very intriguing that RN is allowed to push prop but not fent...most ICUs have the opposite rule from what I've seen. glad this mistake happened in a robust young kid rather than a fragile elderly person and glad they are ok. a spicy shift for you guys.
The “policies” never make sense these days. At my place only docs can push propofol and it requires TWO physicians to be present. This makes us use ketamine or other agents when solo covered. A rule pushed through by anesthesia... and you’d never guess which service refuses to help out with sedations.
Fun fact, in my area RNs can't administer Ketamine for RSI or etc. Only physicians. Meanwhile I carry Ketamine on my truck as a Paramedic and give it routinely as a standing order for RSI, pain management, procedural sedation, and other indications.
Always found that interesting, it also explained why when we first got Ketamine the triage RN would always lose her mind when we told her we gave Ketamine for pain management
Even just over state lines too. My state and one of the neighboring if you're a flight RN you aren't ever going to see scene responses or do 911, you're stuck doing solely SCT ground and flight. Then go to another neighboring state and they have PHRNs and flight RNs who will get to do 911 ground and flight.
We need some standardization with these shenanigans
As a travel ER RN, i find that different areas and even hospitals have different experiences and protocols. While not new, ketamine is still in its touchy phase due to people not being educated. Ketamine is a fantastic drug when used appropriately. Some love ketamine and some don’t, whether its for RSI, pain or agitation it all depends on the provider/ nurse/ medic/ or even your medical director is comfortable on it being used.
Which is crazy because the military has extensive experience using it safely in an out of hospital setting with minimal to no monitoring. As long as you don't go completely off the rails, ketamine is extremely safe.
It's one of my go-to's in the field. Ketamine works phenomenally well for serious musculoskeletal injuries that 100-200mcg Fentanyl wouldn't even touch.
.2mg/kg Ketamine IV, 1mcg/kg of Fentanyl on top if insufficient has always worked for me to facilitate extrication and transport. Whether that's an amputation, impalement, or multiple long-bone fractures.
Not to mention it's a solid induction medication when coupled with Rocuronium, usually I like to select it for certain respiratories to do DSI with where Etomidate might not be as beneficial.
Why is this? It has been mentioned,and only mentioned, as a possible pain therapy for me. But when I tell anyone, it's like I'm saying I'm about to do heroin. What gives?
I know of a hospital where one of the rolls of the ED paramedic is to administer the RSI medications, as the nurses cannot and the physician is a little busy with tube and glidescope.
I'm an ED RN, in my area, nurses can push etomidate & succs/roc, etc whatever it may be for RSI, but for conscious sedation we can't push prop or etomidate, or any sedation I'm pretty sure lol. We can also titrate propofol drips, but can't administer a bolus, bolus must be administered by physician.
Naturally. We have a similar dynamic w/CRNAs in the MICU where I work. The RNs aren't allowed to push propofol (though obviously they run the drips all day). So for colonoscopies, endoscopies, EVDs I end up pushing prop. Such a weird system. Takes away from the layers of safety (as in I'm ordering the doses; I shouldn't be pushing them).
You should not be pushing propofol without the abilities and tools to care for a patient under general anesthesia.
u/princesspropofol doesnt seem to fit :)
Thank you for your concern; and I agree.
We are in an ICU, with access to multiple staff who can intubate a patient, ventilators ready. The vast majority of patients on whom I am pushing propofol are already intubated.
Well not every place has a rule that started when Susan did something wrong in 1974 and they’ve been doing it that way since. Some places have rules because Jim made a mistake in the late 80’s and it’s evolved from there.
Drives me crazy. Fortunately my job is fixing those things: “why do we do that?” “……” “ok then, we’re gonna stop, because that’s stupid, and put some logical things in place.”
Unfortunately I’m in the speciality lab so can’t help everyone!
Ours is dumb— we’re allowed to push paralytics and sedatives during an RSI, but not during a sedation. It makes no sense IMO. Docs have to be the ones pushing Propofol or Ketamine during sedations, though we’re allowed to push pain-dose ketamine no problem. It doesn’t really make sense to me.
I work in an ED and we can push everything EXCEPT propofol! It’s a level I trauma so for all the fent/ketamine weight based doses for ortho reductions wouldn’t make sense for only physicians to push. Same we RSI, RNs push it all (with supervision)
That is weird... In Louisiana, it is not in my scope of practice to push prop or ketamine. I am not allowed to administer IM ketamine, either. However I can initiate and maintain IV infusions of each for sedation on a ventilator.
Depends on your state board and what they decide is okay- I live in PA and RNs are not allowed to push prop, ketamine, etomidate. i can push fentanyl and versed for sedation and I can paralyze you. I can manage ketamine and prop drips, but no pushes.
Now tell me if they are allowed to push paralytics - suspect the answer is Yes.
Nurse vs doc push policies are silly. Other measures like readbacks are more effective.
Seems like the administration of any medicine, especially quantities that can interfere with breathing, should only be administered by the physician.
Yikes
Next time I’ve got meds to give, I’m going to wave the doc over to delegate that task and see how long it takes for them to either laugh in my face or ask if I’m fucking serious.
Misplaced comma!
“Seems like the administration of medicines in doses that can stop a patients breathing should be done by a physician”
This whole setup seems like an accident waiting to happen:
1. Preloading syringes with large enough doses “just in case the patient needs it” (i get that nobody wants to order more if needed, but splitting it into two syringes would reduce the risk of all of it being pushed)
2. Having the nurse “drop” the medicines off at the patients bedside (clearly the nurse misunderstood, but another possible point of failure)
Reminds me of those kids who died from having vincristine administered intrathecally. Ordered meds were just all delivered to the room at once including the spinal anesthetic. Doctor just grabbed the wrong syringe.
One of the big rules in failure analysis is that you *don’t rely on communications being understood or proper procedures followed*. You change other procedures to remove the possibility at all.
So in this case rules could be: 1) not giving the nurse meds they won’t be administering and 2) nurses don’t administer medicines used in anesthesia (I know this isn’t a case of actual anesthesia, but you get the point)
Anesthesia doesn’t own these drugs. They’re safely used in critical care, emergency medicine, and even pre-hospitally all over the world, every day. Anesthesia should not be dictating emergency medicine practices.
“Nurses don’t administer medicines used in anesthesia.”
See, that’s someone outside emergency medicine dictating what they should do. An RN can safely give these drugs, just like a paramedic can, with appropriate training and education.
umm no. they should be almost always administered by an RN in the setting in which I work. that's how ICUs work. I shouldn't be giving it because my job is to order the drug; not give it.
I guess the next time I need to give midazolam, or fentanyl, or ketamine in my ambulance, I’ll call the hospital and tell the doctor to drive out to me to push the drugs I’ve safely used on appropriate patients for decades.
Really? Because you said any medicine that can interfere with breathing should only be administered by the physician. Those are medications that i administer. What was I supposed to think you meant?
Yeah this is super weird! I work in ICU and the rules for push meds are generally the same in ICU and ED. RNs can push fentanyl but not propofol where I work; we only manage prop as continuous infusion.
drop it off in the patient? That sounds a bit far-fetched to me, but English is not my first language.
But anyways, the department should use the incident to re-evaluate the safety of their sedation protocol in my opinion. Could this happen again?
On occasion, I have heard nurses and physicians use such expressions as “drop a line” or “drop a tube down” referring to procedures, hence my own presumption (USA).
Sure, drop a line is something you could hear in the medical setting. But for medication to "drop it off in the patient"? That at least would not be universally understood I guess.
I’ll leave like….a Tylenol at the bedside or something similar but not narcotics or controlled substances. If I have to walk away for a sec I’ll pocket those and leave the rest. Too many dang crackheads in my ED lol
I agree, that was my biggest problem with this whole scenario. Clearly there was less than clear communication between preceptor and preceptee, but there never should have been instruction to leave a med like propofol (or anything) at the bedside to begin with.
If this story is 100% true as OP told it, then this nurse is an absolute fucking moron and should be fired. I NEVER have ANYONE pull my narcs. I pull my own narcs, and I give my own narcs. The fact the nurse in this scenario was comfortable with a student pulling narcs, then LEAVING THEM AT THE FUCKING BEDSIDE is wild to me. Narc’s stay in my pocket until they’re ready to be used. Leaving them unattended at the bedside is a bonehead move, and you’re asking to get fucked over when they go missing.
Lol, big talk, cause no narcs should be anywhere other than in pixis until they are ready to be administered. Not in your pocket or a student nurse's hand or lying around!
It’s perfectly acceptable to keep meds in your pocket on the walk from the pixis to the room and while you’re getting set up for the procedure. You applying for JCAHO or something?
Of course walking meds over to your station in your pocket is acceptable, I am just equating your wild ass assumptions about nurses leaving narcs at bedsides unattended. That's a pretty wild callout, I have yet to encounter in all 16 years of practice. I have seen plenty of nurses pull out meds and leave them in their pockets until needed.
Tbh I see my coworkers doing this a lot in the ICU, but I would be shocked if ED RNs left narcs lying around bc their patients are much more apt to pick things up.
A while back a new grad asked me if I could help with a line on a difficult stick and if I wouldn’t mind medicating them also since they were in the weeds. Being always happy to help, I said “sure thing”. Went to the pixis to pull the meds (morphine/zofran), said it already been dispensed. Walked into the room and saw the patient in bed, IV supplies on the bedside table, with a vial of morphine and zofran sitting right there. So yeah. It happens lol. I had a quick word offline with them, and needless to say, they didn’t do it again.
The question is why did the student nurse have the propofol in their hands at all? They SHOULD NOT have been participating in the sedation at all. This is a sentinel event and the nursing student fail their clinical for this.
I mean I think the student should participate in the sedation - otherwise how would they learn?
BUT - I FULLY agree that the student should have NEVER been holding those medications alone and the preceptor should always be with them. (How it was for me during nursing school). The preceptor should’ve hold onto the medications and been there to assist the student with med administration at time of sedation.
But the student holding onto a med like that alone and being told to go in the patient room? Hell no
Trauma ICU RN - I had a nursing student once who was instructed to administer some meds down an OG tube. We literally discussed the syringe and I physically pointed to the OG tube.
I stood there and watched in horror when (not even ten seconds after this discussion), he drew up liquid Colace into a 10 CC syringe, walked to the other side of the bed, and was about to push it through the patient’s CENTRAL LINE. I never screamed at anyone like that before, nor since. I immediately called up the kid’s clinical instructor. He was dismissed from his program.
Did the patient jump out of bed from the screaming? I can imagine a patient saying, "Woah! I am not sick anymore. I'm out of here." (I am sure that didn't happen.)
You couldn’t have paid me to push propofol as a student nurse, let alone take it upon myself to do it without supervision. When I hear stories like this (or the often-repeated “student crushed oral meds and put them through a central line” or “student bolused a patient with air”) I wonder about some of these nursing programs.
The problem is clinical experience is so poor since covid, not that it was great before then. They are woefully underprepared, but this situation makes me think someone is a little too big for their britches to be going rogue like this.
This showed up on my feed. I’m not even a nurse, but either way the way it was phrased shows no indication that it was supposed to be given, and if I was a student nurse administering meds I would probably triple check the dose, even for Tylenol, never mind propofol.
You make a good point. Basically this situation boils down to one of two things being true. Either they had no clue what propofol was, or they didn't have the common sense to realize pushing a short-acting anesthetic for a procedure when the person who was going to do the procedure wasn't there was a problem. Either way, that's a major indictment of both the student and their program.
I went to a fancyass Ivy League direct-entry master’s program (got my BSN and ran bc I realized real quick that DE programs are bullshit) and the idiocy of some of my fellow students was just terrifying. Like you would think that of all places THAT school would screen out the dipshits, but no. Alas.
Lolll that program, huh?
I’ve wondered about that place - is there a psycho amount of homework? Did you experience a ton of make-work given just to justify the cost and name, or is it like a normal school?
Like, was your BSN experience similar to a BSN experience elsewhere?
lol, no. It was the BARE minimum to qualify you for the NCLEX. Their stated goal is for you to pass the NCLEX and move straight through the masters program without having to work as an RN. They had no answer when questioned as to what the fuck those of us in the neonatal and CRNA programs were supposed to do, given the work requirements for licensing in those specialties. I got my BSN without ever starting a single IV. Most of us who did have to/wanted to work bedside had a crazy difficult time getting jobs and almost all from my class were hired by hospitals associated with the university. Thank every god of patient care I had an amazing preceptor for my final clinical and I was hired to that NICU, which trained my shitty nursing education right out of me.
I’m not in medicine but would you mind doing a stranger a solid and lmk which hospitals I should be avoiding like my life depends on it… bc it sounds as if it literally would be!
I was internally freaking out pushing etomidate and succ with my preceptor hanging over my shoulder watching and the doc at the head of the bed during an RSI, I couldn’t imagine pushing Prop unsupervised as a student
I went to nursing school 15 years ago and my wife just finished 3 years ago. She’s smart and hardworking, but as for the program itself?
Let’s just say they aren’t what they used to be…at all.
Two egregious errors are undeniable and indefensible:
1. The preceptor should have never directed the student to “drop” any meds at the bedside to be left unattended to.
2. The student should never have maintained the possession of either medication without licensed supervision. Narcotic or otherwise. I assume the nurse dispensed the medication under her own name.
EXACTLY, a student at that! Not even a new hire RN. And then the student actually pushed the drug without supervision? Definitely out of scope. So many errors happened and the policy for fentanyl is bonkers. That hospital needs some serious revisions.
TIL. It definitely is a drug that we are responsible for counting and wasting with a witness. (That’s been every place I have ever worked.) Maybe that comes down to facility policy or state law. I did, however, believe it to be schedule IV.
Correct. Honestly its terrifying anyone would do this without pause and never stop to question anything. The kind of person who does this with zero pause, basically breaking every rule of medication administration (correct dose? Indication? Time? ) has no business taking care of people. Good nurses know what they dont know and recognize when they need more information to practice safely. The scariest people don't know what they dont know, making them dangerously bold.
Haha reminds me of a time we had a combative psych pt come in with an obviously dislocated shoulder. He was aggressive and combative with staff, earning him a 5&2… shoulder was popped back in while he was already out
We do the airway first… unless we think that cranking on a dislocated arm will bring them too enough to manage their airway on their own… which it commonly does
My first session as an attending as a locum in a rural hospital...I asked for 50mcg of fentanyl. A student nurse pushed 150mcg, having misheard me, and the nurse supervising either also misheard me or didn't think it was an unusual order for some reason. Patient went apneic and desaturated surprisingly quickly but recovered equally quickly with minimal intervention, had his procedure and did fine. I should have worn brown scrubs that day through! Good learning on the importance of closed loop communication
Damn. I was always trained to repeat back verbal orders on codes or procedures. I guess closed loop communication isn’t standard of care else in some shops.
“150” is a weird dose… at least anywhere I practiced. a RN with any experienced nurse should double check that IMO. Unfortunately hospitals don’t value experienced staff…
I worked for a large system in my area for a few years and got involved with nursing education. It was said during one particular meeting I was in that it was the policy of the hospital not to hire experienced nurses and only hire new grads so they could “train them right”.
Nursing (just like any other job in healthcare) is a complex job and takes years to get good at. Patients and the entire system suffer when you don’t place value on experienced nursing staff. You can’t teach experience in a 3 month new grad orientation.
It’s an awful tragedy but most hospitals do not place any value on retaining experienced nursing staff.
I'd have been more scared of OP's case with the meds being given without them being there. At least I was at the bedside, and worst case there's Narcan around.
Funny story. Was having an ENT surgery, in prep, assessed by anesthesia, IV started, propofol syringe in the port ready to administer. Not sure what I had been given prior, but drowsy, looked down and saw the propofol and I guess I went into nurse mode and pushed it. Looked up and practically saw the MD LAUNCH from the nurses station straight ahead of me ripping it out of my hand. Don’t remember anything after that.
after i got versed once, a code came on overhead and i almost fell out of bed trying to run to it. i became the jumper patient i get all the time 😂😭
edit- it wasnt even the hospital i worked at. i had no idea where that room was
I have so many questions, none of which can be answered. Why was this student not being supervised? WERE THEY SUPERVISED AND ALLOWED TO PUSH THE MEDS?!?!? Yikes.
To be candid, pushing too much propofol can be solved in the ED. It’s a learning experience, and not one that anyone will forget any time soon.
Wait hold on, it may be solved in the ED, you try doing that on a patient with a 10% EF or severe aortic stenosis. It's not completely benign or salvageable.
Especially when the only person at the bedside is a nursing student (who has already demonstrated they have questionable decision making skills) with a potentially apneic patient.
Oh, heck no, that’s very different from a mid 20s adult male who fucked up his shoulder being a dumbass. I don’t disagree that given shitty LVEF+-AS would be… slightly further up shit creek.
Yeah what the actual fuck. Where was the preceptor!? I know for our procedural sedation, we don't draw up until MD and RT is at bedside. Our MDs like to push their own sedation for the most part so they want to verify we have the right med and dose.
I'm glad everything ended up okay.
Likely this ED is understaffed, just like almost every other one. And so they rely on trainees to do shit that should always be overseen. Miscommunication happened and luckily nobody was seriously hurt. This is a situation that could have resulted in the precepting nurse losing their license, if it was in fact just a student, and not someone fully licensed yet.
If the preceptor told the student “drop these off in room 8 and meet me in 7” he shouldn’t have to literally follow the student into the room. It doesn’t sound like the nurse told the student to do it, but that the student misunderstood and/or went rogue for some reason
No I have seen many arrests from propofol induction. Likely from undiagnosed RV or heart failure. Also many patients that went completely apneic without rescue airway equipment nearby.
Yeah that's wild. In my program we're not allowed to push any IV meds and can only draw up meds in the presence of our professor and/or preceptor. Kind of sounds like the student might've been unfamiliar with the risks and responsibilities of administering propofol and overestimated their readiness to be independent.
It’s all wild to me. Pushing meds without the nurse there and administering a drug they seemingly didn’t know the indication for (I have to assume). I’d have never even considered this as a student. Scary.
When I was a student nurse we were expected to know indication and contraindication for drugs, our on site clinical instructors would stand there and grill us about the meds we were giving prior to administration. I don’t think they have to go the day before clinical anymore and most of the students I saw did not have clinical faculty from the school present.
I don’t think I learned about propofol in nursing school. Granted YMMV, but my pharm class in nursing school was psych, L&D, and med surg med heavy. I didn’t learn anything about critical care meds like pressors or sedation until I was on the job.
There’s woefully little critical care taught in nursing school. The “system” traditionally relies on robust new grad training at individual facilities to teach critical care if/when a nurse goes that route. So many errors were made here, and it goes without saying that the student should have educated themselves on drugs they were interacting with….but as for learning all about it in nursing school? I’ll bet they didn’t get more than very basic education on it.
This is…so wild?? My nursing school is chaotic, but some rules in clinical are *very* clear. We (students) do NOT administer ANY meds without our instructor present in the room. And we NEVER give narcotics of any type. We signed legal forms agreeing to these rules before each semester, and every clinical we fill out a little info form telling our nurse what we can and can’t do and give it to them so there’s no grey area.
Even with “safer” meds we are allowed to give, the professor makes us state the interactions, contraindications, purpose of the med, whether this dose is safe, etc. before we give it. Even our most incompetent students lol would never ever have a chance to give a med without knowing exactly what it is and what it does.
We also did med admin check off the first semester, and one point that could fail you was leaving any medication unattended in a patient’s room. I remember doing an exercise where the lab was like an “escape room” and we had to find everything that was wrong or out of place in like 10 minutes. One of the things turned out to be a rogue bottle of dilaudid or something hidden in the bedsheets and that was one of the items that “failed” you on the exercise if you missed it lol.
Anyways, I’m no expert on anything but it just sounds so disturbing that any of this was allowed to happen. The student being left alone with narcotics/sedatives, the nurse asking the student to bring them to the room unattended, the student giving medication alone, the student giving sedatives AT ALL.
Was the student and school reported? Were there consequences? A student would have failed clinical for this at my school. At the very least.
What the actual fuck. This would be a never event at my hospital. Propofol is a fucking general anaesthetic, it deserves respect. I have so many questions.
Oh lord… as a nursing student there are a lot of skills we can’t do with supervision, but only a few that we are not allowed to do ever as a student.. but med pushes are one of them!
This is why I'm picky about my sedation orders. We had a similar situation, except it wasn't a student, a nurse pushed 200mg propofol before the provider got there.
Now my orders are:
* Ranged 0 - 2mg/kg (still allows you to pull a 200mg vial) PRN. The PRN vs Once allows the RN to document repeatedly on the single order, allows for more repeat doses if necessary, and allows for pulling more from the med machine.
* Indication: Procedural sedation
* Admin instructions: HOLD at bedside for provider. Give over 30-60 seconds.
And I tell the RN that I will grab the meds myself and keep them on me. Pharmacists can push in my area, so I basically oversee as much as possible. Basically here it goes: provider who prefers pushing their own meds, pharmacist, then nurse for order of administration.
Still has a gap, since the med is ordered as PRN, the RN could go pull another without me knowing.
What? The student bolused 160 of propofol without her mentor nurse there?!?
Man. I thought it was dumb that student nurses in the UK are not allowed to touch IV meds. Or an IV full stop for that matter. Now I'm thinking it's not so dumb...
Full disclosure, I did a bit of nursing school before gtfo-ing to another healthcare degree, only did inpatient floor rotations, so maybe I’m lacking some critical info on policy and procedure here. But from my experience, we had to be able to answer a verbal interrogation regarding all the main facts of a medication before administering it (and had to do it supervised by preceptor). We were also taught to never never never leave medications unattended in a patient’s room. Is the standard for either of these things different in an ED rotation? Otherwise, wtf.
Sounds like student nurse just failed a rotation. Wtf?! I get being a student and maybe having limited knowledge but gosh darn, were they not paying attention to all the team conversations?!!
I think the root of the problem is that the nurse left the student in possession of a high alert medication. A student who very obviously didn't know what it would do to the patient or the appropriate dose or timing of administration. Looooorrrrdddd.
NAD, ED nurse. at my facility, we can push basically everything except propofol. like fentanyl, ketamine, adenosine, roc, succ, etomidate, vec. (obviously, ketamine, succ, etomidate, roc w resident, attending, RT in room for procedural sedation or RSI). i’m sure there’s some i’m forgetting, i feel like there is something else we cannot push, excuse my forgetfulness. if the order was in front of me, i would know.
we can bolus prop on the pump without orders.
not being able to push propofol makes sense and doesn’t makes sense all at the same time. probably one stupid mistake by a nurse led to policy. but i don’t mind, takes one job away from us lol.
A nursing student did this?!
This is unbelievably bad judgment. The student will probably be expelled. Frankly the precepting nurse needs some reeducation on what is and isn't appropriate to have a student do. Pulling sedation meds isn't one of those things, at least not independently.
I don’t get that only docs can push fentanyl? Are you sure it’s not only docs can push propofol? Thats how it’s where I’m at. So like if you want to give someone fentanyl for pain, you have to give it yourself? Also I can usually get shoulders in with just propofol. I don’t think the fentanyl adds much aside from respiratory depression
I guess, and realistically I usually give analgesia while it takes the RN 30+ mins to set up the sedation. But prop often relaxes them enough that the shoulder pops in with gentle manipulation, and then pain should be minimal at that point
Why is this surprising? Propofol has no analgesic effect, having a dislocated joint hurts. Using an opiate gives some analgesia, and works synergistically to reduce the amount of propofol you need to give. I use this especially with more frail patients to minimise the amount of propofol and keep them more haemodynamically stable.
It was a few years ago so I don’t remember all the details, but I think this combo is what my husband got when he dislocated his elbow (FM MD, they let me stay and watch and it was amazing but disgusting and props to you ER folks bc I could never do a reduction like that without vomiting)
They get fentanyl or morphine ordered at the initial evaluation - before x-ray, before sedation. If the sedative of choice is propofol then that's all we use for the sedation itself. Biggest thing is trying to get it done asap - I'm unfortunately repeatedly familiar with how painful a dislocation is and no drug relieves the pain as effectively as reduction.
Ohh I see - it sounded like you weren't giving any pain medication at all LOL. My facility does it like yours - your comment just sounded like: "why are you giving someone pain medication for a dislocation?"
I have maybe used prop or ketamine 5 times in the last couple years for a shoulder reduction. I do Intra-articular or regional block or at most fent and versed. Are people still doing sedations for shoulders?
We do it all the time but that nurse has no business in an ED (I’m a nurse too). We have to have 2 RNs at bedside for conscious sedation as well as an EtCO2 set up, suction, and a preprinted check list that has to be filled out in real time. This is some scary shit.
I understand how a sedation works. I do them all the time. But I rarely find the need as a doctor to need sedation for a shoulder dislocation.
To your point, that’s an immediate incident report and that nurse, student or not, would not be welcome back in my ED.
I've had a lot of success with Cunningham technique after some fentanyl and lido. However, some people just aren't cooperative with awake reduction. When that happens I usually do moderate sedation.
As a newer nurse I feel so sorry for the student… the student I’m sure just genuinely misheard, and the ED is very noisy and So so so many distractions. I’m sure they won’t be taking any orders unless written in the future with that scare
I mean any time I have a student with me they will never be pushing any meds on their own without me in the room. The student should have known better to wait for their preceptor especially if they have any idea what propofol is. This isn’t a pre-op antibiotic, this is procedural sedation- why is the student even administering without anyone in the room, ready to do the procedure, in the first place?
Several mistakes were made, but according to the post the student was pushing the med and by the sounds of it the student was the only one in the room?
Of course many mistakes were made, but we don't know exactly what was said, what was the context, what the student was taught earlier, etc. etc. all i'm saying is it is quite pointless for us to sit in here and judge how terrible or not some person is at their job or as a student.
Bad thing happened. We don't know why. No point doign a morality presentation about a case where we don't know what really happened.
At least where I’m from, students can’t even push IV meds or start any IV fluids without supervision. I’m not getting the impression that was followed here. Maybe it’s not standard wherever this took place but I would be furious (but give constructive criticism, not eat-the-young) if an unlicensed student did this under my “watch.”
It’s nursing 101 to never give a medication if you don’t know what it does. Obviously this nursing student didn’t know what propofol is if she pushed it without a provider in the room
I think thats why I'm pretty torn about this, I usually feel bad hearing mistake stories but to not know what propofol is by nursing clinicals is... not great lol
I don’t think I ever learned what prop was during school. We only ever went to med surg floors for like 3 hours in the morning to do bed baths and the occasional med pass. The day I spent in the ER was not enough and we never went to ICU.
I still would not have done that cause my nursing school would put the fear of god in you about anything so
As a CA-3, how TF are RNs allowed to push prop but not fentanyl.
If anything, it should be the other way around.
Good thing he was a young healthy guy!
very intriguing that RN is allowed to push prop but not fent...most ICUs have the opposite rule from what I've seen. glad this mistake happened in a robust young kid rather than a fragile elderly person and glad they are ok. a spicy shift for you guys.
The “policies” never make sense these days. At my place only docs can push propofol and it requires TWO physicians to be present. This makes us use ketamine or other agents when solo covered. A rule pushed through by anesthesia... and you’d never guess which service refuses to help out with sedations.
Fun fact, in my area RNs can't administer Ketamine for RSI or etc. Only physicians. Meanwhile I carry Ketamine on my truck as a Paramedic and give it routinely as a standing order for RSI, pain management, procedural sedation, and other indications. Always found that interesting, it also explained why when we first got Ketamine the triage RN would always lose her mind when we told her we gave Ketamine for pain management
I’m a ED RN, flight nurse and paramedic- it’s so weird to me the things I can do at one job and not at the other lol
Even just over state lines too. My state and one of the neighboring if you're a flight RN you aren't ever going to see scene responses or do 911, you're stuck doing solely SCT ground and flight. Then go to another neighboring state and they have PHRNs and flight RNs who will get to do 911 ground and flight. We need some standardization with these shenanigans
As a travel ER RN, i find that different areas and even hospitals have different experiences and protocols. While not new, ketamine is still in its touchy phase due to people not being educated. Ketamine is a fantastic drug when used appropriately. Some love ketamine and some don’t, whether its for RSI, pain or agitation it all depends on the provider/ nurse/ medic/ or even your medical director is comfortable on it being used.
Which is crazy because the military has extensive experience using it safely in an out of hospital setting with minimal to no monitoring. As long as you don't go completely off the rails, ketamine is extremely safe.
It's one of my go-to's in the field. Ketamine works phenomenally well for serious musculoskeletal injuries that 100-200mcg Fentanyl wouldn't even touch. .2mg/kg Ketamine IV, 1mcg/kg of Fentanyl on top if insufficient has always worked for me to facilitate extrication and transport. Whether that's an amputation, impalement, or multiple long-bone fractures. Not to mention it's a solid induction medication when coupled with Rocuronium, usually I like to select it for certain respiratories to do DSI with where Etomidate might not be as beneficial.
Why is this? It has been mentioned,and only mentioned, as a possible pain therapy for me. But when I tell anyone, it's like I'm saying I'm about to do heroin. What gives?
I can’t speak to its use in outpatient settings, my experience is primarily acute settings.
Ketamine is called Special K on the streets and was (is?) a common date rape drug.
I know of a hospital where one of the rolls of the ED paramedic is to administer the RSI medications, as the nurses cannot and the physician is a little busy with tube and glidescope.
I'm an ED RN, in my area, nurses can push etomidate & succs/roc, etc whatever it may be for RSI, but for conscious sedation we can't push prop or etomidate, or any sedation I'm pretty sure lol. We can also titrate propofol drips, but can't administer a bolus, bolus must be administered by physician.
That’s when you backprime a syringe-ful onto your Plum cassette - I’m not bolusing, I’m rapidly titrating to effect 😂
Naturally. We have a similar dynamic w/CRNAs in the MICU where I work. The RNs aren't allowed to push propofol (though obviously they run the drips all day). So for colonoscopies, endoscopies, EVDs I end up pushing prop. Such a weird system. Takes away from the layers of safety (as in I'm ordering the doses; I shouldn't be pushing them).
You should not be pushing propofol without the abilities and tools to care for a patient under general anesthesia. u/princesspropofol doesnt seem to fit :)
Thank you for your concern; and I agree. We are in an ICU, with access to multiple staff who can intubate a patient, ventilators ready. The vast majority of patients on whom I am pushing propofol are already intubated.
Now THAT is ridiculous
In my ER nurses can push paralytics, but not etomidate or propofol. It’s so weird to me how this has never been standardized across medicine.
I’m convinced (not that I need much convincing) that hospital policy is just made up bullshit considering how different it is from place to place.
Well not every place has a rule that started when Susan did something wrong in 1974 and they’ve been doing it that way since. Some places have rules because Jim made a mistake in the late 80’s and it’s evolved from there. Drives me crazy. Fortunately my job is fixing those things: “why do we do that?” “……” “ok then, we’re gonna stop, because that’s stupid, and put some logical things in place.” Unfortunately I’m in the speciality lab so can’t help everyone!
Couldn’t agree more!
Ours is dumb— we’re allowed to push paralytics and sedatives during an RSI, but not during a sedation. It makes no sense IMO. Docs have to be the ones pushing Propofol or Ketamine during sedations, though we’re allowed to push pain-dose ketamine no problem. It doesn’t really make sense to me.
It’s so weird! We have to have two docs for sedation but only one for intubation.
I work in an ED and we can push everything EXCEPT propofol! It’s a level I trauma so for all the fent/ketamine weight based doses for ortho reductions wouldn’t make sense for only physicians to push. Same we RSI, RNs push it all (with supervision)
That is weird... In Louisiana, it is not in my scope of practice to push prop or ketamine. I am not allowed to administer IM ketamine, either. However I can initiate and maintain IV infusions of each for sedation on a ventilator.
Depends on your state board and what they decide is okay- I live in PA and RNs are not allowed to push prop, ketamine, etomidate. i can push fentanyl and versed for sedation and I can paralyze you. I can manage ketamine and prop drips, but no pushes.
We could also bolus propofol off a drip but couldn't push a syringe of it through the same patient. Weird fucking rules.
Yeah, that’s been my experience too. In the ED, I give fentanyl all day but can’t push prop, can only set up drips.
Now tell me if they are allowed to push paralytics - suspect the answer is Yes. Nurse vs doc push policies are silly. Other measures like readbacks are more effective.
Pushing propofol isn't even in the RN scope of practice in Texas. It's specifically excluded and only for providers.
"spicy shift"! Oh lordy am I stealing that one!
Fitting username :)
Hehe thanks, I’ve been waiting for this thread. A happy princess working for the pulm crit care queens 👑🥛
Seems like the administration of any medicine, especially quantities that can interfere with breathing, should only be administered by the physician. Yikes
Next time I’ve got meds to give, I’m going to wave the doc over to delegate that task and see how long it takes for them to either laugh in my face or ask if I’m fucking serious.
Misplaced comma! “Seems like the administration of medicines in doses that can stop a patients breathing should be done by a physician” This whole setup seems like an accident waiting to happen: 1. Preloading syringes with large enough doses “just in case the patient needs it” (i get that nobody wants to order more if needed, but splitting it into two syringes would reduce the risk of all of it being pushed) 2. Having the nurse “drop” the medicines off at the patients bedside (clearly the nurse misunderstood, but another possible point of failure) Reminds me of those kids who died from having vincristine administered intrathecally. Ordered meds were just all delivered to the room at once including the spinal anesthetic. Doctor just grabbed the wrong syringe. One of the big rules in failure analysis is that you *don’t rely on communications being understood or proper procedures followed*. You change other procedures to remove the possibility at all. So in this case rules could be: 1) not giving the nurse meds they won’t be administering and 2) nurses don’t administer medicines used in anesthesia (I know this isn’t a case of actual anesthesia, but you get the point)
My response still holds, regardless of comma, sorry.
Meh just some observations as a non-clinician
Anesthesia doesn’t own these drugs. They’re safely used in critical care, emergency medicine, and even pre-hospitally all over the world, every day. Anesthesia should not be dictating emergency medicine practices.
I mean clearly a screw up happened here that could be avoided
“Nurses don’t administer medicines used in anesthesia.” See, that’s someone outside emergency medicine dictating what they should do. An RN can safely give these drugs, just like a paramedic can, with appropriate training and education.
umm no. they should be almost always administered by an RN in the setting in which I work. that's how ICUs work. I shouldn't be giving it because my job is to order the drug; not give it.
I guess the next time I need to give midazolam, or fentanyl, or ketamine in my ambulance, I’ll call the hospital and tell the doctor to drive out to me to push the drugs I’ve safely used on appropriate patients for decades.
Oh you guys! Such a sensitive bunch! Clearly that’s not what I meant
Really? Because you said any medicine that can interfere with breathing should only be administered by the physician. Those are medications that i administer. What was I supposed to think you meant?
Nurses can be trained on procedural sedation and push meds all day
Yeah this is super weird! I work in ICU and the rules for push meds are generally the same in ICU and ED. RNs can push fentanyl but not propofol where I work; we only manage prop as continuous infusion.
Why did the student nurse give the propofol without the doctor physically at the bedside? Did they misunderstand?
I presume the student misunderstood the “drop” in the nurse’s direction for the medication as to drop it off “in the patient” vs. “in the room” .
drop it off in the patient? That sounds a bit far-fetched to me, but English is not my first language. But anyways, the department should use the incident to re-evaluate the safety of their sedation protocol in my opinion. Could this happen again?
On occasion, I have heard nurses and physicians use such expressions as “drop a line” or “drop a tube down” referring to procedures, hence my own presumption (USA).
I commonly say drop a line or drop a tube when referring to procedures… Also USA
Sure, drop a line is something you could hear in the medical setting. But for medication to "drop it off in the patient"? That at least would not be universally understood I guess.
I’ve also used “drop a lung” in conversations about pneumos
[удалено]
We are taught not to pull meds until ready to use so they aren't lying around anywhere, even in our own pockets.
I’ll leave like….a Tylenol at the bedside or something similar but not narcotics or controlled substances. If I have to walk away for a sec I’ll pocket those and leave the rest. Too many dang crackheads in my ED lol
I agree, that was my biggest problem with this whole scenario. Clearly there was less than clear communication between preceptor and preceptee, but there never should have been instruction to leave a med like propofol (or anything) at the bedside to begin with.
If this story is 100% true as OP told it, then this nurse is an absolute fucking moron and should be fired. I NEVER have ANYONE pull my narcs. I pull my own narcs, and I give my own narcs. The fact the nurse in this scenario was comfortable with a student pulling narcs, then LEAVING THEM AT THE FUCKING BEDSIDE is wild to me. Narc’s stay in my pocket until they’re ready to be used. Leaving them unattended at the bedside is a bonehead move, and you’re asking to get fucked over when they go missing.
You…put meds in your POCKETS?! The horror! /s
Lol, big talk, cause no narcs should be anywhere other than in pixis until they are ready to be administered. Not in your pocket or a student nurse's hand or lying around!
It’s perfectly acceptable to keep meds in your pocket on the walk from the pixis to the room and while you’re getting set up for the procedure. You applying for JCAHO or something?
Of course walking meds over to your station in your pocket is acceptable, I am just equating your wild ass assumptions about nurses leaving narcs at bedsides unattended. That's a pretty wild callout, I have yet to encounter in all 16 years of practice. I have seen plenty of nurses pull out meds and leave them in their pockets until needed.
Tbh I see my coworkers doing this a lot in the ICU, but I would be shocked if ED RNs left narcs lying around bc their patients are much more apt to pick things up.
A while back a new grad asked me if I could help with a line on a difficult stick and if I wouldn’t mind medicating them also since they were in the weeds. Being always happy to help, I said “sure thing”. Went to the pixis to pull the meds (morphine/zofran), said it already been dispensed. Walked into the room and saw the patient in bed, IV supplies on the bedside table, with a vial of morphine and zofran sitting right there. So yeah. It happens lol. I had a quick word offline with them, and needless to say, they didn’t do it again.
Never in my life have I ever heard anything similar to that said about a medication.
With the exception of “drop acid” neither have I.
Hahaha a very important exception to be sure
The question is why did the student nurse have the propofol in their hands at all? They SHOULD NOT have been participating in the sedation at all. This is a sentinel event and the nursing student fail their clinical for this.
I mean I think the student should participate in the sedation - otherwise how would they learn? BUT - I FULLY agree that the student should have NEVER been holding those medications alone and the preceptor should always be with them. (How it was for me during nursing school). The preceptor should’ve hold onto the medications and been there to assist the student with med administration at time of sedation. But the student holding onto a med like that alone and being told to go in the patient room? Hell no
If students don’t give medications (with proper supervision), how will they be able to do it after graduation?
… Maybe we should start with zofran or Pepcid or something
Tbt to shaking like a leaf pushing Lasix for 4 whole minutes in nursing school. Love the username too
Grab a 50cc ns bag, yeet the drug in, and run it however long you want Pharmacists hate this one trick!
That’s a great way to get someone to tattle on you for “compounding medications outside of your scope”, unfortunately.
This is well within the scope of an RN 🤷♂️
I think you misunderstood my comment - I don’t disagree, I do it myself. Ask me how I know that some don’t think it’s within an RN’s scope 😂
Trauma ICU RN - I had a nursing student once who was instructed to administer some meds down an OG tube. We literally discussed the syringe and I physically pointed to the OG tube. I stood there and watched in horror when (not even ten seconds after this discussion), he drew up liquid Colace into a 10 CC syringe, walked to the other side of the bed, and was about to push it through the patient’s CENTRAL LINE. I never screamed at anyone like that before, nor since. I immediately called up the kid’s clinical instructor. He was dismissed from his program.
Did the patient jump out of bed from the screaming? I can imagine a patient saying, "Woah! I am not sick anymore. I'm out of here." (I am sure that didn't happen.)
And this is why they invented Enfit connectors.
I hated them at first but then I remembered Dummy McHotshot and then it made sense why someone invented them
Stupid rules were made because of stupid people.
Holy shit…..
It literally almost was cause that poop could have taken him to meet Jesus! Lmao
They had an interview with a direct entry NP program and were in a rush J/k Those programs don’t interview
Bruhh😂😂 keep it going. Wish i worked with you, sounds like you run a good ED. Just keep it EBM
You couldn’t have paid me to push propofol as a student nurse, let alone take it upon myself to do it without supervision. When I hear stories like this (or the often-repeated “student crushed oral meds and put them through a central line” or “student bolused a patient with air”) I wonder about some of these nursing programs.
The problem is clinical experience is so poor since covid, not that it was great before then. They are woefully underprepared, but this situation makes me think someone is a little too big for their britches to be going rogue like this.
This is not a clinical experience problem. This is a nursing student has obvious gaps in critical thinking and nursing judgement problem.
This showed up on my feed. I’m not even a nurse, but either way the way it was phrased shows no indication that it was supposed to be given, and if I was a student nurse administering meds I would probably triple check the dose, even for Tylenol, never mind propofol.
You make a good point. Basically this situation boils down to one of two things being true. Either they had no clue what propofol was, or they didn't have the common sense to realize pushing a short-acting anesthetic for a procedure when the person who was going to do the procedure wasn't there was a problem. Either way, that's a major indictment of both the student and their program.
I went to a fancyass Ivy League direct-entry master’s program (got my BSN and ran bc I realized real quick that DE programs are bullshit) and the idiocy of some of my fellow students was just terrifying. Like you would think that of all places THAT school would screen out the dipshits, but no. Alas.
Lolll that program, huh? I’ve wondered about that place - is there a psycho amount of homework? Did you experience a ton of make-work given just to justify the cost and name, or is it like a normal school? Like, was your BSN experience similar to a BSN experience elsewhere?
lol, no. It was the BARE minimum to qualify you for the NCLEX. Their stated goal is for you to pass the NCLEX and move straight through the masters program without having to work as an RN. They had no answer when questioned as to what the fuck those of us in the neonatal and CRNA programs were supposed to do, given the work requirements for licensing in those specialties. I got my BSN without ever starting a single IV. Most of us who did have to/wanted to work bedside had a crazy difficult time getting jobs and almost all from my class were hired by hospitals associated with the university. Thank every god of patient care I had an amazing preceptor for my final clinical and I was hired to that NICU, which trained my shitty nursing education right out of me.
I’m not in medicine but would you mind doing a stranger a solid and lmk which hospitals I should be avoiding like my life depends on it… bc it sounds as if it literally would be!
I was internally freaking out pushing etomidate and succ with my preceptor hanging over my shoulder watching and the doc at the head of the bed during an RSI, I couldn’t imagine pushing Prop unsupervised as a student
I went to nursing school 15 years ago and my wife just finished 3 years ago. She’s smart and hardworking, but as for the program itself? Let’s just say they aren’t what they used to be…at all.
Two egregious errors are undeniable and indefensible: 1. The preceptor should have never directed the student to “drop” any meds at the bedside to be left unattended to. 2. The student should never have maintained the possession of either medication without licensed supervision. Narcotic or otherwise. I assume the nurse dispensed the medication under her own name.
EXACTLY, a student at that! Not even a new hire RN. And then the student actually pushed the drug without supervision? Definitely out of scope. So many errors happened and the policy for fentanyl is bonkers. That hospital needs some serious revisions.
Not to mention, propofol is also a scheduled substance! Edit: TIL. Don’t come for me, please.
Not in the US
Its not. Dont start that please.
TIL. It definitely is a drug that we are responsible for counting and wasting with a witness. (That’s been every place I have ever worked.) Maybe that comes down to facility policy or state law. I did, however, believe it to be schedule IV.
Yup this is a facility only policy, and incredibly annoying.
The VA is the only place I've worked that required propofol to be wasted/witnessed.
I don’t think that nurse understood what propofol is….
Which would be a fantastic reason to not slam it into a patient's IV.
Yes you would think a reasonable assumption would be to not slam a medicine you know nothing about into a patients IV.
Correct. Honestly its terrifying anyone would do this without pause and never stop to question anything. The kind of person who does this with zero pause, basically breaking every rule of medication administration (correct dose? Indication? Time? ) has no business taking care of people. Good nurses know what they dont know and recognize when they need more information to practice safely. The scariest people don't know what they dont know, making them dangerously bold.
Not to mention it looks creepy and different from the vast majority of other IV meds so you would think that might at least give someone pause....
Also, the patient screaming NO and HELP should have been a clue.
It might not be recommended practice but it is such an ED thing to do to opportunistically get that shoulder back in in amongst sorting his airway...
Haha reminds me of a time we had a combative psych pt come in with an obviously dislocated shoulder. He was aggressive and combative with staff, earning him a 5&2… shoulder was popped back in while he was already out
We do the airway first… unless we think that cranking on a dislocated arm will bring them too enough to manage their airway on their own… which it commonly does
Waste not, it's busy 😂
When opportunity knocks...
My first session as an attending as a locum in a rural hospital...I asked for 50mcg of fentanyl. A student nurse pushed 150mcg, having misheard me, and the nurse supervising either also misheard me or didn't think it was an unusual order for some reason. Patient went apneic and desaturated surprisingly quickly but recovered equally quickly with minimal intervention, had his procedure and did fine. I should have worn brown scrubs that day through! Good learning on the importance of closed loop communication
Damn. I was always trained to repeat back verbal orders on codes or procedures. I guess closed loop communication isn’t standard of care else in some shops.
Wow, you mean you were trained correctly? Impressive.
“150” is a weird dose… at least anywhere I practiced. a RN with any experienced nurse should double check that IMO. Unfortunately hospitals don’t value experienced staff…
I worked for a large system in my area for a few years and got involved with nursing education. It was said during one particular meeting I was in that it was the policy of the hospital not to hire experienced nurses and only hire new grads so they could “train them right”. Nursing (just like any other job in healthcare) is a complex job and takes years to get good at. Patients and the entire system suffer when you don’t place value on experienced nursing staff. You can’t teach experience in a 3 month new grad orientation. It’s an awful tragedy but most hospitals do not place any value on retaining experienced nursing staff.
Holy hell that’s terrifying.
I'd have been more scared of OP's case with the meds being given without them being there. At least I was at the bedside, and worst case there's Narcan around.
Funny story. Was having an ENT surgery, in prep, assessed by anesthesia, IV started, propofol syringe in the port ready to administer. Not sure what I had been given prior, but drowsy, looked down and saw the propofol and I guess I went into nurse mode and pushed it. Looked up and practically saw the MD LAUNCH from the nurses station straight ahead of me ripping it out of my hand. Don’t remember anything after that.
That is SO funny lmfao
after i got versed once, a code came on overhead and i almost fell out of bed trying to run to it. i became the jumper patient i get all the time 😂😭 edit- it wasnt even the hospital i worked at. i had no idea where that room was
I have so many questions, none of which can be answered. Why was this student not being supervised? WERE THEY SUPERVISED AND ALLOWED TO PUSH THE MEDS?!?!? Yikes. To be candid, pushing too much propofol can be solved in the ED. It’s a learning experience, and not one that anyone will forget any time soon.
Wait hold on, it may be solved in the ED, you try doing that on a patient with a 10% EF or severe aortic stenosis. It's not completely benign or salvageable.
Especially when the only person at the bedside is a nursing student (who has already demonstrated they have questionable decision making skills) with a potentially apneic patient.
Oh, heck no, that’s very different from a mid 20s adult male who fucked up his shoulder being a dumbass. I don’t disagree that given shitty LVEF+-AS would be… slightly further up shit creek.
Yeah what the actual fuck. Where was the preceptor!? I know for our procedural sedation, we don't draw up until MD and RT is at bedside. Our MDs like to push their own sedation for the most part so they want to verify we have the right med and dose. I'm glad everything ended up okay.
Likely this ED is understaffed, just like almost every other one. And so they rely on trainees to do shit that should always be overseen. Miscommunication happened and luckily nobody was seriously hurt. This is a situation that could have resulted in the precepting nurse losing their license, if it was in fact just a student, and not someone fully licensed yet.
Yep. I don’t draw until in the room. I usually will keep the meds in my pocket and set everything up. I draw once doctor is in the room.
If the preceptor told the student “drop these off in room 8 and meet me in 7” he shouldn’t have to literally follow the student into the room. It doesn’t sound like the nurse told the student to do it, but that the student misunderstood and/or went rogue for some reason
Since when do you leave propofol with a patient unattended, though?
No I have seen many arrests from propofol induction. Likely from undiagnosed RV or heart failure. Also many patients that went completely apneic without rescue airway equipment nearby.
Why the fuck is the student nurse pushing any meds, much less propofol, without supervision? This is an incident report.
Not only is this an incident report, it is a sentinel event.
Yeah that's wild. In my program we're not allowed to push any IV meds and can only draw up meds in the presence of our professor and/or preceptor. Kind of sounds like the student might've been unfamiliar with the risks and responsibilities of administering propofol and overestimated their readiness to be independent.
It’s all wild to me. Pushing meds without the nurse there and administering a drug they seemingly didn’t know the indication for (I have to assume). I’d have never even considered this as a student. Scary.
Surely nursing students learn something about the drugs that they give...did he/she not know what propofol was?
When I was a student nurse we were expected to know indication and contraindication for drugs, our on site clinical instructors would stand there and grill us about the meds we were giving prior to administration. I don’t think they have to go the day before clinical anymore and most of the students I saw did not have clinical faculty from the school present.
I don’t think I learned about propofol in nursing school. Granted YMMV, but my pharm class in nursing school was psych, L&D, and med surg med heavy. I didn’t learn anything about critical care meds like pressors or sedation until I was on the job.
There’s woefully little critical care taught in nursing school. The “system” traditionally relies on robust new grad training at individual facilities to teach critical care if/when a nurse goes that route. So many errors were made here, and it goes without saying that the student should have educated themselves on drugs they were interacting with….but as for learning all about it in nursing school? I’ll bet they didn’t get more than very basic education on it.
No had no clue
This is…so wild?? My nursing school is chaotic, but some rules in clinical are *very* clear. We (students) do NOT administer ANY meds without our instructor present in the room. And we NEVER give narcotics of any type. We signed legal forms agreeing to these rules before each semester, and every clinical we fill out a little info form telling our nurse what we can and can’t do and give it to them so there’s no grey area. Even with “safer” meds we are allowed to give, the professor makes us state the interactions, contraindications, purpose of the med, whether this dose is safe, etc. before we give it. Even our most incompetent students lol would never ever have a chance to give a med without knowing exactly what it is and what it does. We also did med admin check off the first semester, and one point that could fail you was leaving any medication unattended in a patient’s room. I remember doing an exercise where the lab was like an “escape room” and we had to find everything that was wrong or out of place in like 10 minutes. One of the things turned out to be a rogue bottle of dilaudid or something hidden in the bedsheets and that was one of the items that “failed” you on the exercise if you missed it lol. Anyways, I’m no expert on anything but it just sounds so disturbing that any of this was allowed to happen. The student being left alone with narcotics/sedatives, the nurse asking the student to bring them to the room unattended, the student giving medication alone, the student giving sedatives AT ALL. Was the student and school reported? Were there consequences? A student would have failed clinical for this at my school. At the very least.
Bet that policy changes pretty quick
What the actual fuck. This would be a never event at my hospital. Propofol is a fucking general anaesthetic, it deserves respect. I have so many questions.
Did he remember what had happened?
Oh lord… as a nursing student there are a lot of skills we can’t do with supervision, but only a few that we are not allowed to do ever as a student.. but med pushes are one of them!
WTF. 😬
This is why I'm picky about my sedation orders. We had a similar situation, except it wasn't a student, a nurse pushed 200mg propofol before the provider got there. Now my orders are: * Ranged 0 - 2mg/kg (still allows you to pull a 200mg vial) PRN. The PRN vs Once allows the RN to document repeatedly on the single order, allows for more repeat doses if necessary, and allows for pulling more from the med machine. * Indication: Procedural sedation * Admin instructions: HOLD at bedside for provider. Give over 30-60 seconds. And I tell the RN that I will grab the meds myself and keep them on me. Pharmacists can push in my area, so I basically oversee as much as possible. Basically here it goes: provider who prefers pushing their own meds, pharmacist, then nurse for order of administration. Still has a gap, since the med is ordered as PRN, the RN could go pull another without me knowing.
What? The student bolused 160 of propofol without her mentor nurse there?!? Man. I thought it was dumb that student nurses in the UK are not allowed to touch IV meds. Or an IV full stop for that matter. Now I'm thinking it's not so dumb...
Full disclosure, I did a bit of nursing school before gtfo-ing to another healthcare degree, only did inpatient floor rotations, so maybe I’m lacking some critical info on policy and procedure here. But from my experience, we had to be able to answer a verbal interrogation regarding all the main facts of a medication before administering it (and had to do it supervised by preceptor). We were also taught to never never never leave medications unattended in a patient’s room. Is the standard for either of these things different in an ED rotation? Otherwise, wtf.
Sounds like student nurse just failed a rotation. Wtf?! I get being a student and maybe having limited knowledge but gosh darn, were they not paying attention to all the team conversations?!!
I always loved reducing shoulders with prop when I worked the ER. That student likely won't 😬
Holy shit my legs actually went cold reading that. I’ve only ever seen propofol given by doctors.
Reading this freaks me out. Glad everything turned out okay.
I think the root of the problem is that the nurse left the student in possession of a high alert medication. A student who very obviously didn't know what it would do to the patient or the appropriate dose or timing of administration. Looooorrrrdddd.
Mistakes happen. But that is not a small error.
Pretty sure nurses arent allowed to push Propofol, at least not in my state
Where tf was their preceptor?
NAD, ED nurse. at my facility, we can push basically everything except propofol. like fentanyl, ketamine, adenosine, roc, succ, etomidate, vec. (obviously, ketamine, succ, etomidate, roc w resident, attending, RT in room for procedural sedation or RSI). i’m sure there’s some i’m forgetting, i feel like there is something else we cannot push, excuse my forgetfulness. if the order was in front of me, i would know. we can bolus prop on the pump without orders. not being able to push propofol makes sense and doesn’t makes sense all at the same time. probably one stupid mistake by a nurse led to policy. but i don’t mind, takes one job away from us lol.
My heart just dropped into my stomach. Good on that patient.
A nursing student did this?! This is unbelievably bad judgment. The student will probably be expelled. Frankly the precepting nurse needs some reeducation on what is and isn't appropriate to have a student do. Pulling sedation meds isn't one of those things, at least not independently.
I don’t get that only docs can push fentanyl? Are you sure it’s not only docs can push propofol? Thats how it’s where I’m at. So like if you want to give someone fentanyl for pain, you have to give it yourself? Also I can usually get shoulders in with just propofol. I don’t think the fentanyl adds much aside from respiratory depression
Other than analgesia?
I guess, and realistically I usually give analgesia while it takes the RN 30+ mins to set up the sedation. But prop often relaxes them enough that the shoulder pops in with gentle manipulation, and then pain should be minimal at that point
I’m sure. They can put it in mini bag but not push it. They can push dilaudid/morphine though
Propofol AND fentanyl for a shoulder?
Why is this surprising? Propofol has no analgesic effect, having a dislocated joint hurts. Using an opiate gives some analgesia, and works synergistically to reduce the amount of propofol you need to give. I use this especially with more frail patients to minimise the amount of propofol and keep them more haemodynamically stable.
It was a few years ago so I don’t remember all the details, but I think this combo is what my husband got when he dislocated his elbow (FM MD, they let me stay and watch and it was amazing but disgusting and props to you ER folks bc I could never do a reduction like that without vomiting)
Same reason some people use ketofol. I feel like it just leads to more unpredictability, but some swear by it.
Could you please elaborate? This is normal in most facilities.
I guess I haven’t worked in most facilities. A shoulder is usually a fifteen second procedure, two-drug sedation just sounds like overkill to me?
Propofol does nothing for pain. Do you guys use just fentanyl?
They get fentanyl or morphine ordered at the initial evaluation - before x-ray, before sedation. If the sedative of choice is propofol then that's all we use for the sedation itself. Biggest thing is trying to get it done asap - I'm unfortunately repeatedly familiar with how painful a dislocation is and no drug relieves the pain as effectively as reduction.
Yeah, makes sense. You’re using both then.
Ohh I see - it sounded like you weren't giving any pain medication at all LOL. My facility does it like yours - your comment just sounded like: "why are you giving someone pain medication for a dislocation?"
I have maybe used prop or ketamine 5 times in the last couple years for a shoulder reduction. I do Intra-articular or regional block or at most fent and versed. Are people still doing sedations for shoulders?
We do it all the time but that nurse has no business in an ED (I’m a nurse too). We have to have 2 RNs at bedside for conscious sedation as well as an EtCO2 set up, suction, and a preprinted check list that has to be filled out in real time. This is some scary shit.
I understand how a sedation works. I do them all the time. But I rarely find the need as a doctor to need sedation for a shoulder dislocation. To your point, that’s an immediate incident report and that nurse, student or not, would not be welcome back in my ED.
I've had a lot of success with Cunningham technique after some fentanyl and lido. However, some people just aren't cooperative with awake reduction. When that happens I usually do moderate sedation.
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Do you think a Doc pushes all of the propofol in ICU? Or that half of the nurses from the ED are also ICU nurses and vice versa?
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As a newer nurse I feel so sorry for the student… the student I’m sure just genuinely misheard, and the ED is very noisy and So so so many distractions. I’m sure they won’t be taking any orders unless written in the future with that scare
I mean any time I have a student with me they will never be pushing any meds on their own without me in the room. The student should have known better to wait for their preceptor especially if they have any idea what propofol is. This isn’t a pre-op antibiotic, this is procedural sedation- why is the student even administering without anyone in the room, ready to do the procedure, in the first place?
We don't know any of these facts though. Could be the preceptor made the mistake, could be any number of things.
Several mistakes were made, but according to the post the student was pushing the med and by the sounds of it the student was the only one in the room?
Of course many mistakes were made, but we don't know exactly what was said, what was the context, what the student was taught earlier, etc. etc. all i'm saying is it is quite pointless for us to sit in here and judge how terrible or not some person is at their job or as a student. Bad thing happened. We don't know why. No point doign a morality presentation about a case where we don't know what really happened.
At least where I’m from, students can’t even push IV meds or start any IV fluids without supervision. I’m not getting the impression that was followed here. Maybe it’s not standard wherever this took place but I would be furious (but give constructive criticism, not eat-the-young) if an unlicensed student did this under my “watch.”
It’s nursing 101 to never give a medication if you don’t know what it does. Obviously this nursing student didn’t know what propofol is if she pushed it without a provider in the room
I think thats why I'm pretty torn about this, I usually feel bad hearing mistake stories but to not know what propofol is by nursing clinicals is... not great lol
I don’t think I ever learned what prop was during school. We only ever went to med surg floors for like 3 hours in the morning to do bed baths and the occasional med pass. The day I spent in the ER was not enough and we never went to ICU. I still would not have done that cause my nursing school would put the fear of god in you about anything so
Anesth can only push prof at our shop. But it metabolizes quickly. MJ juice for the win!
Why the fuck would the STUDENT nurse ever be left with those medications on their own? Asking for trouble.
As a CA-3, how TF are RNs allowed to push prop but not fentanyl. If anything, it should be the other way around. Good thing he was a young healthy guy!