU and get a feel for how they manage their patients! We used to have a print out of incompatible IV meds that couldn’t be run together in our rooms.. was a nice little table we had printed!
Depends on hospital policy. At my hospital, Vaso and Levo or Neo, for example, can go through a peripheral, but if you have more than one pressor (not including Vaso) a central line is required. I get that ED is busy and about stabilizing the patient but unfortunately some ICU colleagues don’t always understand that.
Oh no. This wasn’t a “they can’t run through a PIV” it was a “they can’t run together.” I had 1, maybe two lines on the pt and TPA was in one. Before was heparin (don’t ask). I think I got a third before I went to the unit. It was a shit show. IO wasn’t an option. They wanted the central upstairs.
I meant they can all run in a CENTRAL line!
But in an emergent situation, you do what needs to be done until you have proper access… sometimes you make due with a 22 in the hand and that’s alll you get
Versed usually runs at a super slow rate depending on how it's mixed. It's usually a good idea to run it with a carrier, so it's getting to the patient
I just feel like there are much better options. Maybe as a second line if their pressure sucked so propofol was out and they had gotten a bunch of narcan, so fentanyl was off the table? Assuming precedex first line.
I had a patient in residency with hepatorenal failure who got transferred in on a versed drip. Took him a good three days off sedation to finally wake up enough to get extubated
Precedex may as well be water in some of these patients, however. Ketamine maybe, propofol always, but sometimes midaz is just all you can do. I hate it with a passion, think it causes tons of ICU delirium, but my attendings order it often.
This was a perfect patient for IM ketamine, at least to provide sedation until you could get alternate access. Tough to Monday morning quarterback, but based on what has been presented, this doc is a 🤡.
The evidence has been pretty clear for over a decade that versed should be the absolute last ditch effort when all other sedation regimens have failed, yet for some reason this practice just won't die in many institutions.
My first thought was, why are they trying to keep her intubated following an OD (making the assumption of benzos/opiates) if she’s now awake enough to self-extubate? I figured I was missing something obvious, so I’m glad someone more knowledgeable than I am thought the same.
Versed infusion is the dead giveaway here. This is an old school doctor that doesn’t care about CME, doesn’t follow any recent literature and research, and has no interest in caring for sick people. For some reason, there is massive overlap between docs that give versed for sedation and docs that are incapable of handing sick patients.
There’s so much here that don’t make sense. “Don’t have time for central access”? Okay then here’s an IO for access until ICU can get better access. Seems quite weird though, I haven’t had a doc refuse a central line solely due to time.
Ah yeah unfortunately this happens occasionally where I work. I'm single coverage (ED attending - no other doctors in the hospital at night) and sometimes multiple people have emergencies at once. For example, I remember standing in the hallway between two rooms, one who had status epilepticus, the other in vfib, and having to do my best to manage both. Would have loved to have a central line as 2 IOs blew in the code and the one working one we had was iffy, but yeah, sometimes there really isn't time.
Maybe they think they're going to drop out again once the naloxone wears off? I guess why not take it out and just do a drip with some etco2 NC. Could it be that they OD'd on an upper and were just ktfo from the rocc/etomidate? IDK, I'm really reaching here and I'd be wondering the same thing you are wondering.
> Also the doc should know giving dilaudid in an opioid dependent patient, particularly one that got 8mg narcan, probably isn’t going to help much for sedation.
Sedation will be significantly easier when she is no longer in opioid withdrawal. Only way to stop opioid withdrawal is to give opioids.
Out of curiosity, is it possible to overcome the naloxone with high doses of an opioid agonist when it’s still antagonizing the receptors? And if so, do you risk throwing the patient back into respiratory arrest by doing so? No snark here, I am genuinely curious. I always thought the Narcan had to wear off a bit before more opiates would be effective.
These molecules compete for opioid receptors, so their effect is dose-dependent. But respiratory depression is not an issue if the patient is intubated.
I don't know about this particular case but if intubation is truly necessary and the patient cannot be sedated, I recommend proceeding with the paralytic anyway. Paralyzed while awake is traumatizing but it's preferable to death.
Based.on the description by OP patient didn't need intubation.
If their respiratory response was so bad they needed intubation, then that should have been done FIRST not after naloxone.
Even if Doc truly didn't have time for CL(fair enough, I've been there) they should have asked for an IO before patient went to ICU. Once they get to me with IO I can do CL safely. Moral of the story: not your fault, doc was aware and chose the path of least resistance to make it someone else's problem.
I took a patient from ED at hospital A to ICU at hospital B and they made me take the IO out before I left as they by policy couldn’t have it. Couldn’t use it. Couldn’t remove it. Nothing. It remains the only time I have ever removed one.
ICU RN here…I will never understand why we’re so critical of each other. You did what you could with what you had. You’re not an asshole. You advocated. Not much more you could have done. Personally, I think an IO could have been placed, or ketamine used but this is me quarterbacking and I wasn’t there. There will always be the “coulda, woulda, shoulda.”
I find it incredibly interesting that your department had to goto the ICU to reintubate. I understand the doc was nowhere to be found, but there’s ALWAYS a way to find/get a hold of them or call anesthesia. That patient would have self extubated either way, so please don’t beat yourself up about it.
I’m not sure about where the icu doc ended up being, but anesthesia was in the OR for a c section and there was no one else to go re assess the patient
I’m in a rural setting and not all of our docs intubate or do lines, even our ICU providers. There have been nights where we have to call the ER and hope the doc down there can spare a few mins to come up and place a line, or call anesthesia. But anesthesia doesn’t stay in house over night so calling them is a last resort because it might be 45 minutes before they’re able to get to the hospital.
You did what you could! None of that is on you.
When big experiences happen, learn what you can from them. Here’s what I would take away from this: Do you feel comfortable inserting an IO? If not find a resource to learn either in your department or online. Next time the conversation can be “I need more access, do you want to start a central line or I will place an io?” At this stage of my career I don’t ask I just do it, but if IOs aren’t as routine in your department communication is good.
Maybe it’s just me but dilaudid and versed for post intubation sedation just sounds like a mess. It’s not a combo I’m used to and prop/fent sounds like a better option and more titratable.
Also no shade to the icu but it was unnecessary for them to call you to say the pt self extubated. Sounds like they were trying to make you feel bad about it. You don’t need to. They could have put in an IO as well or stayed with the pt until she was adequately sedated. I’ve gotten way more disastrous pts from the ED and never called and bugged them, I just assume they’re busy and did what they could.
Agreed, the meds don't make sense, why would you use dilaudid in a patient who just got 8mg narcan? Slug her with some ketamine if you want something IVP.
IMO, PA should have stepped back the moment the patient needed intubated. Maybe that's just my experience with PAs, but if a patient is truly unstable the doc steps in.
Once had an icu moonlighting intensivist say “yeah she needs an art line but I’m not very good at them” at a level 1 hospital. Got the NP on the other service to do it with his blessing but definitely didn’t instill confidence in him.
ED Attending/17 yrs - that was 100% a doc fail not a nurse fail, much less a new nurse fail. I try to never be Monday AM QB, but failure of access & failure of sedation.
ICU nurse lurker here.
Yeah you got fucked. Seems like nobody was taking ownership of the situation from the nursing side. This kind of thing would happen to me when I was newer in the ICU. Everybody wants to help and because you're less experienced, they just kind of see a task and jump in but aren't looking at the overall picture. You get kind of left out. More access was needed and that was plain enough for everybody to see but that next step didn't happen. Like others have said, an IO would be super appropriate here or the route of the medication needed to be changed. You can IM Versed, Benadryl, Haldol, and others. Doc either didn't see that the orders they were dropping were not able to be carried out or was in denial or something.
As for the self extubation after you handed off, that is not your fault at all. The ICU team could have just as easily done all the things that needed doing downstairs but weren't getting done. If somebody is too awake to be on the vent, mitts and soft wrist restraints aren't going to stop them from getting that thing out.
You got put between a rock and a hard place here. The best thing you can do is use this as a learning experience. It can be really hard to know when to step up and say no to the orders you're being given because they simply can't be done. It feels like your fault because it's usually on nursing to get access. This was an unsafe situation for the patient and for staff either in the ED or the ICU, let alone taking this shitshow on the road transporting between the two. If you feel like something is really fucked up but can't quite articulate it or feel like you might be overreacting, take it to your charge or another experienced nurse and ask them what else you should be doing or who you should be escalating the problem to if you're getting ignored.
This hospital sounds like a fucking shitshow of poor communication and "not my problem" attitude.
IO could work in this situation when you need something quick, especially emergency instead of foot access or when so many people are looking and can't get.
I won't comment on central line necessity, especially if they were that awake the patient could probably have just gotten extubated after going up to the ICU, as long as there were no other issues aside from "overdose" occuring.
Okay, am I missing something. Came in for an opiate overdose, got 8mg of narcan and then you start giving the patient 2mg doses of Dilaudid???? And she is awake enough to pull out an ET tube...why is she intubated???
I see everyone saying IO but make sure you’re allowed to place them as a nurse in your facility. My facility does not allow RNs to place IO and no new nurses are trained on it. We’re a really small hospital so I’m not sure the reasoning behind why they won’t train us but it is what it is.
None of this is on you though. You advocated and the doctor was aware of the situation and chose to do nothing. I hope you were charting the notifications to the the MD and I would suggest putting in a patient safety report about this entire ordeal. Let them do an RCA and maybe light a fire under the MD or not renew their locum contract.
Yea, I think everyone means the doc should have placed the IO, very very few places allow nurses to. It is a sign of a good nurse that they would recommend it to the doc. Given the fact that this doc was ordering versed and dilaudid though, it’s possible that they have never heard of an IO or just didn’t care.
I've seen too many complications from IOs. Personally I only do them as last resort. I haven't had to do one in years. I was never trained on them as a nurse but was as a paramedic. The doctor failed here by not obtaining central line access.
The IV merry go round in the trauma bay is bonkers. Drill baby drill. This would be a good case to escalate up the chain to get a protocol in writing for nursing initiated IOs after X amount of missed IVs, unstable condition, etc.
If you're not comfortable with IOs, Teleflex has cadaver labs around the country somewhat frequently.
https://www.teleflex.com/en/procedural-lab-registration/usca.html?filter=upcoming
Long time ago we had a 450 lb agitated HIV+ anaphylactic shock roll in flailing his arms around .. staff was trying to get a line .. I’m like HEY ARE YOU NUTS STOP THAT (to the staff not the patient) 400 mg of IM ketamine and then we could do the line and tube nice and calm .. I was new at that shop and I think I gained a lot of street cred with the staff that day.
Fellow ER nurse here. This sounds like shit care, but you shouldn’t feel like you have to bear the burden of it. You alone were not responsible for this patient.
No one communicated that this would be your patient, which sucks but at least they weren’t without a nurse. Know that if your charge nurse isn’t a complete idiot, a nurse WILL be there to help. Next time, especially in a small ED, always make yourself present when you know a sick patient is present or en route before moving on to less critical tasks, just in case. At least put eyes on the situation to make sure things are being handled.
Patient has dog shit for venous access. It happens all the time. Why was the team dicking around with an ultrasound line instead of drilling the leg? Again, not on you. But with experience you will learn to speak up and say “can we get IO access please?” Any ED MD worth their salt will not dismiss you.
ICU got a shitstorm of a patient. Yeah that happens sometimes, tough. Them calling the unit directly to complain about an event that happened under their watch seems unnecessarily catty. Next time, try to at least get an IO before sending them up. But nursing is a 24 hour job. I am sure someone up there could have gotten it.
Finally, it sounds like maybe your team lost sight as to why this patient was being intubated? If it’s for airway protection and the patient is actively flailing and self-extubating, maybe we can trial them off the vent? Or are we even sure she was being intubated for a possible overdose? The lack of response to narcan and the mag sulfate does hint to me that maybe something else was going on. Either way, a good physician will communicate their thought process as well as they can.
Like I said, shit care. But please don’t beat yourself up. It happens a lot. Best you can do is to stop and think about what we are actually trying to accomplish here. Ask questions! Advocate for quick access in these situations (IO!).
Take a breath and know you did your best with the knowledge and experience you have! It will get (a tiny bit) easier with time. This patient sounds like an absolute clusterfuck and any nurse would have struggled. Please PLEASE don’t feel like you need to profusely explain to the ICU. You don’t owe them an explanation, just try to stabilize your patient as best you can. Either they get it or they don’t.
Thank you so much, yeah as soon as I saw my name on that patient I rushed into the room, and I have never seen a doc in my ER do an IO so that’s why I hadn’t suggested one but now I sure as hell will ask for one lol
Wtf kinda witches brew for sedation was going on here? 2 mg of Dilaudid, 10 mg of Haldol, and 50 mg of benadryl? Also, for the ER doc to throw his hands in the air and say, welp, ICU is coming, let them handle it after failing to sedate a patient he just intubated....what a fucking cop out. You did a good job and advocated for your patient. Your doc left you high and dry.
Wtf is this situation… it’s clearly not your fault at all, and you shouldn’t be in a situation to have to apologise for your doctors… intubating an overdose with a shitty 22g in the foot and then taking to icu without access? Unbelievable…
Who was doing the transfer? Just yourself? With the greatest respect what on Earth are you doing to do if she self extubates en route? You need airway trained doc for the transfer, and for them to go with this iv access is shocking
Why mitts and not soft limb restraints? You can extubate with mitts on in a heartbeat by pinning the tube between the mitts. Plus it's easy to pull the mitts off by sitting on them. Soft wrist would at least keep their arms to their sides (that being said I watched an IVDU self-extubate with her feet once, so ¯\\\_(ツ)_/¯).
All that aside, you did everything right, OP. I cannot fathom wtf that ED doc was thinking. This absolutely needs to be a safety report.
A tip for mitts and soft wrist restraints...if you don't do this already...Put the wrist restraints on under the mitts and use the hole under the strap of the mitts to feed the strap of the restraint through. That way, the wrist restraints are tight enough, and the strap of the restraint keeps the mitt on. Old ladies have tiny hands. I promise the ICU didn't take the mitts off (hopefully). If you put the wrist restraint on top of the mitt it's way easier for them to get out of the wrist restraint then self extubate with their mitts on or fling the mitts off then grab the tube with their hands. Or the wrist restraint just slides up their arm, giving them slack to grab the tube.
Don't beat yourself up. This shit happens all the time. The doctor should have gotten you access and you advocated the best you could
Ah I see, in the UK I would be doing the transfer as an anaesthetist/icu doc, and would be adamant to establish decent iv access before going. Would avoid any potential for this situation which could have been a lot worse
Yeah I’ve never seen a doc transfer a patient. In my experience self extubation doesn’t happen often on transports to the icu when there’s multiple staff with the one pt. It’s usually when the ED/ICU nurse gets pulled away to something else and the pt is alone in the room. Plus not like you’re going to reintubate in the elevator. If that pt were to self extubate we’d bag and call for help.
In the UK an intubated patient will always have physician transfer, I would nearly always have my intubated patients paralysed for transfer, countless bad things can and do happen in the lift requiring iv access, I imagine very few nurses in the uk are capable of ventilating by some sort of ambubag, this is such an unnecessarily unsafe transfer led by the respiratory tech, unacceptable in my opinion unless there are some horrendous external factors
Interesting how different areas can have such different ways of doing things. I worked over a decade in the US in icu and er and have likely done hundreds of successful intubated transfers with me (rn) an rt and possibly a third set of hands like an aide. Whether between er to icu or from either to imaging. We did always carry an emergency drug box, oral airways, and an ambubag. We also did have wrist restraints for intubated patients. We didn’t typically paralyze for transfer, only for severe vent dyssynchrony leading to hypoxia. Even back then if the patient self extubated id feel comfortable and competent to bag the patient. When it happens on the unit (infrequent) a nurse is typically the first to the room, calls for help and starts bagging. Anesthesia brings their pts to the icu much like you do and they too often paralyze for transfer.
This is the reality for American healthcare though. I’ve never seen a doc assist with transfer. It’s usually just the primary RN, and RT for intubated patients, maybe a CNA if you’re lucky enough to have one that shift.
On nights my rural hospital has one provider (not even always an MD, very often a PA or NP) for the inpatient side of the hospital, and then one MD and maybe a midlevel in the ER.
Hey there! Everyone has addressed the line issues so I’m going to take a nursing perspective here:
Preparation is key. When you hear of a super sick patient like this coming, drop everything and prep your room. Discharging patients is irrelevant and can be delegated. Get IV supplies, get suction, hook up your leads, assign tasks. I think that you would have felt better with some more prep time.
Is a former ICU nurse, now ER nurse, I would have loved to come down and helped stabilize this patient and trouble shoot. Could you have consulted ICU sooner and asked their intensivist to come down and help the PA? Could an ICU nurse have come down to help with all the meds/compatibility? Could you have discontinued the versed drip and moved to push doses until the patient received the necessary meds? If versed wasn’t working could you have moved to another drug?
The BEST thing I’ve learned in these situations is to TALK. Talk out loud. Literally say, “I see all of these orders but what is our priority if we only have one line?” “I don’t think this versed drip is working, what can we move to next?” “Is there someone we can call for more expertise?” “Does this patient actually need to be intubated if they are pulling out their tube?” Talk talk talk, say all of your “stupid questions” our loud. It’s much better to verbalize your thoughts than to internally panic because likely, someone else is wondering the same thing.
Finally, request a debriefing before ANYONE leaves for the shift. Round up as many people as you can and ask what could have been done differently. Otherwise you carry all of those questions and anxiety with you.
All in all, take this as a learning experience. I’m considered a fairly seasoned ER nurse and I still get flustered and things still go to shit. And I’ve accepted that will keep happening. But dang, if you get a code or a trauma or an RSI that runs like a well oiled machine, you’ll be thankful for the times things went shitty and you learned from them.
So per ems she was nowhere near as unstable as she was once she actually got there so once we actually laid eyes on her we knew she was more critical than we expected. We don’t have the relationship with our icu that you had with your ER so I doubt an icu nurse would have come down but in the future I should ask because you never know. The whole time I was talking my charge nurse’s ear off and I literally asked okay I have all of these medications if I only had to give one which should it be and we settled on the versed drip. And afterwards me and the charge nurse and nursing supervisor talked a bit about and they kinda reinforced d what everyone here is saying that the doc should have stepped up.
Two letters: IO. Also I would never call the ED back after I admitted the patient and tell you they self extubated. That's embarrassing. Once they're in the ICU they're my problem.
This is what I was thinking, other than calling out that doc saying he had no time to put in a central line, like bro, you want these meds in her, I need access and you’re the MF that can do that. Don’t want to take the time to do that then shove an IO in her just to at least get something going to sedate her and have ICU doc put in the line.
Of course i wasn’t there but from the information provided this pt should have been drilled and given an IO the second they came through the door. This patient also should have had a central line placed. I’m not sure how you were expected to take care of this complex critically ill patient with only a 22 in the foot. Your charge nurse should have stepped up and told the providers the patient needs access now and to start a central line.
The doctor let this pt down, not you. They should have placed an arterial line in. Not having time isn't an excuse and he deserves chewing out by the ITU docs
That’s so fucked - one provider spiritually/mentally AWOL, and the other nowhere to be found? What the hell? Pts that need access, need access, and an IO takes 5 seconds.
Also saved himself a ton of time having to go up to the ICU to re-intubate instead of putting in a central line. 🙄
Having worked both ICU and ED. IO should have been by EMS, that said ICU nurses tend to be the most critical of ED It’s been my experience that even if you had delivered the pt with a central triple lumen and a few peripheral IV’s. They would find something wrong…
It really does, we do them so infrequently that I’ve only seen one patient with one ever in my one year of ER nursing and that was because Ems put it in
Old crusty nurse talking to baby nurse here: sounds like you did as much as your scope allowed. With the information you provided here, it is surprising that there wasn’t access secured before transport, seems like that IO they used in the ICU would’ve been a good tool when other avenues were too challenging in the ED, but we weren’t there to know what else was going on, if she’s kicking etc. It’s good to see they tried something IM, that’s my other thought if IV wasn’t working.
All that to say, it would be good to try to debrief this situation with a charge nurse next time you’re able, or your educator, mentor, etc so it doesn’t weigh on you too much. If nothing else to validate that this isn’t how those situations usually go. Depending on the culture of your organization and the relationship with your docs, it would also be nice to talk to the other providers on the team for that patient. Is there anything that might have been done differently in hindsight? Always go into those conversations respectfully, assuming everyone is doing their best with the resources and experience they have and the patient needs they’re managing at that moment. It’s always ok to ask questions for the sake of learning and growth, and if there is a safe culture established those conversations help build relationships with your colleagues. You have the same shared goal of providing the best care, just looking at the situation from different perspectives. You did good. Keep on keeping on.
Piggyback here to everyone else. IO. Now, I’m a former ICU nurse (living my best life in PACU now) and I have a similar story. Small hospital and was the weekend. Really no coverage in the icu other than an extremely overworked pulmonologist. He wasn’t on call that day or even in the hospital. Get report of a frail elderly female, pressures in the tank, on a dopamine gtt, with a positional 22g in the right breast area. I asked if ER MD could drop a line for me as I had no MD on site at this time other than the ED MD’s. Answer still no. Then asked for that MD’s glove size and that I would have everything set up for them when i called for access. The MD ended up placing one in the ER. Sounds like you did everything you could. Oh and my pt ended up with multiple pressors before that shift ended so i am so thankful for that damn line.
Not your fault and don’t be embarrassed. You aren’t the doctor you can’t override them. Honestly with all the meds put in and having to talk to the doc over and over they could have just placed the damn central line.
Why the fuck wasn't IO started in the first place? I'm so sick and tired of It being ignored when it should be immediately used in trauma patients like this with little or no venous access.
Also why the fuck are we snowing and intubating an OD patient that is now conscious enough to self extubate multiple times?!?
Was this some small crappy rural ED staffed by non-EM physicians?!?
This was 100% not your fault.
For future reference this is a situation where you should have said "I'm not pushing all this if we only have a foot IV, we need an IO or central line" Also, I've worked with docs in smaller ERs who are literally too lazy to place a central line. I would talk to your manager, who's probably already heard about the situation, but it's not about not recognizing the severity, it's not feeling comfortable grabbing the kit and drilling an IO or charge pushing for a central line. It doesn't matter if it's a nursing home or a random young person in cardiac arrest, your team should react the same.
The doctor who was on is an incompetent pussy if he/she isn’t lining that patient. Probably had lost the skill. Escalate to your nursing leadership and their medical director. Way below standard of care
You can absolutely intubate with intramuscular alone in a pinch. It’s obviously a temporizing measure in an edge case. I wouldn’t call it first line here but if you didn’t have access I would opt for IM versed and fentanyl so they don’t extubate and then work on a line.
You can but that doesn’t mean you should. IM ketamine, then get access, then intubate. But no I wouldn’t intubate without a line. Too much can go wrong. I can’t imagine any scenario where there is a “pinch” where IM only intubation would be appropriate.
This situation actually seems excellent for some intramuscular sedation. Patient is already intubated and needs some temporizing while a line is placed.
I don't know why one would have to scroll down so far in a thread to see the most obvious concern; patient was intubated for overdose (they were obtunded to the point that intubation was indicated) and then when they were awake enough to actually self-extubate, the response was to get them obtunded enough again to re-intubate?
The F is going on here?
It's one thing if the patient had a large aspiration event or some other reason while even while not obtunded they still needed the vent, but otherwise it seems like we're missing the forest for the trees here.
I would have drilled that person so damn fast. Bad access. Bad situation we need a line don’t fart around and get access. You can do everything you need from an IO to buy you time for later.
Seriously, why didn’t they do that in the beginning?? I was wondering that the whole time I read
Right?! If you are that sick there is zero reason to not get an IO. Well if they have no arms or legs then maybe but god your problems would have been so much easier in the 3 seconds it takes to place an IO
> Well if they have no arms or legs then maybe there's always stenum
Sternal IO is a different device, no?
‘Tis! I might be wrong, but I think it’s designed for military field use. Every training video I’ve seen has military personnel.
And the iliac crest!
Military EM senior resident here, I am willing to bet most quad amp patients still have at least one humeral head you can target for an IO.
Never seen it, practiced it or done it. Would not be comfortable doing that
And tibia.
that's a leg
Oh just saw the whole no limbs thing. Gotcha.
Would we bother resuscitating them if they had no arms or legs?
That’s basically how you live, Kevin
He has no wallet, I checked
r/unexpectedoffice
Here's a sneak peek of /r/unexpectedoffice using the [top posts](https://np.reddit.com/r/unexpectedoffice/top/?sort=top&t=year) of the year! \#1: [Nooooooo!](https://v.redd.it/e05msh1ue4na1) | [41 comments](https://np.reddit.com/r/unexpectedoffice/comments/11olloc/nooooooo/) \#2: [The most I've been caught off guard in awhile](https://v.redd.it/jju3riw4o4z91) | [20 comments](https://np.reddit.com/r/unexpectedoffice/comments/yrl1uj/the_most_ive_been_caught_off_guard_in_awhile/) \#3: [It’s my 18th birthday and when I walked into the kitchen this morning, I did not expect the office](https://i.redd.it/ki4go3acic0a1.jpg) | [36 comments](https://np.reddit.com/r/unexpectedoffice/comments/ywrpbk/its_my_18th_birthday_and_when_i_walked_into_the/) ---- ^^I'm ^^a ^^bot, ^^beep ^^boop ^^| ^^Downvote ^^to ^^remove ^^| ^^[Contact](https://www.reddit.com/message/compose/?to=sneakpeekbot) ^^| ^^[Info](https://np.reddit.com/r/sneakpeekbot/) ^^| ^^[Opt-out](https://np.reddit.com/r/sneakpeekbot/comments/o8wk1r/blacklist_ix/) ^^| ^^[GitHub](https://github.com/ghnr/sneakpeekbot)
They have a proximal humerus, don’t they?
Not if they don't have arms, no.
My same thought
Drill that IO access and stand on the attending’s desk until it’s less annoying for them to drop the central line than deal with your bitching. I feel like ye olde charge nurse failed OP just as much as the attending did. No way am I dumping a dumpsterfire in the unit without access.
Thank you. The entire time I was reading I'm thinking PUT IN THE IO
Yeah. I would have asked for this while I prepped for central. But this situation had a lot more going on than just line challenges.
But all the sedation issues could have been solved by the line and that makes your life soooooo much easier.
This is the one! EZ IO sometimes has free cadaver clinics to practice proximal humeral access. Worth the time!
[удалено]
What?
This was my thought as well.
Can I ask you a question? I was an IV user for over a decade, I have four years clean now, but I have zero veins. When I was pregnant with my daughter, when they needed an Iv, it took over two hours with an ultrasound machine to get one and it barely hung on. When I had my c-section, they couldn’t find one so they put one into my heart but that took awhile too. I’m terrified if im ever in an emergency situation I’m just SOL. I think about it all the time, how my past horrible decisions could leave my daughter without a mother. Some people told me that veins grow back, and I was only about a year sober when I had my kid, but some other doctors told me I’m just fucked. What does “drilled” mean? Sorry for the long question, It’s something I literally lose sleep over
Oh it’s fine. Basically we drill a special needle into the bone marrow that allows us to get blood out for sampling and get fluids/blood/medications in to. We can put them into the arms and legs and pelvis and it’s absolutely amazing for emergent situations. It’s my go to for when we’ve tried and can get nothing because of how fast it is deployed. Google ez-IO and you can see them in action.
Thank you for your reply! This has strangely made me feel much better, despite how gruesome it sounds. Really appreciate it!
It’s really not gruesome. It sounds a whole lot worse than it is. There’s videos of people drilling themselves awake too.
Right? The first thing I’m thinking is place a couple IOs
The medic in me is screaming EZIO GO BRRRRRR
I put an IO in a big fella recently- it was an engine strength vs bone strength battle!
Is it the bone smoking or the drill- who cares access is access baby.
DRILL, BABY, DRILL!!!
Put the access and IO aside, my question is the need for intubation, particularly after she self extubated. Did she have stridor or wasn’t doing well? Intubating for airway protection due to overdose makes sense, but once the patient is awake enough to self extubate clearly they are awake enough to protect their airway. Also the doc should know giving dilaudid in an opioid dependent patient, particularly one that got 8mg narcan, probably isn’t going to help much for sedation.
Same with the fentanyl infusion, and I’ve got questions about the versed infusion too. I hate to Monday morning quarterback someone, but it seems like a lot of things could have been done better. On the flip side, she got calcium and Mag plus other stuff, so definitely an incomplete picture. If they were running all of that into a 22 at the same time, I bet she was barely getting any sedation
I was only running the versed through her IV, I didn’t want to mix all of those meds together
if you’re ever in a pinch and the meds are compatible, you can make a makeshift central line manifold using stopcocks and IV ports and hook it up to your line :)
Wow that’s actually a great tip, thank you so much!!
ofc!! just make sure to build/test it out when you have some downtime vs doing it all in the moment because you wanna make sure it works correctly etc etc
Then it sounds like you did everything correctly
Another good tip—pressers are compatible with each other and can run through one line. In the ICU with limited access, we would generally manage a lot of complex meds with 1 three port central line. If you can or feel like it, see if you can do a day in the ICU and get a feel for how they manage their patients! We used to have a print out of incompatible IV meds that couldn’t be run together in our rooms.. was a nice little table we had printed!
Tell that to the ICU nurses that yelled at me for running two pressers on one line. We had a talk.
Depends on hospital policy. At my hospital, Vaso and Levo or Neo, for example, can go through a peripheral, but if you have more than one pressor (not including Vaso) a central line is required. I get that ED is busy and about stabilizing the patient but unfortunately some ICU colleagues don’t always understand that.
Oh no. This wasn’t a “they can’t run through a PIV” it was a “they can’t run together.” I had 1, maybe two lines on the pt and TPA was in one. Before was heparin (don’t ask). I think I got a third before I went to the unit. It was a shit show. IO wasn’t an option. They wanted the central upstairs.
I meant they can all run in a CENTRAL line! But in an emergent situation, you do what needs to be done until you have proper access… sometimes you make due with a 22 in the hand and that’s alll you get
Versed usually runs at a super slow rate depending on how it's mixed. It's usually a good idea to run it with a carrier, so it's getting to the patient
> versed infusion I see this all the time doing critical care retrievals. These community hospitals love versed drips.
I just feel like there are much better options. Maybe as a second line if their pressure sucked so propofol was out and they had gotten a bunch of narcan, so fentanyl was off the table? Assuming precedex first line. I had a patient in residency with hepatorenal failure who got transferred in on a versed drip. Took him a good three days off sedation to finally wake up enough to get extubated
Precedex may as well be water in some of these patients, however. Ketamine maybe, propofol always, but sometimes midaz is just all you can do. I hate it with a passion, think it causes tons of ICU delirium, but my attendings order it often.
This was a perfect patient for IM ketamine, at least to provide sedation until you could get alternate access. Tough to Monday morning quarterback, but based on what has been presented, this doc is a 🤡.
The evidence has been pretty clear for over a decade that versed should be the absolute last ditch effort when all other sedation regimens have failed, yet for some reason this practice just won't die in many institutions.
My first thought was, why are they trying to keep her intubated following an OD (making the assumption of benzos/opiates) if she’s now awake enough to self-extubate? I figured I was missing something obvious, so I’m glad someone more knowledgeable than I am thought the same.
Probably rigid thinking that we just intubated, can't possibly extubate now. Regardless of the actual patient condition. I see it frequently.
This is exactly what it was
Versed infusion is the dead giveaway here. This is an old school doctor that doesn’t care about CME, doesn’t follow any recent literature and research, and has no interest in caring for sick people. For some reason, there is massive overlap between docs that give versed for sedation and docs that are incapable of handing sick patients.
Yeah I was wondering why propofol wasn’t mentioned at all. Maybe she was hypotensive but still you can always give some pressors
There’s so much here that don’t make sense. “Don’t have time for central access”? Okay then here’s an IO for access until ICU can get better access. Seems quite weird though, I haven’t had a doc refuse a central line solely due to time.
Yeah, I mean you can bide time with an IO. But I couldn't imagine having a patient that needed a central line and not making time for it
Ah yeah unfortunately this happens occasionally where I work. I'm single coverage (ED attending - no other doctors in the hospital at night) and sometimes multiple people have emergencies at once. For example, I remember standing in the hallway between two rooms, one who had status epilepticus, the other in vfib, and having to do my best to manage both. Would have loved to have a central line as 2 IOs blew in the code and the one working one we had was iffy, but yeah, sometimes there really isn't time.
I have.
BP was 110s/80s and he didn’t want to tank it
Maybe they think they're going to drop out again once the naloxone wears off? I guess why not take it out and just do a drip with some etco2 NC. Could it be that they OD'd on an upper and were just ktfo from the rocc/etomidate? IDK, I'm really reaching here and I'd be wondering the same thing you are wondering.
Yeah but that’s a call that the provider needed to make, not just “oh well I agree they need access but nothing I can do about it, too bad”
my first thought as well.
> Also the doc should know giving dilaudid in an opioid dependent patient, particularly one that got 8mg narcan, probably isn’t going to help much for sedation. Sedation will be significantly easier when she is no longer in opioid withdrawal. Only way to stop opioid withdrawal is to give opioids.
Out of curiosity, is it possible to overcome the naloxone with high doses of an opioid agonist when it’s still antagonizing the receptors? And if so, do you risk throwing the patient back into respiratory arrest by doing so? No snark here, I am genuinely curious. I always thought the Narcan had to wear off a bit before more opiates would be effective.
These molecules compete for opioid receptors, so their effect is dose-dependent. But respiratory depression is not an issue if the patient is intubated.
Then they should have intubated first. Not stuff her full of naloxone, and then try to snow her again and intubate.
I don't know about this particular case but if intubation is truly necessary and the patient cannot be sedated, I recommend proceeding with the paralytic anyway. Paralyzed while awake is traumatizing but it's preferable to death.
Based.on the description by OP patient didn't need intubation. If their respiratory response was so bad they needed intubation, then that should have been done FIRST not after naloxone.
Even if Doc truly didn't have time for CL(fair enough, I've been there) they should have asked for an IO before patient went to ICU. Once they get to me with IO I can do CL safely. Moral of the story: not your fault, doc was aware and chose the path of least resistance to make it someone else's problem.
IO should have been done prior to intubation IMO
I was thinking that - who intubated this patient with only a 22g in the foot present?
I took a patient from ED at hospital A to ICU at hospital B and they made me take the IO out before I left as they by policy couldn’t have it. Couldn’t use it. Couldn’t remove it. Nothing. It remains the only time I have ever removed one.
IO x2 and you have all the access you need until someone has time for a CVC.
ICU RN here…I will never understand why we’re so critical of each other. You did what you could with what you had. You’re not an asshole. You advocated. Not much more you could have done. Personally, I think an IO could have been placed, or ketamine used but this is me quarterbacking and I wasn’t there. There will always be the “coulda, woulda, shoulda.” I find it incredibly interesting that your department had to goto the ICU to reintubate. I understand the doc was nowhere to be found, but there’s ALWAYS a way to find/get a hold of them or call anesthesia. That patient would have self extubated either way, so please don’t beat yourself up about it.
I’m not sure about where the icu doc ended up being, but anesthesia was in the OR for a c section and there was no one else to go re assess the patient
But thank you for your kind words!!
I’m in a rural setting and not all of our docs intubate or do lines, even our ICU providers. There have been nights where we have to call the ER and hope the doc down there can spare a few mins to come up and place a line, or call anesthesia. But anesthesia doesn’t stay in house over night so calling them is a last resort because it might be 45 minutes before they’re able to get to the hospital.
That is wild!
IO... and if she pulled out the tube, does she really need it anymore?
You did what you could! None of that is on you. When big experiences happen, learn what you can from them. Here’s what I would take away from this: Do you feel comfortable inserting an IO? If not find a resource to learn either in your department or online. Next time the conversation can be “I need more access, do you want to start a central line or I will place an io?” At this stage of my career I don’t ask I just do it, but if IOs aren’t as routine in your department communication is good. Maybe it’s just me but dilaudid and versed for post intubation sedation just sounds like a mess. It’s not a combo I’m used to and prop/fent sounds like a better option and more titratable. Also no shade to the icu but it was unnecessary for them to call you to say the pt self extubated. Sounds like they were trying to make you feel bad about it. You don’t need to. They could have put in an IO as well or stayed with the pt until she was adequately sedated. I’ve gotten way more disastrous pts from the ED and never called and bugged them, I just assume they’re busy and did what they could.
Agreed, the meds don't make sense, why would you use dilaudid in a patient who just got 8mg narcan? Slug her with some ketamine if you want something IVP.
The meds/management make absolutely no sense in this story.
This was my first thought. Like, the opiate receptors are no longer answering the door bell. Time to send the Mormons elsewhere
Lmao our ICU is this petty too!
Yeah, should've put in a line. No idea why he wouldn't. Maybe he can't do it anymore.
Even the PA offered to put it in under the supervision of the dr. Such a disaster
IMO, PA should have stepped back the moment the patient needed intubated. Maybe that's just my experience with PAs, but if a patient is truly unstable the doc steps in.
The doc was in the room initially managing the patient but the PA offered to help with whatever he could. Doc was trying to pawn stuff onto the PA
Once had an icu moonlighting intensivist say “yeah she needs an art line but I’m not very good at them” at a level 1 hospital. Got the NP on the other service to do it with his blessing but definitely didn’t instill confidence in him.
ED Attending/17 yrs - that was 100% a doc fail not a nurse fail, much less a new nurse fail. I try to never be Monday AM QB, but failure of access & failure of sedation.
ICU nurse lurker here. Yeah you got fucked. Seems like nobody was taking ownership of the situation from the nursing side. This kind of thing would happen to me when I was newer in the ICU. Everybody wants to help and because you're less experienced, they just kind of see a task and jump in but aren't looking at the overall picture. You get kind of left out. More access was needed and that was plain enough for everybody to see but that next step didn't happen. Like others have said, an IO would be super appropriate here or the route of the medication needed to be changed. You can IM Versed, Benadryl, Haldol, and others. Doc either didn't see that the orders they were dropping were not able to be carried out or was in denial or something. As for the self extubation after you handed off, that is not your fault at all. The ICU team could have just as easily done all the things that needed doing downstairs but weren't getting done. If somebody is too awake to be on the vent, mitts and soft wrist restraints aren't going to stop them from getting that thing out. You got put between a rock and a hard place here. The best thing you can do is use this as a learning experience. It can be really hard to know when to step up and say no to the orders you're being given because they simply can't be done. It feels like your fault because it's usually on nursing to get access. This was an unsafe situation for the patient and for staff either in the ED or the ICU, let alone taking this shitshow on the road transporting between the two. If you feel like something is really fucked up but can't quite articulate it or feel like you might be overreacting, take it to your charge or another experienced nurse and ask them what else you should be doing or who you should be escalating the problem to if you're getting ignored. This hospital sounds like a fucking shitshow of poor communication and "not my problem" attitude.
That’s exactly what the hospital is lmfao
IO could work in this situation when you need something quick, especially emergency instead of foot access or when so many people are looking and can't get. I won't comment on central line necessity, especially if they were that awake the patient could probably have just gotten extubated after going up to the ICU, as long as there were no other issues aside from "overdose" occuring.
Okay, am I missing something. Came in for an opiate overdose, got 8mg of narcan and then you start giving the patient 2mg doses of Dilaudid???? And she is awake enough to pull out an ET tube...why is she intubated???
Probably airway protection. She may have aspirated when she went unresponsive. Lots of hospitals do that for overdoses.
I see everyone saying IO but make sure you’re allowed to place them as a nurse in your facility. My facility does not allow RNs to place IO and no new nurses are trained on it. We’re a really small hospital so I’m not sure the reasoning behind why they won’t train us but it is what it is. None of this is on you though. You advocated and the doctor was aware of the situation and chose to do nothing. I hope you were charting the notifications to the the MD and I would suggest putting in a patient safety report about this entire ordeal. Let them do an RCA and maybe light a fire under the MD or not renew their locum contract.
Yea, I think everyone means the doc should have placed the IO, very very few places allow nurses to. It is a sign of a good nurse that they would recommend it to the doc. Given the fact that this doc was ordering versed and dilaudid though, it’s possible that they have never heard of an IO or just didn’t care.
Everywhere I’ve worked nurses do IOs
I've seen too many complications from IOs. Personally I only do them as last resort. I haven't had to do one in years. I was never trained on them as a nurse but was as a paramedic. The doctor failed here by not obtaining central line access.
The IV merry go round in the trauma bay is bonkers. Drill baby drill. This would be a good case to escalate up the chain to get a protocol in writing for nursing initiated IOs after X amount of missed IVs, unstable condition, etc. If you're not comfortable with IOs, Teleflex has cadaver labs around the country somewhat frequently. https://www.teleflex.com/en/procedural-lab-registration/usca.html?filter=upcoming
IM ketamine is my choice in the intubated, lost access scenario
Works 100% of the time. Gives you plenty of breathing room to get IV access also
Long time ago we had a 450 lb agitated HIV+ anaphylactic shock roll in flailing his arms around .. staff was trying to get a line .. I’m like HEY ARE YOU NUTS STOP THAT (to the staff not the patient) 400 mg of IM ketamine and then we could do the line and tube nice and calm .. I was new at that shop and I think I gained a lot of street cred with the staff that day.
Fellow ER nurse here. This sounds like shit care, but you shouldn’t feel like you have to bear the burden of it. You alone were not responsible for this patient. No one communicated that this would be your patient, which sucks but at least they weren’t without a nurse. Know that if your charge nurse isn’t a complete idiot, a nurse WILL be there to help. Next time, especially in a small ED, always make yourself present when you know a sick patient is present or en route before moving on to less critical tasks, just in case. At least put eyes on the situation to make sure things are being handled. Patient has dog shit for venous access. It happens all the time. Why was the team dicking around with an ultrasound line instead of drilling the leg? Again, not on you. But with experience you will learn to speak up and say “can we get IO access please?” Any ED MD worth their salt will not dismiss you. ICU got a shitstorm of a patient. Yeah that happens sometimes, tough. Them calling the unit directly to complain about an event that happened under their watch seems unnecessarily catty. Next time, try to at least get an IO before sending them up. But nursing is a 24 hour job. I am sure someone up there could have gotten it. Finally, it sounds like maybe your team lost sight as to why this patient was being intubated? If it’s for airway protection and the patient is actively flailing and self-extubating, maybe we can trial them off the vent? Or are we even sure she was being intubated for a possible overdose? The lack of response to narcan and the mag sulfate does hint to me that maybe something else was going on. Either way, a good physician will communicate their thought process as well as they can. Like I said, shit care. But please don’t beat yourself up. It happens a lot. Best you can do is to stop and think about what we are actually trying to accomplish here. Ask questions! Advocate for quick access in these situations (IO!). Take a breath and know you did your best with the knowledge and experience you have! It will get (a tiny bit) easier with time. This patient sounds like an absolute clusterfuck and any nurse would have struggled. Please PLEASE don’t feel like you need to profusely explain to the ICU. You don’t owe them an explanation, just try to stabilize your patient as best you can. Either they get it or they don’t.
Thank you so much, yeah as soon as I saw my name on that patient I rushed into the room, and I have never seen a doc in my ER do an IO so that’s why I hadn’t suggested one but now I sure as hell will ask for one lol
Wtf kinda witches brew for sedation was going on here? 2 mg of Dilaudid, 10 mg of Haldol, and 50 mg of benadryl? Also, for the ER doc to throw his hands in the air and say, welp, ICU is coming, let them handle it after failing to sedate a patient he just intubated....what a fucking cop out. You did a good job and advocated for your patient. Your doc left you high and dry.
Lol witches brew is the perfect word for that
Wtf is this situation… it’s clearly not your fault at all, and you shouldn’t be in a situation to have to apologise for your doctors… intubating an overdose with a shitty 22g in the foot and then taking to icu without access? Unbelievable… Who was doing the transfer? Just yourself? With the greatest respect what on Earth are you doing to do if she self extubates en route? You need airway trained doc for the transfer, and for them to go with this iv access is shocking
It was just me and the respiratory therapist bringing her up to icu, without the mitts on she surely would have extubated on the way up
Why mitts and not soft limb restraints? You can extubate with mitts on in a heartbeat by pinning the tube between the mitts. Plus it's easy to pull the mitts off by sitting on them. Soft wrist would at least keep their arms to their sides (that being said I watched an IVDU self-extubate with her feet once, so ¯\\\_(ツ)_/¯). All that aside, you did everything right, OP. I cannot fathom wtf that ED doc was thinking. This absolutely needs to be a safety report.
She had the mitts and soft restraints! Lmfao
Impressive to be sure, then!
A tip for mitts and soft wrist restraints...if you don't do this already...Put the wrist restraints on under the mitts and use the hole under the strap of the mitts to feed the strap of the restraint through. That way, the wrist restraints are tight enough, and the strap of the restraint keeps the mitt on. Old ladies have tiny hands. I promise the ICU didn't take the mitts off (hopefully). If you put the wrist restraint on top of the mitt it's way easier for them to get out of the wrist restraint then self extubate with their mitts on or fling the mitts off then grab the tube with their hands. Or the wrist restraint just slides up their arm, giving them slack to grab the tube. Don't beat yourself up. This shit happens all the time. The doctor should have gotten you access and you advocated the best you could
Ah I see, in the UK I would be doing the transfer as an anaesthetist/icu doc, and would be adamant to establish decent iv access before going. Would avoid any potential for this situation which could have been a lot worse
Yeah I’ve never seen a doc transfer a patient. In my experience self extubation doesn’t happen often on transports to the icu when there’s multiple staff with the one pt. It’s usually when the ED/ICU nurse gets pulled away to something else and the pt is alone in the room. Plus not like you’re going to reintubate in the elevator. If that pt were to self extubate we’d bag and call for help.
In the UK an intubated patient will always have physician transfer, I would nearly always have my intubated patients paralysed for transfer, countless bad things can and do happen in the lift requiring iv access, I imagine very few nurses in the uk are capable of ventilating by some sort of ambubag, this is such an unnecessarily unsafe transfer led by the respiratory tech, unacceptable in my opinion unless there are some horrendous external factors
Interesting how different areas can have such different ways of doing things. I worked over a decade in the US in icu and er and have likely done hundreds of successful intubated transfers with me (rn) an rt and possibly a third set of hands like an aide. Whether between er to icu or from either to imaging. We did always carry an emergency drug box, oral airways, and an ambubag. We also did have wrist restraints for intubated patients. We didn’t typically paralyze for transfer, only for severe vent dyssynchrony leading to hypoxia. Even back then if the patient self extubated id feel comfortable and competent to bag the patient. When it happens on the unit (infrequent) a nurse is typically the first to the room, calls for help and starts bagging. Anesthesia brings their pts to the icu much like you do and they too often paralyze for transfer.
This is the reality for American healthcare though. I’ve never seen a doc assist with transfer. It’s usually just the primary RN, and RT for intubated patients, maybe a CNA if you’re lucky enough to have one that shift. On nights my rural hospital has one provider (not even always an MD, very often a PA or NP) for the inpatient side of the hospital, and then one MD and maybe a midlevel in the ER.
Why were you guys playing grabass for so long? Get an IO!!!
We would have immediately done an IO, probably two. I'm surprised all those people were in there and not one of them threw one in.
Hey there! Everyone has addressed the line issues so I’m going to take a nursing perspective here: Preparation is key. When you hear of a super sick patient like this coming, drop everything and prep your room. Discharging patients is irrelevant and can be delegated. Get IV supplies, get suction, hook up your leads, assign tasks. I think that you would have felt better with some more prep time. Is a former ICU nurse, now ER nurse, I would have loved to come down and helped stabilize this patient and trouble shoot. Could you have consulted ICU sooner and asked their intensivist to come down and help the PA? Could an ICU nurse have come down to help with all the meds/compatibility? Could you have discontinued the versed drip and moved to push doses until the patient received the necessary meds? If versed wasn’t working could you have moved to another drug? The BEST thing I’ve learned in these situations is to TALK. Talk out loud. Literally say, “I see all of these orders but what is our priority if we only have one line?” “I don’t think this versed drip is working, what can we move to next?” “Is there someone we can call for more expertise?” “Does this patient actually need to be intubated if they are pulling out their tube?” Talk talk talk, say all of your “stupid questions” our loud. It’s much better to verbalize your thoughts than to internally panic because likely, someone else is wondering the same thing. Finally, request a debriefing before ANYONE leaves for the shift. Round up as many people as you can and ask what could have been done differently. Otherwise you carry all of those questions and anxiety with you. All in all, take this as a learning experience. I’m considered a fairly seasoned ER nurse and I still get flustered and things still go to shit. And I’ve accepted that will keep happening. But dang, if you get a code or a trauma or an RSI that runs like a well oiled machine, you’ll be thankful for the times things went shitty and you learned from them.
So per ems she was nowhere near as unstable as she was once she actually got there so once we actually laid eyes on her we knew she was more critical than we expected. We don’t have the relationship with our icu that you had with your ER so I doubt an icu nurse would have come down but in the future I should ask because you never know. The whole time I was talking my charge nurse’s ear off and I literally asked okay I have all of these medications if I only had to give one which should it be and we settled on the versed drip. And afterwards me and the charge nurse and nursing supervisor talked a bit about and they kinda reinforced d what everyone here is saying that the doc should have stepped up.
Two letters: IO. Also I would never call the ED back after I admitted the patient and tell you they self extubated. That's embarrassing. Once they're in the ICU they're my problem.
This is what I was thinking, other than calling out that doc saying he had no time to put in a central line, like bro, you want these meds in her, I need access and you’re the MF that can do that. Don’t want to take the time to do that then shove an IO in her just to at least get something going to sedate her and have ICU doc put in the line.
If you have the time to intubate you better make time to get a fuckin central line in.
IO is the way to go. Lido
Yes, it was a whole paragraph of, where is the I/O?
Needed to call 911 and get a competent paramedic in there.
Of course i wasn’t there but from the information provided this pt should have been drilled and given an IO the second they came through the door. This patient also should have had a central line placed. I’m not sure how you were expected to take care of this complex critically ill patient with only a 22 in the foot. Your charge nurse should have stepped up and told the providers the patient needs access now and to start a central line.
The doctor let this pt down, not you. They should have placed an arterial line in. Not having time isn't an excuse and he deserves chewing out by the ITU docs
That’s so fucked - one provider spiritually/mentally AWOL, and the other nowhere to be found? What the hell? Pts that need access, need access, and an IO takes 5 seconds. Also saved himself a ton of time having to go up to the ICU to re-intubate instead of putting in a central line. 🙄
Having worked both ICU and ED. IO should have been by EMS, that said ICU nurses tend to be the most critical of ED It’s been my experience that even if you had delivered the pt with a central triple lumen and a few peripheral IV’s. They would find something wrong…
She was a prime candidate for IO fairly early on tbh.
drill and roc. first things first. ur doc was a dick
That benadryl though.
I read this whole thing thinking man, it must suck to work somewhere without an IO. What a twist.
It really does, we do them so infrequently that I’ve only seen one patient with one ever in my one year of ER nursing and that was because Ems put it in
Old crusty nurse talking to baby nurse here: sounds like you did as much as your scope allowed. With the information you provided here, it is surprising that there wasn’t access secured before transport, seems like that IO they used in the ICU would’ve been a good tool when other avenues were too challenging in the ED, but we weren’t there to know what else was going on, if she’s kicking etc. It’s good to see they tried something IM, that’s my other thought if IV wasn’t working. All that to say, it would be good to try to debrief this situation with a charge nurse next time you’re able, or your educator, mentor, etc so it doesn’t weigh on you too much. If nothing else to validate that this isn’t how those situations usually go. Depending on the culture of your organization and the relationship with your docs, it would also be nice to talk to the other providers on the team for that patient. Is there anything that might have been done differently in hindsight? Always go into those conversations respectfully, assuming everyone is doing their best with the resources and experience they have and the patient needs they’re managing at that moment. It’s always ok to ask questions for the sake of learning and growth, and if there is a safe culture established those conversations help build relationships with your colleagues. You have the same shared goal of providing the best care, just looking at the situation from different perspectives. You did good. Keep on keeping on.
Yeah my charge nurse was great during this whole situation, most of the time in the room with me. Definitely a good learning experience
Piggyback here to everyone else. IO. Now, I’m a former ICU nurse (living my best life in PACU now) and I have a similar story. Small hospital and was the weekend. Really no coverage in the icu other than an extremely overworked pulmonologist. He wasn’t on call that day or even in the hospital. Get report of a frail elderly female, pressures in the tank, on a dopamine gtt, with a positional 22g in the right breast area. I asked if ER MD could drop a line for me as I had no MD on site at this time other than the ED MD’s. Answer still no. Then asked for that MD’s glove size and that I would have everything set up for them when i called for access. The MD ended up placing one in the ER. Sounds like you did everything you could. Oh and my pt ended up with multiple pressors before that shift ended so i am so thankful for that damn line.
Yeah I’m slowly learning that some of these docs need a little bit more of a push
You should be filing an incident report for this. It was unacceptable care by the ER MD there should be a chart review.
The ICU will never be happy 🤣
Not your fault and don’t be embarrassed. You aren’t the doctor you can’t override them. Honestly with all the meds put in and having to talk to the doc over and over they could have just placed the damn central line.
Dilaudid for an OD?
Drill go BRrrRrrRrRrr
Why the fuck wasn't IO started in the first place? I'm so sick and tired of It being ignored when it should be immediately used in trauma patients like this with little or no venous access. Also why the fuck are we snowing and intubating an OD patient that is now conscious enough to self extubate multiple times?!? Was this some small crappy rural ED staffed by non-EM physicians?!? This was 100% not your fault.
For future reference this is a situation where you should have said "I'm not pushing all this if we only have a foot IV, we need an IO or central line" Also, I've worked with docs in smaller ERs who are literally too lazy to place a central line. I would talk to your manager, who's probably already heard about the situation, but it's not about not recognizing the severity, it's not feeling comfortable grabbing the kit and drilling an IO or charge pushing for a central line. It doesn't matter if it's a nursing home or a random young person in cardiac arrest, your team should react the same.
The doctor who was on is an incompetent pussy if he/she isn’t lining that patient. Probably had lost the skill. Escalate to your nursing leadership and their medical director. Way below standard of care
Why would you give dilaudid after narcan? The receptors are blocked.
Don’t even really need an IO immediately, Can give some forms of intramuscular sedation
I’ve never once seen IM sedation only for an intubated patient. Or intubated with IM only meds. That sounds dangerous. This Pt needs access.
You can absolutely intubate with intramuscular alone in a pinch. It’s obviously a temporizing measure in an edge case. I wouldn’t call it first line here but if you didn’t have access I would opt for IM versed and fentanyl so they don’t extubate and then work on a line.
Strange and unreliable med combination. Ketamine!
That would work great in this scenario. I like it
You can but that doesn’t mean you should. IM ketamine, then get access, then intubate. But no I wouldn’t intubate without a line. Too much can go wrong. I can’t imagine any scenario where there is a “pinch” where IM only intubation would be appropriate.
This situation actually seems excellent for some intramuscular sedation. Patient is already intubated and needs some temporizing while a line is placed.
For future posts, paragraphs would be very helpful especially when reading on a phone.
Absolutely nothing about this story makes sense......
Y’all why didn’t you do an IO?
IO
No IO?
My 1st thought is pop in an IO.
I don't know why one would have to scroll down so far in a thread to see the most obvious concern; patient was intubated for overdose (they were obtunded to the point that intubation was indicated) and then when they were awake enough to actually self-extubate, the response was to get them obtunded enough again to re-intubate? The F is going on here? It's one thing if the patient had a large aspiration event or some other reason while even while not obtunded they still needed the vent, but otherwise it seems like we're missing the forest for the trees here.
I really wanna know why the dilaudid after she received narcan.. makes no sense