Narc control

[GassiusClay]

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Any of you new CA-1s find the whole narc guarding thing an issue?

I know programs want every cc accounted for because some of us historically decided to be ******ed and do some fentanyl, but can't people make honest mistakes like drop it, accident squirt out, etc. Also, let's throw in the OR is open for anyone tampering with it including techs, those covering your room, whatever.

What do some of you graduates and CA-3s do in terms of a protocol to protect against narc issues? Sometimes, the patient needs to be wheeled off to ICU and stuff may be left behind. Last thing I need is to be labeled some sort of druggie. Feels like I have to get lucky for the next 3 years for something not to happen.

 

[Fastrach]

Any of you new CA-1s find the whole narc guarding thing an issue?

I know programs want every cc accounted for because some of us historically decided to be ******ed and do some fentanyl, but can't people make honest mistakes like drop it, accident squirt out, etc. Also, let's throw in the OR is open for anyone tampering with it including techs, those covering your room, whatever.

What do some of you graduates and CA-3s do in terms of a protocol to protect against narc issues? Sometimes, the patient needs to be wheeled off to ICU and stuff may be left behind. Last thing I need is to be labeled some sort of druggie. Feels like I have to get lucky for the next 3 years for something not to happen.

Dude, better get used to staying on top of every drop pretty quick. Vigilance is the cornerstone of our profession. Yes, people do make honest mistakes, and as long as you're honest about them with the pharmacist, it's usually not a big deal, though each incident will still be recorded and reviewed periodically. Eyebrows will start to be raised when it is repeatedly an issue with the same person.

 

[2ndyear]

I put all controlled substances in my pocket before leaving the OR. It's a pain at first, but do what you can to never leave them unattended. Put them in the anesthesia cart and close it, or a machine drawer. JHACO says that since these are 'off limits' areas they don't have to technically be locked. Don't ever lie about something, the consequences are still bad. If you lost it, say so. If it broke, same thing.

 

[tussionex]

like everyone else has stated, if you're honest, we won't give you a hard time.
everyone drops or loses a narc here or there sometimes, please just let pharmacy know and we will help you document it as such.

it's a lot of paperwork and a pain in the butt for everyone, but the laws are there and ya just gotta suck it up!

the rules, not the drugs!😉

 

[jetproppilot]

Any of you new CA-1s find the whole narc guarding thing an issue?

I know programs want every cc accounted for because some of us historically decided to be ******ed and do some fentanyl, but can't people make honest mistakes like drop it, accident squirt out, etc. Also, let's throw in the OR is open for anyone tampering with it including techs, those covering your room, whatever.

What do some of you graduates and CA-3s do in terms of a protocol to protect against narc issues? Sometimes, the patient needs to be wheeled off to ICU and stuff may be left behind. Last thing I need is to be labeled some sort of druggie. Feels like I have to get lucky for the next 3 years for something not to happen.

The easiest thing for you to do is don't pull it unless youre gonna use all of it. Pull smaller fentanyls/midazolams.

Dont ever pull extra. Save the 250ug fentanyls for cases youre sure youre gonna give all of it.

Much, much less hassle factor.

 

[Express08]

I'm not an anesthesiologist nor resident, but a hopsital OR pharmacist. Perhaps I can give you perspective.

Yes - we do count every drop! Yes - things get broken, wasted, drawn up & never used, dropped on the floor - all sorts of things. We even break vials & ampules ourselves.

I must document every drop which is used on my shift - that means by all of you in all the rooms. Yes - I do track you down to document (a copy of your flow sheet(s) comes to me to be filed) if the counts don't match. If you case goes beyond my shift, another pharmacist will come find you. I will admit - the locums are really tough - those cases go to the Chief of Surgery. He/she just documents after the fact there was a loss on my documents.

I hear all the codes overhead & know a pharmacist will respond from somewhere. That pharmacist will determine if you've brought something with you, which is very common, from the OR. That pharmacist will call me with the info & I enter it into the pyxis from "my side" of the machine. You don't even need to bring back the syringe (PLEASE DON'T!) or ampule - the pharmacist or nurse who might be writing the info on the code sheet will put it into the discard bin of pyxis at the end.

Don't worry - it takes a pattern to develop any kind of questionable behavior. I think Noyak a few years ago had a good description of a physician who falls into this.

I'd advise against trying to take any - you'll get caught eventually. But, I've only known of one physician in my own experience of work who did & he was a surgeon - not anesthesia. In hospitals, evidence has shown physicians are not the most common group which steals narcotics, now that we have computerized tracking.

You'll get into the habit at the end of the case documenting wastage - like anything else - it gets easier with time.

 

[Tenesma]

what used to drive me nuts was having a syringe of fentanyl (pre-drawn for ICU transfer) forgetting about it in my pocket - hitting the bunk beds while on call and waking up with a big wet spot ---

as long a you can document missing doses as either discarded/wasted then that is all the pharmacists care about...

however, as you get more senior you will notice that you actually need less drugs then you think - --- that definitely helps protect you, and makes your pockets bulge less as you wander around the hospital.

 

[radslooking]

what used to drive me nuts was having a syringe of fentanyl (pre-drawn for ICU transfer) forgetting about it in my pocket - hitting the bunk beds while on call and waking up with a big wet spot ---

as long a you can document missing doses as either discarded/wasted then that is all the pharmacists care about...

however, as you get more senior you will notice that you actually need less drugs then you think - --- that definitely helps protect you, and makes your pockets bulge less as you wander around the hospital.

tenesma, i think you could refrain from talking about going to bed and waking up with a big wet spot. thanks.

 

[radslooking]

 

[Tenesma]

at least somebody is reading my posts

 

[Planktonmd]

The easiest thing for you to do is don't pull it unless youre gonna use all of it. Pull smaller fentanyls/midazolams.

Dont ever pull extra. Save the 250ug fentanyls for cases youre sure youre gonna give all of it.

Much, much less hassle factor.

Exaclty.
Whatever Fenatnyl I pull goes in the patient.
I rarely have to waste any narcotics.

 

[loveumms]

Exaclty.
Whatever Fenatnyl I pull goes in the patient.
I rarely have to waste any narcotics.

Same here - although one of my attendings scolded me saying that 100mcg of fentanyl costs just as much as 250mcg (packaging is the main cost factor???).

Anyway, I usually pull 250mcg to start the case and if I need more, I pull out 100s. I hate the hastle of wasting!

 

[GassiusClay]

what used to drive me nuts was having a syringe of fentanyl (pre-drawn for ICU transfer) forgetting about it in my pocket - hitting the bunk beds while on call and waking up with a big wet spot ---

as long a you can document missing doses as either discarded/wasted then that is all the pharmacists care about...

however, as you get more senior you will notice that you actually need less drugs then you think - --- that definitely helps protect you, and makes your pockets bulge less as you wander around the hospital.

I don't plan on lying about highly controlled substances. That would be the stupidest thing ever after spending all that time in med school and now residency. However, tenesma's situation is what I fear on a daily basis.

Right now, I'm hyperviligant about the patient, narcs are a second priority. Hopefully the anesthesia techs don't touch my cart next time before I get back to the room. They even freaking lost my copy of the narc order. I shouldn't have to come back to find my cart already "refurbished" by the time I walk back from the ICU.

 

[tussionex]

be careful what you put in your pockets.

http://theunderweardrawer.blogspot.com/search?q=power+bar


much worse than big wet spots.

 

[Tenesma]

i don't advocate lying at all - that big wet spot was estimated and documented as wasted... 🙂

 

[Bougie]

Thanks for posting Express 08. Speaking of pharmacists...we just won a huge battle with our pharmacy about having drug packs with us for floor intubations. These bags contain the usual floor intubation drugs as well as some vasoactives (baby epi, neo, esmolol) with prelabeled syringes. The code resident just carries a few of these bags in the code bag. All we have to do is pop the top and draw them up ourselves like we do in the OR instead of waiting for some fat old floor nurse to waddle over to the Pyxis by way of the donut box to get these for us during a semi-emergent airway case. The pharmacy complained about billing but shut up after a patient arrested during a failed airway where vec instead of succ was used since the floor Pyxis was out of succ. Definitely recommend this if something like this is not in place at your institution.

Agree with checking out just the right amount of narcs and ALWAYS keeping them with you. Get a fanny pack if you need to...it's a total chick magnet.

 

[Arch Guillotti]

Having issues with the whole narcotic control thing I think is a normal part of residency. I can remember being very paranoid about leaving things out early on. As time passed I really didn't care as much because I got to know a lot of the techs, environmental services, nurses etc a lot better as well as the pharmacy folks. Whenever I would break a bottle of fentanyl or whatever I would give the pharmacy an explanation but after a while I got to know all of them by their first name and didn't really care about explaining things as much and they didn't really care either. Narc control should never be taken lightly but there is only so much you can do to control them.

 

[radslooking]

Thanks for posting Express 08. Speaking of pharmacists...we just won a huge battle with our pharmacy about having drug packs with us for floor intubations. These bags contain the usual floor intubation drugs as well as some vasoactives (baby epi, neo, esmolol) with prelabeled syringes. The code resident just carries a few of these bags in the code bag. All we have to do is pop the top and draw them up ourselves like we do in the OR instead of waiting for some fat old floor nurse to waddle over to the Pyxis by way of the donut box to get these for us during a semi-emergent airway case. The pharmacy complained about billing but shut up after a patient arrested during a failed airway where vec instead of succ was used since the floor Pyxis was out of succ. Definitely recommend this if something like this is not in place at your institution.

Agree with checking out just the right amount of narcs and ALWAYS keeping them with you. Get a fanny pack if you need to...it's a total chick magnet.

lol, thanks bougie, i needed that. not being a gas man, why did the patient arrest with vec vs. succ

 

[Arch Guillotti]

lol, thanks bougie, i needed that. not being a gas man, why did the patient arrest with vec vs. succ

I always carried a pack of drugs leftover from the day cases w/me on floor stuff. No way I was gonna wait on anyone to get them for me.

To the above poster, the pt. arrested because vecuronium is a paralyzer that is not reversible right after you give a dose. They couldn't intubate or ventilate so right away things they were dealing with a **** sandwich. Sux at leats wears off pretty quickly.

 

[pgg]

lol, thanks bougie, i needed that. not being a gas man, why did the patient arrest with vec vs. succ

Succ wears off quickly. Vec doesn't. If you induce and paralyze someone, then find you can't intubate and can't ventilate, you're less screwed if you used succ than if you used vec. The idea being, that succ may wear off soon enough for the patient to resume spontaneous respiration and not die. With vec, you've bet the patient's life that you'll be able to intubate or at least ventilate.

Vec also takes about 5x as long as succ to produce optimal intubating conditions. It's a dumb drug to use during a code and I've got to wonder WTF was wrong with the guy who called for the vec.

 

[radslooking]

Succ wears off quickly. Vec doesn't. If you induce and paralyze someone, then find you can't intubate and can't ventilate, you're less screwed if you used succ than if you used vec. The idea being, that succ may wear off soon enough for the patient to resume spontaneous respiration and not die. With vec, you've bet the patient's life that you'll be able to intubate or at least ventilate.

Vec also takes about 5x as long as succ to produce optimal intubating conditions. It's a dumb drug to use during a code and I've got to wonder WTF was wrong with the guy who called for the vec.

they said the pyxis was out of succ, so they went to vec....

 

[pgg]

they said the pyxis was out of succ, so they went to vec....

If a patient has pneumonia, and the Pyxis is out of the correct antibiotic, you don't just substitute the wrong antibiotic because it's what's available.

 

[radslooking]

If a patient has pneumonia, and the Pyxis is out of the correct antibiotic, you don't just substitute the wrong antibiotic because it's what's available.

my understanding was it was a code and that's all that was available emergently...i can't tell upon rereading his story...

 

[nutmegs]

I dunno man. Yeah, patient care comes first, but I can't say I've ever really found it challenging to keep my narcs on me. We have mini tackle-box type things with a standard set that we check out of the Pyxis for every patient (2x250, 2x100 Fentanyl, 2x2 and 1x5 midaz, 2x10 morphine) and return, in a baggie with our waste syringes, into a drop box after each and every case. It used to be a day-long pack but our Medicare people said not enough control, so we got the Pyxis the next week (who thought a University Hospital could move so fast?).

Anyway, these fit into my back pocket, and the "blue" syringe(s) go in my pocket just before hitting the door, ICU transfer or not. It's not worth having to deal with the pharmacy (and the police, at my institution) for leaving your whole box out when it walks off.

And are you seriously complaining about having your room turned over/cart restocked "too fast"????

BTW, having just had "the JC" here this week, the standard is most meds can be kept in a drawer/inaccessible to passerby, but controlled substances have to be in your "immediate control" at all times.

 

[Bougie]

IThey couldn't intubate or ventilate so right away things they were dealing with a **** sandwich.

Bingo. Extra sauce on the ****e sandwich please. Green resident who thought he was God's gift to airways got talked into using vec by some nursing assassin on the floor.

Fat + poor preoxygenation + poor positioning + poor reserve + vec + cocky resident + can't intubate + can't ventilate = shirt, tie, white coat, aqua-lube PR for next month's M&M conference.

 

[radslooking]

Bingo. Extra sauce on the ****e sandwich please. Green resident who thought he was God's gift to airways got talked into using vec by some nursing assassin on the floor.

Fat + poor preoxygenation + poor positioning + poor reserve + vec + cocky resident + can't intubate + can't ventilate = shirt, tie, white coat, aqua-lube PR for next month's M&M conference.

I prefer astroglide for my M&M conferences. Nobody's ever complained either.

 

[nutmegs]

I prefer astroglide for my M&M conferences. Nobody's ever complained either.