N.P vs MD/DO ?

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DutchgirlRN said:
You can bolus a patient by setting the pump at 999ml/hr and that usually runs it in faster than wide open, unless you have an IV in that is at least a 18g...
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Many years ago, working small urgent care; A healthy young person comes in at closing (n/v)...Doc tells me to get 1 litre in "as fast as I can"
Pt okays 16g...
Infused in twelve minutes, gravity only (hang 'em high...)

We get out on time...
 
chimichanga said:
Many years ago, working small urgent care; A healthy young person comes in at closing (n/v)...Doc tells me to get 1 litre in "as fast as I can"
Pt okays 16g...
Infused in twelve minutes, gravity only (hang 'em high...)

We get out on time...
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With a 16g definately doable
 
Paseo Del Norte said:
Ummm, ok then. Regarding propofol: You mean to say that people in your ER are simply given IV push propofol for ongoing sedation? You would essentially need a one on one provider to push propofol. I could not see a patient going to ICU with propofol IVP PRN orders. 😱
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I only use propofol for procedural sedation.
I have never hung a propofol drip in my entire career.
most of my drips are abx, banana bags, anticonvulsants, antiarrhythmics, pressors, etc
have hung narcan drips several times as well(and yes, without a pump).
and if someone needs fluids NOW they are getting an 18g or larger and no pump.....
when I was a medic intern we could only count 18g or larger as IV access so although we could use smaller they didn't count toward the required total #.
 
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emedpa said:
have hung narcan drips several times as well(and yes, without a pump).
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I really don't get the reluctance to use a pump but to each his own. I hope it doesn't ever come back to bite you in the butt.
 
DutchgirlRN said:
I really don't get the reluctance to use a pump but to each his own. I hope it doesn't ever come back to bite you in the butt.
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when I work day shift the nurses can use pumps if they want if they are the ones mixing and monitoring the drips, etc
for me it just seems like a waste of time. I'm the only provider covering an 11 bed dept at night with 1 nurse so my time is better spent seeing pts and doing procedures than futzing with a pump.
I have used syringe pumps before for heparin and ntg drips as a medic but not for a LONG time.
 
emedpa said:
when I work day shift the nurses can use pumps if they want if they are the ones mixing and monitoring the drips, etc
for me it just seems like a waste of time. I'm the only provider covering an 11 bed dept at night with 1 nurse so my time is better spent seeing pts and doing procedures than futzing with a pump.
I have used syringe pumps before for heparin and ntg drips as a medic but not for a LONG time.
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No pharmacy?
 
Ok then, it's all fun and games until you bomb somebody with a massive amount of norepinephrine or insulin.
 
Wow. I've given Propofol IV continuous infusion in the PICU; BUT those kids were on ventilatory support. There was a whole procedure on it, plus the need to change the IV tubing in 4hours or less. Needless to say, we set it on an infusion controller/pump. We used the same documentation for base concentration and checks-administration that we used for our kids on fentanyl, midazalam, neuromuscular blockade meds, pressors, like milrinone, dopa, doputa, and all the rest.
 
I'm with these guys...

It's a safety issue...

Do you send r/o appy pts to the OR w/o a CT (anymore)...If you do, then you are a rarity...Haven't seen that happen in ten plus years...My point is that technology evolves...Move with it...

Dopamine w/o a pump should really only be done in EMS, or maybe, maybe, intraprocedure in the cath lab...From a legal standpoint, you'd have no leg to stand on. The plantiff can establish that: you have access to pumps, everybody else in your dept uses one, and it's been the standard of care since before I started in nursing...

Wow, ballsy, but unnecessarily dumb (IMO)

I also can't get over why a provider (doc or PA) is hanging IV solutions...I've worked in small EDs at night, being the only RN...Never had a doc do more than start a line...Those are RN responsibilities...

Interesting...I guess I would appreciate the help, but if you're hanging pressors, insulin, or narcan by gravity, I wouldn't go anywhere near documenting on that chart...
 
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jl lin said:
Wow. I've given Propofol IV continuous infusion in the PICU; BUT those kids were on ventilatory support. There was a whole procedure on it, plus the need to change the IV tubing in 4hours or less. Needless to say, we set it on an infusion controller/pump...
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In defense of Em, propofol for procedural sedation, (IV push) is very common, and a pump in that instance would not make sense...
 
In 34 years I've never seen a doctor start an IV. Probably they could but without regular practice I doubt the patient would appreciate it. I start 20-30 a day. I think that is a job best left to those who do it regularly such as nurses, anesthesiologists, CRNA's, etc...

...and I agree, pumps should always be used with anything other than maintaince fluids. It makes no sense to fight it. Perhaps an orientation on how to operate an IV pump is in order?
 
20-30 a day?

where? Not ER I hope...Maybe pre-op or cath lab? just curious...

I worked with a pediatrician in the UC...She didn't mind starting kids' IVs, if nursing couldn't get it (at night, that was me, and only me)...She moonlighted as an intensivist in a PICU, so I could see where doing that could get you enough IV practice...

I think we have gotten way off topic...

Where are Taurus and Tired to take us back to the original topic?
 
chimichanga said:
It's a safety issue...

Interesting...I guess I would appreciate the help, but if you're hanging pressors, insulin, or narcan by gravity, I wouldn't go anywhere near documenting on that chart...
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Well, w/what sounds like average 1/10 patient ratio on nights---highly doubt whoever would have the time to fully document their own stuff much less what EMED's doing while 'helping'....

I dont know, I gotta believe he's having fun and just blowin' smoke.
EMS machismo flashback or something?

No way anyone's truly that casual about those meds off pump(pressors, insulin, K+, etc)

especially w/ a total licensed staff of 2 and a possible 10 pts....
I call BS

one can hope??😕
 
Paseo Del Norte said:
Ok then, it's all fun and games until you bomb somebody with a massive amount of norepinephrine or insulin.
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or you underdose them with a critical med or don't fluid resuscitate them adequately due to a simple pump error(by the rn) , both of which I have seen several times.
we had a dka pt a few yrs ago who was supposed to be getting 750 cc/hr of fluid.
the pump was set at 7.5cc/hr. fortunately I noticed the error in the first half hr and found a competent rn to reprogram the pump....
 
chimichanga said:
Interesting...I guess I would appreciate the help, but if you're hanging pressors, insulin, or narcan by gravity, I wouldn't go anywhere near documenting on that chart...
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come on, most of these are so easy you can do them in your head:
narcan 10mg in 1000 cc= 1mg/100cc. 100 cc/hr= 1 mg/hr
there is a free video on www.emrap.tv (which I highly recommend by the way) showing em residents how to mix and hang their own epi drips without a pump...and it's encouraged by the em residency faculty who host the show....
 
emedpa said:
or you underdose them with a critical med or don't fluid resuscitate them adequately due to a simple pump error(by the rn) , both of which I have seen several times.

Hardly bro. Since it's anecdotal hour at SDN, I remember coming on shift after a nurse hung an insulin drip to gravity. Kinda sucks when you bomb a patient with 100 units of regular insulin. Oh well, after all, he was in DKA and needed the insulin...


we had a dka pt a few yrs ago who was supposed to be getting 750 cc/hr of fluid.
the pump was set at 7.5cc/hr. fortunately I noticed the error in the first half hr and found a competent rn to reprogram the pump....

Sounds like a nurse problem and not a pump problem.
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I all for wide open with a pressure infuser or blood pressure cuff in the ghetto if you need to give a bolus; however, vasoactive medications and antidysrhythmic infusions simply hung to gravity utilising the old drop factor formula and counting drops with a roller clamp as the only thing between the patient and 4 mg of norepinephrine?
 
Miss Mab said:
Well, w/what sounds like average 1/10 patient ratio on nights---highly doubt whoever would have the time to fully document their own stuff much less what EMED's doing while 'helping'....

I dont know, I gotta believe he's having fun and just blowin' smoke.
EMS machismo flashback or something?

No way anyone's truly that casual about those meds off pump(pressors, insulin, K+, etc)

especially w/ a total licensed staff of 2 and a possible 10 pts....
I call BS

one can hope??😕
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we actually have 11 beds but it is rare that they are all full on night shifts(after 1 am anyway). our techs help out quite a bit as well. they are credentialed for venipuncture, foleys, im and subq meds(except for subq insulin), neb tx, ekg's, etc.
only a few of us who work nights start our own lines, etc(basically those of us who used to be medics) but it does speed up the flow considerably vs having to wait on the 1 rn to do all of them. anyone sick enough for serious drips won't be in our dept very long as they make for easy admits and the floor can deal with them however they like.
if you can do basic math you can do drips without a pump. paramedics all over the world do it everyday, even with pressors.....I suppose next you guys will try to convince me that dynamaps are better than manual bp cuffs....don't get me started......
 
emedpa said:
I suppose next you guys will try to convince me that dynamaps are better than manual bp cuffs....don't get me started......
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It is amazing the difference between the two. I'd check a patients BP on the machine at 4am and it would be 80/40. I'd recheck it manually before telling the nurse if the patient was alert/oriented. Most of the time it would be 100/60 or higher.

I got to the point where I didn't really trust them. On all my patients who needed an accurate BP I'd always do it manually.
 
foreverLaur said:
It is amazing the difference between the two. I'd check a patients BP on the machine at 4am and it would be 80/40. I'd recheck it manually before telling the nurse if the patient was alert/oriented. Most of the time it would be 100/60 or higher.

I got to the point where I didn't really trust them. On all my patients who needed an accurate BP I'd always do it manually.
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yup, they are ridiculously inaccurate.
I end up rechecking all of the ones that sound way off manually myself or if I'm busy I write an order for a manual bp.
so the question is, if a manual bp is the standard to recheck an abnormal bp why do we accept anything else?
it's like axillary temps instead of rectals on kids....or wee bags instead of cath urines....it's about laziness.....
 
The only "plus" to the machines is that I can do all my vitals in the dark. The patients sure do appreciate it when it is 4am.

I research all my patients so I know who the more critical ones are and who the ones are who need a very accurate BP. Those I always do manually. Then I recheck manually any abnormal values. The rest I let go because the machine is going to pick up anything drastic. I suppose that might change depending on the type of floor I work on but this was just med/surg and mostly post-ops who were going home the next day after routine surgery.
 
emedpa said:
\...if you can do basic math you can do drips without a pump. paramedics all over the world do it everyday, even with pressors......
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Oh, well in that case.......🙄
I admit I'm usually much too quick to give others the benefit of the doubt.
I definitely gotta stop w/that.

Be assured the issue is not so much about 'tricky' math troubles that will prevent MOST of us from running critical meds sans pump for no other reason than, well, just 'cause.
And from your posts it does seem like you're only concerned with errors that could come up w/the mixing.
And, agreed, it's not exactly rocket science---those calcs aren't even learned in nursing programs usually. That's more pharm/nursing pre-req territory, right? Let's get real.

My ED we do hang propofol drips---- dopamine, insulin and amniodarone are entirely routine meds. Bottom line, there's simply no excuse to purposefully bypass such a crucial safety measure (in favor of what--a 21 cent plastic roller clip w/out even the pretense of pt/family lockout mech.???) particularly if done only for convenience or 'cause ya think it might somehow just 'sound cool' to say crazy-Azzz stuff like:

"I never use a pump-----even for dopamine"

That's some scary ***T.......but mostly it's just reckless.....both for your patients and your license.
 
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How then do you deal w/ 0.5 ml w/ the roller clamp?

Round up?

Ah what the hell, he'll probably need the extra vasopressin anyway...

Titrate schmitrate...We just estimate in these parts...

Again, let's say you are right on all points...You have the pt/family factor, and the human factor...Legally you have no leg to stand on if someone messes w/ the clamp...

Us using the pump has nothing to do w/ "easy calculations" as you say...

You didn't answer my appy question...I know you likely used to do a history/physical, draw a cbc, lay hands on the pt, then off to the OR...Now it's all of the above, and a CT (and if the kid opposes, jam an NGT down to administer oral contrast)...
Hell, with your (anti technology) logic, just skip the CT...EMS doesn't use all the "fancy" technology...We all know their "diagnoses" are always accurate...

I live in a rural community and have for several years; Gone to many tape and charts, and was pre hospital coordinator for a spell...Not once ever (big city and little) have I seen EMS give a pressor (in a drip form)...Fluid first...By the time a litre or two is infused, they are here...

And Miss Mab, we do still teach drip factor calculations...It's still standard nursing school curriculum, in second semester...
 
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Paseo Del Norte said:
...however, vasoactive medications and antidysrhythmic infusions simply hung to gravity utilising the old drop factor formula and counting drops with a roller clamp as the only thing between the patient and 4 mg of norepinephrine?
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I was transporting (CCT, interfacility) a pt on dopamine...While transferring to my pump, he was off the dop for about a minute...His SBP (art line) dropped about 30 points...I thought no biggie, and opened the clamp for three seconds...I **** my pants as his BP kept rising...Finally topped off at 200...Won't do that again...

Only propofol will I do that with...

Just sayin'
 
chimichanga said:
You didn't answer my appy question...I know you likely used to do a history/physical, draw a cbc, lay hands on the pt, then off to the OR...Now it's all of the above, and a CT (and if the kid opposes, jam an NGT down to administer oral contrast)...
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about appys....we have gotten away from oral contrast for all but kids and thin folks as with the newer scanners oral contrast adds nothing to IV(there have been several studies to support this)...
with a classic appy in a male we do have some surgeons who will operate based on a good hx and physical, a neg ua, and leukocytosis.
happens probably twice/yr.
 
chimichanga said:
I was transporting (CCT, interfacility) a pt on dopamine...While transferring to my pump, he was off the dop for about a minute...His SBP (art line) dropped about 30 points...I thought no biggie, and opened the clamp for three seconds...I **** my pants as his BP kept rising...Finally topped off at 200...Won't do that again...

Only propofol will I do that with...

Just sayin'
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Yeah, you can walk a fine line. As you stated, a pump should not be utilised as a primary means of calculation. Calculating a flow rate is a simple process that involves high school level math. A little linear algebra and a dimensional analysis or two and you can calculate your flow. If the pump has software, you can use it to check your work. In my environment, I utilise my partner.

However, I think the real benefit of a pump is to help ensure that the ordered dose is delivered as ordered. Obviously, somebody above my pay grade can infuse however they want; however, if I am tasked to care for a patient I calculate my flow rates, double check, then utilise a pump. Clearly, this should apply to pressors and antidysrhythmics.

As far as propofol, anecdotally, I have not had good experiences with during transport. Typically, it is hard to titrate in the stimuli rich environment of a helicopter and you always walk a line between sedation and hemodynamic compromise. I cannot speak about propofol bolus therapy as I consider that technique above my pay grade and have never personally utilised it as a bolus for procedures or otherwise. I have taken care of patients where propofol was utilised for procedures and anecdotally it worked quite well.
 
In a ground ambo (CCT)...it was me alone in back...at times, when newly vented pts would buck the vent and fight restraints, a little bolus (above prescribed rate) for two seconds, will make the transport safer for the pt and me...

Our BON prohibits it, as does yours likely (except as described below)...
However, they weren't with me in the back of the rig, and the pt could have self extubated...With the bolus, they drift out,usually for the duration of the transport...It can be a common practice in ICUs

and as far as propofol bolus during ER procedures, the BON does allow RNs to give it when "the physician is involved in airway management"
 
chimichanga said:
In a ground ambo (CCT)...it was me alone in back...at times, when newly vented pts would buck the vent and fight restraints, a little bolus (above prescribed rate) for two seconds, will make the transport safer for the pt and me...

Our BON prohibits it, as does yours likely (except as described below)...
However, they weren't with me in the back of the rig, and the pt could have self extubated...With the bolus, they drift out,usually for the duration of the transport...It can be a common practice in ICUs

and as far as propofol bolus during ER procedures, the BON does allow RNs to give it when "the physician is involved in airway management"
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Yikes! Tough times, no partner on a CCT? Do you have ventilator management, sedation, and analgesia protocols or guidelines? Sometimes, getting the patient and the ventilator to interact can make for a much more comfortable patient. We currently utilise the BMD Crossvent-4 for transport and I find many people often mess with the flow in order to obtain the "perfect" I:E of 1:2. Of course, the patient is generally not comfortable with a flow of 20. I have even seen patients in SIMV without any pressure support who were intubated for respiratory distress, bucking the vent all day long. I often see people in my field default to SIMV on every intubated patient. Therefore, I know getting good patient/ventilator interaction can help. Of course, that can be difficult as most transport ventilators are not synonymous with the ventilators utilised in the hospital.

I also like to use generous amounts of fentanyl followed by benzo's. I am careful with benzo's, as you can have hemodynamic changes; however, I really do like fentanyl.
 
This was about five years ago...We used a simple "monkey vent"...Rate, FiO2 of 50 or 100%, TV, and a peep valve...Most often used for intra hospital transports (to MRI, CT)...No electricity,just O2 driven...

Mostly pts were either newly tubed ED pts (smaller, outlying EDs going to a specialty (neuro, cardiac)) hospial in the inner city...And they were always on propofol (though sometimes a shot of Vec before we left)
The rest were chronics going to the ED for a fever...

I learned quickly to get transport orders from the ED doc before leaving...I did have offline protocol, but those were written for 911 guys...And I always asked that the pt be switched to a Ballard suction device, which made suctioning sooo much easier...

Best RN job I've ever had...Hanging out in quarters w/ mostly guys, napping and watching movies...

No nursing, hospital drama..
 
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Let me guess, you guys were using the good old Autovent 2000?

Yeah, I worked for a CCT truck prior to flying. Good times. HEMS is an interesting environment, however. A very different kind of drama goes on. We often say it's like a soap opera called "as the rotor turns."
 
I rarely had someone in back with me during the 3 yrs I did cct's during pa school in philadelphia.
occasionally a hospital would send an md IM intern along (who was completely worthless) so that they could " do a crich or pericardiocentesis enroute as needed"(none of them it turned out actually knew how to do the things they were sent along to do). (wtf).
we used syringe pumps on this service for ntg and heparin drips. the last yr I was there we got a new siemens pump that could do multiple drips at once but I always opted for multiple syringe pumps instead. we didn't have a transport vent so I got to bag folks on long distance transfers with a watch on my lap to make sure I didn't hyperventilate or hypoventilate them.
we had lifepak 5's and got a 10 with pacing capability the last yr I was there.
cct paid well but I much prefered the time I spent as a 911 medic in southern california.
 
emedpa said:
I rarely had someone in back with me during the 3 yrs I did cct's during pa school in philadelphia.
occasionally a hospital would send an md IM intern along (who was completely worthless) so that they could " do a crich or pericardiocentesis enroute as needed"(none of them it turned out actually knew how to do the things they were sent along to do). (wtf).

I think the RN/PM team that is popular works well and skill sets compliment themselves.

we used syringe pumps on this service for ntg and heparin drips. the last yr I was there we got a new siemens pump that could do multiple drips at once but I always opted for multiple syringe pumps instead.

Utilised syringe drivers in Afghanistan, they are the fo-shnizzle!

we didn't have a transport vent so I got to bag folks on long distance transfers with a watch on my lap to make sure I didn't hyperventilate or hypoventilate them.

I remember those days an EMT. The triad of the EMT. (BCD) "Bag, Compressions, Drive" Ventilators and waveform capnography do make a difference.

we had lifepak 5's and got a 10 with pacing capability the last yr I was there.
Old Skool LOL.

cct paid well but I much prefered the time I spent as a 911 medic in southern california.
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The times they are a changin.
 
The only time I ever used a syringe pump other than for a PCA was for transfusions on infants. Never saw 'em on adults.

I give chemo, so all of our stuff is on the pump, with the few exceptions of chemos you may not run on pump. I doubt anyone would take kindly to someone "going rogue" and deciding to run the chemo by gravity.
 
fab4fan said:
I give chemo, so all of our stuff is on the pump, with the few exceptions of chemos you may not run on pump. I doubt anyone would take kindly to someone "going rogue" and deciding to run the chemo by gravity.
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emedpa said:
come on, most of these are so easy you can do them in your head...
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:lame:
 
chimichanga said:
:lame:
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you guys are blowing this way out of proportion. I never said anything about running chemo, potassium or insulin without a pump. I specifically said abx, anticonvulsants, narcan, banana bags, antiarrhythmics(aka lidocaine for the most part) and dopamine or epi. there are all easily done off pump.
we are talking about rare occurences here. I start a few IV's a month on particularly busy night shifts. the vast majority of these are for fluids only with the occasional drip as above.
anyone getting an insulin drip or long term kcl will be in my dept for less than an hr as we have very easy access to admissions. the protocol is that the floor can not refuse any admissions from us so we basically give report and send the pt.
 
chimichanga said:
In defense of Em, propofol for procedural sedation, (IV push) is very common, and a pump in that instance would not make sense...
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Understood. In those procedural instances most places use CRNAs or the anesthesiologist for that, even if RNs are IV sedation certified. But if you are talking a kid, and a RN is giving it, most places will put that on an infusion pump. There's no reason not to. In peds we put mostly everything on some kind of pump/controller or syringe pump, even our antibiotics or blood aliquots.
 
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emedpa said:
when I work day shift the nurses can use pumps if they want if they are the ones mixing and monitoring the drips, etc
for me it just seems like a waste of time. I'm the only provider covering an 11 bed dept at night with 1 nurse so my time is better spent seeing pts and doing procedures than futzing with a pump.
I have used syringe pumps before for heparin and ntg drips as a medic but not for a LONG time.
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Unbefreakinglievable. Is you facility accredited? It takes less than a minute to program a pump. Not any more time than it takes to watch your drip rate and make sure that it is accurate. And if it's just you and one RN, it seems highly doubtful that you can really monitor your drip rates to make sure they haven't changed such as with changes of position of the arm, especially with the antecubital sites. Meanwhile you're taking manual BP because the pneumatic is inaccurate and titrating the drip to the proper parameters, making sure the dopamine doesn't infiltrate. Sorry, I don't buy it that you are so cavalier about such a potentially dangerous and rate sensitive drug. And if you are, I sure hope you have 5 malpractice policies.

emedpa said:
or you underdose them with a critical med or don't fluid resuscitate them adequately due to a simple pump error(by the rn) , both of which I have seen several times.
we had a dka pt a few yrs ago who was supposed to be getting 750 cc/hr of fluid.
the pump was set at 7.5cc/hr. fortunately I noticed the error in the first half hr and found a competent rn to reprogram the pump....
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So, are you saying the RN didn't know how to reprogram the pump? Or were you just pissy that she incorrectly entered the number. Regrettable mistake of course, and I'm not saying it's okay, and not like I know all the facts of the case, but hey you put it out there. Don't you think a better solution would have been going directly to the nurse that programmed the typo into the pump and reminding him/her to be sure it is set properly before leaving the bedside? **** like that can happen when you're going around checking everybody's dopa gravity gtt rate and manually checking their blood pressure.🙄

emedpa said:
come on, most of these are so easy you can do them in your head:
narcan 10mg in 1000 cc= 1mg/100cc. 100 cc/hr= 1 mg/hr
there is a free video on www.emrap.tv (which I highly recommend by the way) showing em residents how to mix and hang their own epi drips without a pump...and it's encouraged by the em residency faculty who host the show....
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Of course it's easy to calculate a drip rate. The problems is that factors change the drip rate such as patients or family f*cking with the roller clamp or even bending an arm, wrist, kinking the tubing. That is the issue. And the EM residency faculty encouraging free flow epi and dopa? Obviously haven't had the fear of JCAHO put on 'em. Or the hospital legal team.
 
jl lin said:
Understood. In those procedural instances most places use CRNAs or the anesthesiologist for that, even if RNs are IV sedation certified. But if you are talking a kid, and a RN is giving it, most places will put that on an infusion pump. There's no reason not to. In peds we put mostly everything on some kind of pump/controller or syringe pump, even our antibiotics or blood aliquots.
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worked in nine different EDs in the Phoenix area...never have I worked w/ a CRNA...in all of those places, it was the RN or ED doc pushing the propofol...

and anesthesia coming to the ED for a dislocated shoulder?

riiiight...that'll happen 🙄

And I don't get the whole syringe pump for a drug that's to be given as a push...It's not like it will be given over five minutes...it's a push, even in a kid...

I've pushed it a couple of times,and seen it pushed many times for a kiddo...setting up a pump is a waste of time IMO
 
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Propofol is given as a push and as a continuous gtt. I work in ICU where it's used both ways, but it's a posibility that in the ED, it's more commonly used as a push. We'll use it as a push for intubation and as a gtt for maintaing sedation on our vented patients. If they are on a gtt, they have to be vented. If they're being given a push, it's generally in anticipation of getting tubed and if it is not used specifically for that purpose, then procedural sedation precautions (i.e. suction better be set up, and crash cart and intubation kit have to be at the bedside) with 1:1 monitoring.

It's an unwritten practice that when vented pt.'s have significant break through agitation on the gtt that puts them at risk for self extubation, etc, that they're given a bolus which can be pulled by syringe from the bottle or programmed into the pump.
 
The right Path said:
Propofol is given as a push and as a continuous gtt. I work in ICU where it's used both ways, but it's a posibility that in the ED, it's more commonly used as a push. We'll use it as a push for intubation and as a gtt for maintaing sedation on our vented patients. If they are on a gtt, they have to be vented. If they're being given a push, it's generally in anticipation of getting tubed and if it is not used specifically for that purpose, then procedural sedation precautions (i.e. suction better be set up, and crash cart and intubation kit have to be at the bedside) with 1:1 monitoring.

It's an unwritten practice that when vented pt.'s have significant break through agitation on the gtt that puts them at risk for self extubation, etc, that they're given a bolus which can be pulled by syringe from the bottle or programmed into the pump.
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Guess I should have clarified, I have always seen Diprivan given for procedural sedation of short length.
 
chimichanga said:
worked in nine different EDs in the Phoenix area...never have I worked w/ a CRNA...in all of those places, it was the RN or ED doc pushing the propofol...

and anesthesia coming to the ED for a dislocated shoulder?

riiiight...that'll happen 🙄

And I don't get the whole syringe pump for a drug that's to be given as a push...It's not like it will be given over five minutes...it's a push, even in a kid...

I've pushed it a couple of times,and seen it pushed many times for a kiddo...setting up a pump is a waste of time IMO
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Sure EDs do their own things in general. I was talking procedural cases for different areas of the hospital. But especially in kids, I found it pretty wise and safe to put things on a syringe pump--even short admins.

Our kids are monitored. We've caught changes we may not have picked up and stopped infusions when any signs of concern come into play. But you know, I'm a critical care/ ICU nurse, and we are control freaks almost by nature. We're taught to be that way for a reason. And with kids that goes for 10Xs as much.

If you're covered for it and feel comfortable giving that way, do as you like. In adults we were more blase' about giving certain things IV push. When I moved into kids, that changed, and I believe it's better safe than sorry.

I've learned that when you get to where you are doing all kids or mostly kids, you realize how little they can tolerate changes as cpmpared with what an adult can tolerate. The sH*& hits the fan and the babes turn so fast it makes your head spin and practically fall off.

In general, it's just safer practice to take a substance, varify it properly, hook it up to a medfusion pump, which takes a minute, and then go with it. In many peds units they even have protocols for double checking the medfusion dose and set rate for the particular med and patient and added sign-offs for that.

Trauma RN is right. There are variables to bolusing and IVP rates.
I've seen kids so sensitive to things, you push just a tad more than you did a few seconds before and they crumble. I'd rather have it controlled and a set vol to move at a set time, and should there be some problem or something aberrant resp. wise or on the monitor, you can turn the thing off and assess and do no more harm.

I don't take anything for granted and have become infinitely more anal retentive working with neonates, babies, and kids. It's a good thing. The second anyone takes anything for granted with these guys, even by way of what they are sanctioned to do, someone can get hurt. It's like the med errors from nurses failing to do proper double checks in meds administration in the NICUs in recent years. You can get busy or overwhelmed easily and make an error. Following the systems for checks and balances keeps things safe. Bypass them and your patient and you may pay a big price.

Far be it from me to tell you or anyone else how to practice; but just because you CAN do something a certain way does NOT mean that it's best practices and that you should. I"ve been a RN for a long time, and I haven't even so much as been called into court or named in anything. Personally, I'd like to keep it that way.
 
Canned Heat said:
Anyway, I talked to an Emergency Room PA and the only thing they don't "want" him to do is conscious sedation, but even then they are allowed because the physicians trust them. So, he can do everything... .
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Hmmm, so that makes you feel better?
 
Canned Heat said:
Sorry, I went through the first page and just couldn't get myself to skim through the next 8 pages to see if anyone asked my question.

Anyway, I talked to an Emergency Room PA and the only thing they don't "want" him to do is conscious sedation, but even then they are allowed because the physicians trust them. So, he can do everything... They can prescribe up to Schedule 2 medications which is the highest I believe unless you are an oncologist (Schedule 1 = Chemo cocktails). He works three days a week, has a pretty chill lifestyle, and went to PA school for two years.

Besides the more laid back lifestyle, the ability to start a family early, and the less amount of time in school, what are some other benefits of being a PA compared to being an MD/DO? It seems like he makes just as much as some primary care physicians without having to deal with the malpractice, etc.. Yes, I know he can't practice on his own, but I wouldn't mind anyway since I would work with a medical group or hospital.
Click to expand...

You sound like someone who either is worried about getting into medical school or who heavily prioritizes lifestyle. If you want to "do everything a doctor does", be a doctor. You asked only about the benefits of being a PA, which sounds like you want to be talked into it.

The role, range, and scope of a physician assistant ranges pretty widely. On one end of the spectrum is the idealized version you're portraying, and on the other lies scutwork and such. The reality is that while you can probably find a practice environment that would satisfy what you want to do clinically (if you have very general "I want to be some kind of healthcare practitioner" dreams), your role is inextricably subordinate to others in the hierarchy. You can even find jobs where you have an awful lot of autonomy. But again, if you're trying to find the absolute closest scenario possible to actually being a doctor, you should probably just be a doctor. There are lots of good reasons to be a PA. But if your reason is (and it may not be) that you think you'll get to do all the cool stuff doctors do with half the training, work cushy hours, and all the respect because you "do everything they do", that's a recipe for disaster.
 
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