Weird PCA Orders

[jetproppilot]

Got a call the other day from a labor and delivery nurse who I used to work with who now works at another hospital...one of the anesthesiologists there wrote a PCA for a patient (I presume s/p C section)...

....it was a ketamine + fentanyl PCA.....

she refused to do it.....

she called me a few days later and asked me for my opinion which was....

whatcha guys think?

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[Trisomy13]

Got a call the other day from a labor and delivery nurse who I used to work with who now works at another hospital...one of the anesthesiologists there wrote a PCA for a patient (I presume s/p C section)...

....it was a ketamine + fentanyl PCA.....

she refused to do it.....

she called me a few days later and asked me for my opinion which was....

whatcha guys think?

I knew a guy in grad school with a ketamine PCA. When he wanted more he would call his buddy who worked at the vet clinic, then sit on his couch in the dark drooling for about 4 hours. He also went to med school (although not anesthesiology which is probably better for everyone involved).

That useless bit of information aside, I would question the use of ketamine in that situation. Would you want a new mother holding her baby when she gets one of those odd ketamine moments? Dissociatives + newborns seem like a bad mix to me.

 

[meddog1]

Got a call the other day from a labor and delivery nurse who I used to work with who now works at another hospital...one of the anesthesiologists there wrote a PCA for a patient (I presume s/p C section)...

....it was a ketamine + fentanyl PCA.....

she refused to do it.....

she called me a few days later and asked me for my opinion which was....

whatcha guys think?

Very odd order for sure. After all, the big reason Ketamine is used in OB pts is because, in relation to the opiods, it has minimal effect on the newborn or fetus. If this pt is s/p cxn, then I can see no benifit to, or rationale for, using Ketamine... at all.

 

[Gator05]

How much ketamine? If we're talking mcg-range, then it's for added analgesia, and it works well. If we're talking 20 mg with every tap of the button, the kid's in trouble.

 

[VolatileAgent]

http://www.ncbi.nlm.nih.gov/entrez/..._uids=15288412&query_hl=5&itool=pubmed_docsum

otherwise, there's no real good studies looking specifically at fentanyl+ketamine in incisional pain. the other "opioid-sparing effects" studies of ketamine are all over the place. it doesn't look like it has been definitively proven to be of benefit or no benefit at all.

personally, i wouldn't have ordered that concoction. but, the nurse refused an order by another doctor and then called you instead of talking directly with him/her at the time she "refused" to hang the pca with that mix... unless i'm misunderstanding something, i have a bigger problem with that (not that your opinion doesn't count, jet).

 

[camkiss]

Got a call the other day from a labor and delivery nurse who I used to work with who now works at another hospital...one of the anesthesiologists there wrote a PCA for a patient (I presume s/p C section)...

....it was a ketamine + fentanyl PCA.....

she refused to do it.....

she called me a few days later and asked me for my opinion which was....

whatcha guys think?

I have been hearing more and more about this lately. Low dose ketamine in PCA with fentanyl is supposedly very effective analgesia without the "trip" of higher doses of ketamine. Not sure how much, though.

 

[Noyac]

I don't see anything wrong with it if used in the right situation.


I do see a BIG problem with the nurse refusing to do it just because she isn't familiar with it. She needs to be educated and if she does it again, fire her. I'm sick and tired of nurses that think they know better. If it was ordered in the wrong scenario then she needs to talk with the doctor that ordered it.

 

[stoic]

was the pt opiod tolerant? i seem to recall hearing of ketamine used in low doses to trick up the mdma tolerance system... actually i think i read that in this forum?

so maybe that was the reason?

 

[jetproppilot]

Got a call the other day from a labor and delivery nurse who I used to work with who now works at another hospital...one of the anesthesiologists there wrote a PCA for a patient (I presume s/p C section)...

....it was a ketamine + fentanyl PCA.....

she refused to do it.....

she called me a few days later and asked me for my opinion which was....

whatcha guys think?

Just got some new info. I was wrong....it wasnt for a post op C section.

The case was actually a parturient with low platelets who couldnt get an epidural....apparently theres some literature on fentanyl+ketamine PCAs out there.

Can anybody post it????

 

[militarymd]

Just got some new info. I was wrong....it wasnt for a post op C section.

The case was actually a parturient with low platelets who couldnt get an epidural....apparently theres some literature on fentanyl+ketamine PCAs out there.

Can anybody post it????

I remember reading about it or hearing it, but I have no reference.

 

[Noyac]

try this:

http://www.ncbi.nlm.nih.gov/entrez/...=Display&dopt=pubmed_pubmed&from_uid=15954974

 

[sdn1977]

Do you all have endless combinations of pca combinations possible? Our hospital does not. We have set combinations for various mixes approved by the P&T committee & none involve ketamine.

I have no particular feelings for nor against the combinations, but I do feel the standing orders need to be set & clarified ahead of time with parameters which nurses can follow clearly. Otherwise, it is a setup for errors which are already an issue with PCA's. There are already too many documented drug errors from misunderstood pca orders.

This does not preclude giving ketamine separate & apart from the narcotic. There is nothing wrong with this either.

I am hoping this nurse requested information from you & your experience at your facilty with regard to this route of administration to try to obtain knowledge to help write standardized orders. Otherwise, it was an inappropriate intervention which she already had mechanisms in place to deal with (consulting her nursing supervisor, involving the prescribing physician, etc...). I'd be curious what the response of the pharmacy was to the drug order since they would be mixing it & determining pump settings........

 

[jwk]

I don't see anything wrong with it if used in the right situation.


I do see a BIG problem with the nurse refusing to do it just because she isn't familiar with it. She needs to be educated and if she does it again, fire her. I'm sick and tired of nurses that think they know better. If it was ordered in the wrong scenario then she needs to talk with the doctor that ordered it.

All PCA solutions for our facility our standardized and premixed in the hospital pharmacy. No special concoctions are allowed. Maybe that was the situation here and maybe the nurse knew it and the doc didn't. If it's a somewhat bizarre order (which I think this is) that falls outside the usual routines for this facility she certainly has the right to seek clarification.

Your literature cites are ambivalent at best about ketamine for PCA. Maybe that's why this has never become widespread practice.


**************************

Reeves M, Lindholm DE, Myles PS, Fletcher H, Hunt JO.
Department of Anaesthesia & Pain Management, Alfred Hospital, Victoria, Australia.

In this double-blinded, randomized controlled trial we tested if the addition of ketamine to morphine for patient-controlled analgesia (PCA) resulted in improved analgesic efficacy and lower pain scores compared with morphine PCA alone after major abdominal surgery. Seventy-one patients were randomly allocated to receive either morphine 1 mg/mL (Group M) or morphine 1 mg/mL plus ketamine 1 mg/mL (Group MK) delivered via PCA after surgery. No other analgesics or regional blocks were permitted during the 48-h study period. Postoperatively there were no differences between the groups for subjective assessment of analgesic efficacy, pain scores at rest, and on movement, opioid consumption, or adverse events. Group MK patients performed worse in cognitive testing (P = 0.037). There was an increased risk of vivid dreaming in patients who received ketamine (relative risk = 1.8, 95% confidence interval 0.78-4.3). We conclude that small-dose ketamine combined with PCA morphine provides no benefit to patients undergoing major abdominal surgery. Implications: We performed a randomized, controlled trial comparing the use of ketamine and morphine with morphine alone to relieve pain after major abdominal surgery.Ketamine did not improve pain relief and merely increased side effects.
******************

 

[Noyac]

I thought that when you wrote down some things on the order sheet, they were orders. I didn't know that the top of the sheet said "Suggestion" sheet.

 

[Noyac]

All PCA solutions for our facility our standardized and premixed in the hospital pharmacy. No special concoctions are allowed. Maybe that was the situation here and maybe the nurse knew it and the doc didn't. If it's a somewhat bizarre order (which I think this is) that falls outside the usual routines for this facility she certainly has the right to seek clarification.

Your literature cites are ambivalent at best about ketamine for PCA. Maybe that's why this has never become widespread practice.


**************************

Reeves M, Lindholm DE, Myles PS, Fletcher H, Hunt JO.
Department of Anaesthesia & Pain Management, Alfred Hospital, Victoria, Australia.

In this double-blinded, randomized controlled trial we tested if the addition of ketamine to morphine for patient-controlled analgesia (PCA) resulted in improved analgesic efficacy and lower pain scores compared with morphine PCA alone after major abdominal surgery. Seventy-one patients were randomly allocated to receive either morphine 1 mg/mL (Group M) or morphine 1 mg/mL plus ketamine 1 mg/mL (Group MK) delivered via PCA after surgery. No other analgesics or regional blocks were permitted during the 48-h study period. Postoperatively there were no differences between the groups for subjective assessment of analgesic efficacy, pain scores at rest, and on movement, opioid consumption, or adverse events. Group MK patients performed worse in cognitive testing (P = 0.037). There was an increased risk of vivid dreaming in patients who received ketamine (relative risk = 1.8, 95% confidence interval 0.78-4.3). We conclude that small-dose ketamine combined with PCA morphine provides no benefit to patients undergoing major abdominal surgery. Implications: We performed a randomized, controlled trial comparing the use of ketamine and morphine with morphine alone to relieve pain after major abdominal surgery.Ketamine did not improve pain relief and merely increased side effects.
******************

OK, I'll stop being an a**hole about this but I hope I got my point across.

About the literature. That was a list to get you started. You can click on the related articles if you want more. The bottom line is that this stuff works and is not new science. If you don't believe it, I invite you to come spend some time with me in the OR and I'll show you. JWK, I know you have been at this business for a while now and I am not telling you anything you don't know already. But as you know there are meds out there that have lost there appeal but that have some very good uses even today. Ketamine is one of them. If any of you guys don't believe me, try it in the pt on the floor that the surgery team has failed to get comfortable. Give them a PCA like this one or start a very low dose infusion and watch its magic.

 

[UTSouthwestern]

Ketamine's a great drug. Unfortunately, the younger generation of anesthesiologists may not be getting the opportunity to truly appreciate its versatility and strength.

 

[Noyac]

Ketamine's a great drug. Unfortunately, the younger generation of anesthesiologists may not be getting the opportunity to truly appreciate its versatility and strength.

And the older generation is affraid of it (esp nurses) because of the bad rap it got years ago.

 

[SleepIsGood]

I don't see anything wrong with it if used in the right situation.


I do see a BIG problem with the nurse refusing to do it just because she isn't familiar with it. She needs to be educated and if she does it again, fire her. I'm sick and tired of nurses that think they know better. If it was ordered in the wrong scenario then she needs to talk with the doctor that ordered it.

Well said my friend. Unless the doc ordered some arsenic or something, orders are just that.

I'm glad to see there's some attendings with a pair out there

 

[SleepIsGood]

On the topic of PCAs. Noyac perhaps you can chime in.

Typical pts in the SICU what sorta PCA do you start them on? What I usually do is strictly Morphine 2mg bolus with 10 min lockout intervals. I usually allow the pt to get 2mg each times they hit the button. Pretty basic. What do you think?

 

[jetproppilot]

On the topic of PCAs. Noyac perhaps you can chime in.

Typical pts in the SICU what sorta PCA do you start them on? What I usually do is strictly Morphine 2mg bolus with 10 min lockout intervals. I usually allow the pt to get 2mg each times they hit the button. Pretty basic. What do you think?

I'm not Noy, but I'll give you my regimes that are used 99% of the time.

Dilaudid .5 mg, lockout 15 minutes, 4 hour limit 8mg

Morphine 2mg, lockout 10 min, 4 hour limit 40mg.

I don't like basal continuous infusions so always write zero on that line.

Remember a PCA's efficacy is improved if the patient is comfortable when you initiate it... in other words have the PCA nurse (or whoever) bolus them incrementally if they're hurting, then start the PCA....i.e. morphine 2-10 mg or dilaudid .5-2.0 mg first, if necessary.

 

[SleepIsGood]

I'm not Noy, but I'll give you my regimes that are used 99% of the time.

Dilaudid .5 mg, lockout 15 minutes, 4 hour limit 8mg

Morphine 2mg, lockout 10 min, 4 hour limit 40mg.

I don't like basal continuous infusions so always write zero on that line.

aside from the obvious "allergies" and "doc morphine doesnt work for me" why would you do dilaudid over morphine or vice versa?

 

[VolatileAgent]

I don't like basal continuous infusions so always write zero on that line.

agreed. we've had m&m's where we've had interesting discussions about such things as "naloxone drips" after someone thought that a basal rate might've been a good idea.

 

[jetproppilot]

aside from the obvious "allergies" and "doc morphine doesnt work for me" why would you do dilaudid over morphine or vice versa?

Never used dilaudid (except as a backup to morphine in PACU when morphine didnt work) until I came to the new gig in May 04....the guys here used it routinely, so I tried it. Works well. Some claim pruritus is less and that it "works better than morphine"...not so sure thats true, but it is an option, it works well, and my partners routinely used it here before I arrived.

 

[SleepIsGood]

Never used dilaudid (except as a backup to morphine in PACU when morphine didnt work) until I came to the new gig in May 04....the guys here used it routinely, so I tried it. Works well. Some claim pruritus is less and that it "works better than morphine"...not so sure thats true, but it is an option, it works well, and my partners routinely used it here before I arrived.

interesting. everyone where i'm at uses morphine. I want to venture out a little bit...might as well now when I'm in residency right?

I think I'll try it tommorrow. So let me get this straight.

Dilaudid 0.5mg bolus. Then lockout of 15min. How much are you giving each time they hit the button? I assume 0.5mg? And you set your 4 hour limit at 8mg. In the event the dude's RR goes spiraling, I'm assuming you have an order for naloxone on board? What do you write for?

I want to jazz up my PCAs. Run of the mill morphine isnt too exciting

 

[Noyac]

My PCA rec's are the same as Jet's. Thats exactly how I use it. And I agree with the dilaudid.


Now Jet, try putting some of that dilaudid in the CSF.

 

[dfk]

I don't see anything wrong with it if used in the right situation.


I do see a BIG problem with the nurse refusing to do it just because she isn't familiar with it. She needs to be educated and if she does it again, fire her. I'm sick and tired of nurses that think they know better. If it was ordered in the wrong scenario then she needs to talk with the doctor that ordered it.

don't take this the wrong way, and am not a troll.. i am an srna, and a nurse who has been in the SICU business for a while. it is our responsibility to question any order that might appear out of the ordinary, not normal, unsafe, etc... you get the picture.
in my facility, ketamine is only used in the OR.
that doesn't make the nurse that questioned the order who 'refused' and should be 'fired'..
and it doesn't make the doc wrong.
some facilities/-ologists don't use it as a pca order.
i can tell you that if i am uncomfortable, i will question the order, which can be from a very inexperienced doc, any time. not because i think i know more than whomever. but my yrs of practice should give me some leeway on the issue at hand.
agree, if there is literature out there that supports it, then fine, educate those that are unfamiliar.
it is always nice to find another way to alleviate pain.
i think we are all here for the same purpose, the patient.

 

[sdn1977]

I thought that when you wrote down some things on the order sheet, they were orders. I didn't know that the top of the sheet said "Suggestion" sheet.

Noyac - I have tremendous respect for you & others on this forum, but the order sheet is not just a blanket for whatever you want to write. If it doesn't fall within what is allowed - its not given. For example, we don't give ranitidine ever, no matter what you order - its always famotidine! We don't call you - we just change it. We have many other therapeutic changes we make automatically & if this order were to be presented to me...I'd call you & give you your options. You can rant & rave all you want....it still won't be done!

In my facility....I don't care what you want to put into a pca - if it has not been approved by the p&t committee, with concommitant other standing parameters, it does not get done.

As I said before...the ketamine can be given intravenously, but it can't be given by any nurse...it can only be given in one of the intensive care units & by an intensive care nurse - again with concommitant guidelines they follow. It cannot be given by an RN on a med/surg unit in my facility. The reasoning is not because it is a particularly dangerous or "scary" drug - it is just unfamilar to so many. There is no way of knowing what nurse is caring for what patient on any shift. She may not know the pump was programmed for the fentanyl & not the ketamine or vice-versa or have to interpret our labeling when we are not there at the time the bag is changed. Preset standing orders make this very clear for any nurse who is required to treat that patient.

If you want to give ketamine on a med/surg unit in my facility - you as a physician are welcome to push it when you desire. We don't have house staff, so you have to be there to do it - a tremendous disincentive.

Now...if you feel sufficiently strongly that this is a combination which is important for your patients or any patient...certainly it can be considered & processed (the turnaround can be within 24 hours when needed)....but you have to be willing to work with the system so all caregivers know exactly what is in the bag, how the pca is being dosed, what to expect as side effects, the parameters for calling, etc...but....you have to call the pharmacy, which initiates the process of calling the nursing supervisor, the chief of services involved, chief of pharmacy, writing the set orders, etc....

There have been far too many pca drug errors (& these are actually sentinel events) to allow just any combination of drugs based on one physician's particular desire - especially when we have a possible base of 12 or more anesthesiologists & multiple times that many RNs who may or may not be registry people & we are a moderate sized community hospital. There are many studies on drug errors & pcas are usually in the top third of the list.

This is a safety issue - not a therapeutic issue. Just work with the system & you'll get what you want.

 

[The_Sensei]

.... Just work with the system & you'll get what you want.

Pretty much summarizes the problem with medicine nowadays.....no physician autonomy. Everything you do needs to go through 45 subcommittees.........Good times

 

[sdn1977]

Pretty much summarizes the problem with medicine nowadays.....no physician autonomy. Everything you do needs to go through 45 subcommittees.........Good times

And I'd say thats a sticking your head in the sand approach to a huge problem you are either not aware (I'm hoping its this) or just choose to ignore. From 1996 until 2003, there were 6,069 PCA errors & 460 resulted in death or significant morbidity.

18.4% were directly attributed to the use of an unauthorized drug & 9.2% were prescribing errors. Perhaps your physician autonomy needed a little help....certainly the Joint Commission for International Center for Patient Safety, the Institute for Safe Medication Practices & the JCAHO all agree there needed to be more clear delineations of what constitutes safe orders. Since 2003, there have been many standards adopted & one of them is to "design standard order sets to guide drug selection....and determine preset drug concentrations...." in addition to many other efforts related to practice, systems, products, pumps, tubings & regulations all designed to reduce this intervention with carries significant risk.

Just because something seems clear to you does not mean its clear to everyone else who has to use it. If your "order" stands up to scrutiny, it can be adopted as one the the standards - simple as that.

 

[Annette]

Pretty much summarizes the problem with medicine nowadays.....no physician autonomy. Everything you do needs to go through 45 subcommittees.........Good times

That is a bit overboard! While you may hate the red tape, it can (and does) save your patient and your butt! I have seen some horrendous errors when a problem with an order wasn't caught by nursing or pharmacy. If you want complete autonomy, you are free to open up your own clinic.

The hospital is a very complex environment. It would be foolish to believe that any one person should be in complete control of it. Think about the US government- If one person (say, W), had complete control, ewwwhhh I shudder to think about it. Do you know pharmacology as well as SDN? Do you know how to administer half the drugs that you order? Do you know which tubing goes with which drug? There is just way too much for anyone person to know and understand.

 

[Annette]

Pretty much summarizes the problem with medicine nowadays.....no physician autonomy. Everything you do needs to go through 45 subcommittees.........Good times

That is a bit overboard! While you may hate the red tape, it can (and does) save your patient and your butt! I have seen some horrendous errors when a problem with an order wasn't caught by nursing or pharmacy. If you want complete autonomy, you are free to open up your own clinic.

The hospital is a very complex environment. It would be foolish to believe that any one person should be in complete control of it. Think about the US government- If one person (say, W), had complete control, ewwwhhh I shudder to think about it. Do you know pharmacology as well as SDN? Do you know how to administer half the drugs that you order? Do you know which tubing goes with which drug? (Forgot that this was in the anesthiology forum, Bad examples, but would you trust IM/EM/Surg etc with doing these things?)There is just way too much for anyone person to know and understand.

Respect is not a limited pie- where if someone gets more respect, you get less.

 

[The_Sensei]

Do you know how to administer half the drugs that you order?

No.....I know how to administer ALL the drugs I order!

 

[The_Sensei]

... you are free to open up your own clinic.

Most likely will.......with a group of surgeons I know. Many surgeons who are fed up with the buracracy of the hospital open their own surgi-centers.

Peace.

 

[sdn1977]

No.....I know how to administer ALL the drugs I order!

The point of this discussion is the possibility of a registry nurse who originally might have been supposed to work on a postpartum unit from 11P-7A & who is asked to float to med-surg partway into her shift doesn't know how to administer all the drugs YOU order. It could be a registry nurse, a new nurse or just a regular staff nurse who floats & is not familiar with your orders - these circumstances happen all day, on every shift in every hospital. There is no resource nurse around, you are off call, your on-call guy doesn't know what you ordered & can't help. The pharmacy has one person on who doesn't even know this was ever ordered earlier in the day & has no idea how the pump was set & has to deal with all the orders from the whole hospital & now has to go up to see exactly what is running, how the pump is set, etc.......That is how these issues develop & why the protocols need to be standardized & readily available.

As for anesthesia personnel knowing how to administer all the drugs they order...well....I recall a thread, the tpn one I think, in which someone didn't know there was actually tubing specifically for propofol & why. For anesthesia purposes, it is usually not an issue (unless its neonates) since you aren't giving it for long times, but it is when used on the units. Perhaps that individual was not you - congratulations! But, I'd venture to say some of you don't even know what DEHP free tubing is, but an ICU nurse does!

You don't practice in a vacuum - you have to rely on lots of individuals to care for your patient once you are no longer there. And....you have all the autonomy you want - you can come in anytime & push whatever drug you want IV - there are no restrictions on that. But...if it involves other personnel, you have to work with the system.

As for your own clinic - great. To obtain federal funding, you must have JCAHO certification....same situation. Why not try to work with the system rather than against it?

 

[jwk]

The point of this discussion is the possibility of a registry nurse who originally might have been supposed to work on a postpartum unit from 11P-7A & who is asked to float to med-surg partway into her shift doesn't know how to administer all the drugs YOU order. It could be a registry nurse, a new nurse or just a regular staff nurse who floats & is not familiar with your orders - these circumstances happen all day, on every shift in every hospital. There is no resource nurse around, you are off call, your on-call guy doesn't know what you ordered & can't help. The pharmacy has one person on who doesn't even know this was ever ordered earlier in the day & has no idea how the pump was set & has to deal with all the orders from the whole hospital & now has to go up to see exactly what is running, how the pump is set, etc.......That is how these issues develop & why the protocols need to be standardized & readily available.

As for anesthesia personnel knowing how to administer all the drugs they order...well....I recall a thread, the tpn one I think, in which someone didn't know there was actually tubing specifically for propofol & why. For anesthesia purposes, it is usually not an issue (unless its neonates) since you aren't giving it for long times, but it is when used on the units. Perhaps that individual was not you - congratulations! But, I'd venture to say some of you don't even know what DEHP free tubing is, but an ICU nurse does!

You don't practice in a vacuum - you have to rely on lots of individuals to care for your patient once you are no longer there. And....you have all the autonomy you want - you can come in anytime & push whatever drug you want IV - there are no restrictions on that. But...if it involves other personnel, you have to work with the system.

As for your own clinic - great. To obtain federal funding, you must have JCAHO certification....same situation. Why not try to work with the system rather than against it?

The voice of experience vs .....

Ketamine in our hospital is restricted by hospital policy and FULLY supported by the anesthesia department to be ONLY administered personally by an anesthesia provider. Same goes for diprivan (except in the ICU on ventilated patients), pentothal, and brevital. So - if a physician gives an order to give ketamine, it will NOT be followed in our hospital, nor will the pharmacy even release the drug to any physician to administer it personally, unless they are an anesthesiologist.

 

[The_Sensei]

As for your own clinic - great. To obtain federal funding, you must have JCAHO certification....same situation. Why not try to work with the system rather than against it?

Thank you, pharmacist for informing me of the "rules".

 

[Annette]

Sensi, I just re-read my post. Sorry, I didn't mean to come across so strident.

 

[SouthSideSteve]

I thought that when you wrote down some things on the order sheet, they were orders. I didn't know that the top of the sheet said "Suggestion" sheet.

sorry, but lol.

It might cease being a 'Suggestion' sheet when every attending, resident, consultant, intern, etc, etc etc never wrote an incorrect order*.




*grossly wrong dosage, contraindicated d/t allergy, condition etc etc etc.

I know you would like to think you practice in a Utopian environment but a nurse questioning an order usually means a red flag when up when they saw it. Instead of being a ****** and insisting on firing them, educate them so they may educate others. Nurses do not have to blindly follow orders if they believe them a danger to the patient or their license. Nurses who do don't stay licensed long, as well they shouldn't.

If it would have been me, I would have discussed it w/ ordering physician. If I then felt comfortable w/ it no prob. At our facility PCA is standardized with MSO4, Dilaudid and Demerol. Rarely are the latter two even used so ketamine + fent would have seemed 'odd' to me.


Addendum- some of the replies to sdn1977 simply amaze me with regards to the arrogance. You can learn something from everyone, no matter their title. I'm glad people only act this immature behind a computer and I rarely deal with such infantilism with the surgeons I work with.

 

[sdn1977]

Thank you, pharmacist for informing me of the "rules".

You're welcome, doctor. I'm sure it was just an "oversight" in your very busy day.

 

[cloud9]

don't take this the wrong way, and am not a troll.. i am an srna, and a nurse who has been in the SICU business for a while. it is our responsibility to question any order that might appear out of the ordinary, not normal, unsafe, etc... you get the picture.
in my facility, ketamine is only used in the OR.
that doesn't make the nurse that questioned the order who 'refused' and should be 'fired'..
and it doesn't make the doc wrong.
some facilities/-ologists don't use it as a pca order.
i can tell you that if i am uncomfortable, i will question the order, which can be from a very inexperienced doc, any time. not because i think i know more than whomever. but my yrs of practice should give me some leeway on the issue at hand.
agree, if there is literature out there that supports it, then fine, educate those that are unfamiliar.
it is always nice to find another way to alleviate pain.
i think we are all here for the same purpose, the patient.

The order should have been questioned, that is not the issue in my mind. The issue (which has been brought up and not commented on since) is why the nurse in question asked a physician who was not involved in the incident rather than ask the physician who was.

Why did she/he ask Jet rather than the prescriber? I have been the victim of orders that the nurse wasn't familiar with and consequently just canceled them when they were certainly correct and a couple were rather important. Thus they were "suggestions" rather than orders. Other occasions had a nurse about to cancel someone's order until a nurse standing by her decided to ask me what "tagged white cells" meant. Probably would not have been a good idea to just cancel it. (And, no, they don't tell you that they cancel the orders, you find out the next time you go see the patient or when you are looking for the result.)

Questioning the order is certainly not a problem, but the nurse should question the writer at least, and then do a "Jet Consult".

 

[sdn1977]

The order should have been questioned, that is not the issue in my mind. The issue (which has been brought up and not commented on since) is why the nurse in question asked a physician who was not involved in the incident rather than ask the physician who was.

Why did she/he ask Jet rather than the prescriber? I have been the victim of orders that the nurse wasn't familiar with and consequently just canceled them when they were certainly correct and a couple were rather important. Thus they were "suggestions" rather than orders. Other occasions had a nurse about to cancel someone's order until a nurse standing by her decided to ask me what "tagged white cells" meant. Probably would not have been a good idea to just cancel it. (And, no, they don't tell you that they cancel the orders, you find out the next time you go see the patient or when you are looking for the result.)

Questioning the order is certainly not a problem, but the nurse should question the writer at least, and then do a "Jet Consult".

If you go back reread the original post, the nurse refused the order & contacted jet after a couple of DAYS. She did not refuse the order based on his response.....she had already done that & he did not actually specifiy if there had been a conversation prior to the refusal with the writer of the order (I'm not sure he even knew/knows if that occurred).

It appeared from my reading, his question was about the commonality of a fentanyl/ketamine pca admixture. Thus....his post here.

Then...it degenerated into why don't folks just do what they're told to do (thank you Noyac).

My initial suspicion was the nurse was contacting jet because she has had or does have a previous professional relationship with him & admires his opinion & his experience. Since this would fall under his area of expertise, she was asking his opinion of the use of the admixture. It does not appear to me she was asking his permission to disregard an order at all.

I'm sorry for your circumstance in having your orders cancelled, but that does not appear to be the case here from the initial statements.

 

[The_Sensei]

You're welcome, doctor. I'm sure it was just an "oversight" in your very busy day.

Yeah....whew. Thank God you were there to make sure I didn't cause a serious "error"!

 

[jetproppilot]

Yeah....whew. Thank God you were there to make sure I didn't cause a serious "error"!

Sorry but I gotta butt in.

None of us are above making a clerical error, especially after a long night or whatever.

As you progress in your career, unless you are insecure, you'll appreciate someone "clarifying" your order, as long as its done appropriately.

Heres a recent example. One of my partners in haste the other day checked off Dilaudid, then proceeded to write morphine parameters. It was "clarified" by an astute RN. Board certified dude who will put me/my family to sleep if I ever need anything.

Couldda been a disaster.

Leave your ego at the door with order clarification, again, as long as its done appropriately.

 

[jwk]

Sorry but I gotta butt in.

None of us are above making a clerical error, especially after a long night or whatever.

As you progress in your career, unless you are insecure, you'll appreciate someone "clarifying" your order, as long as its done appropriately.

Heres a recent example. One of my partners in haste the other day checked off Dilaudid, then proceeded to write morphine parameters. It was "clarified" by an astute RN. Board certified dude who will put me/my family to sleep if I ever need anything.

Couldda been a disaster.

Leave your ego at the door with order clarification, again, as long as its done appropriately.

And again - the voice of experience...

 

[Noyac]

I don't see anything wrong with it if used in the right situation.


I do see a BIG problem with the nurse refusing to do it just because she isn't familiar with it. She needs to be educated and if she does it again, fire her. I'm sick and tired of nurses that think they know better. If it was ordered in the wrong scenario then she needs to talk with the doctor that ordered it.

So some of what I wrote (suggestion sheet not order sheet) was written tongue in cheek. It was mostly meant to be funny and I'm sorry of some of you guys didn't get it.

As I stated above. She needs to talk to the doctor that ordered it. If the policies don't allow it then the doc needs to work on educating the policy makers. This is unfortunate for some things but it is how it is.

Come on everyone, RELAX.

 

[dogbone65]

A coupla observations:

SDN1977 continues to amaze with her tact, diplomacy and professionalism.

Jet continues to provide sage and sound advice/views.

Egos continue to be rampant.

My view as a nurse from the "other side". Someone already pointed out that this nurse was probably seeking advice at a later point in time. As far as questioning orders, nurses are taught to do this and it is part of the checks and balances of the system to prevent errors. A nurse should NEVER just cancel an order they view as incorrect. They should CLARIFY. There is a huge difference. A nurse that cancels an order because they don't agree is just as negligent as a physician that rights an incorrect or inapropriate order. If an order is questioned, then the MD that wrote it should be called for clarification and the correct order then followed according to institutional policy. The nurse should not be a smarta$$ about it and the MD should be grateful that the nurse is trying to cover everybody's a$$.

 

[VolatileAgent]

A nurse should NEVER just cancel an order they view as incorrect. They should CLARIFY. There is a huge difference.

this is the point. and, if this sequence of events is actually what happened, that's fine. it was not clear that this was the case from jet's original post, and that is what i originally commented on.

and, yes, i have personally seen/had nurses - quite frankly - disobey orders that they didn't feel were appropriate and without consulting a physician. in one case, a nurse turned up a fentanyl drip despite the fact that it was specifically written not to do so (the patient, who was probably going to die anyway, had his death "hastened" by this action). what were the repercussions of this incident for this particular nurse? you guessed it: absolutely nothing. for that, i blame the nursing supervisor and the particular unit director (ie. attending physician) where this happened, both of whom didn't have the cojones to make an issue of it.

this is what frustrates us doctors (mostly residents, i admit) to no end. you have a nurse who's maybe been around for awhile and perhaps knows a good deal about what to do in a particular situation. but, when something falls outside his/her "box" or protocol or whatever you want to call it, they sometimes (and i stress the word sometimes) see this as a license to disregard. i've had this happen to me a couple of times, and when i've asked why or tried to address it, all i get is a bunch of "well... you know... you didn't explain... it wasn't clear..." blah, blah, blah. a simple follow question to them of, "then, why didn't you call me?" somehow never seems to garner an intelligent response. sure, they may learn something after the fact (and hopefully without detriment to the patient), but there never seem to be repercussions for that nurse in what lead to that situation. frustrates the hell out of me.

perhaps this is a institution-specific problem, but i get the sense that this is becoming more the norm across the board (and saw it too in med school at a different city/hospital) where some of the union-empowered nurses occassionally seem to feel that they don't really have to answer to the physician writing the order.

this phenomenon is what i initially commented on. it is relevant. it is critical to patient care. and, it has to stop. not understanding an order is not an adequate justification for ignoring/canceling it by a nurse or pharmacist or lab technician. how this ever became "standard practice" at an institutional level in some hospitals is beyond me.

 

[sdn1977]

How do these threads on this forum degenerate into such anger when it involves someone else trying to do their job?

Volatile - I appreciate your experiences - I do and don't discount they really happened exactly the way you presented them. However, if indeed a nurse (I'm speculating here) or pharmacist (I'm not speculating at all here!) actually disobeyed an order or "ignored" or cancelled an order - let me tell you as a pharmacist, my ass would be on the carpet the next day before the sun set! I cannot speak for the experience you related with the nurses you spoke of, however, I have had the experience of refusing orders & they are never pretty!

However....let me tell you a bit about residents & how teaching hospitals really work, from the employee side. I've worked at two....you may have heard of them....UCSF & Stanford....I'm within spitting distance of both. A resident may write an order...and at this time of year - August....the poorly written or outright incorrectly written orders are rampant. We understand that...its a teaching hospital - you're learning. We know that.

We also know that you don't know that there are some things we can do automatically without checking with you - my previous example...you order ranitidine, we give famotidine. We write the order to change it & we write as per P&T - we don't call you, your on-call buddy or your attending...its just done. We do this with lots of stuff - antibiotics, proton pump inhibitors, etc.. & you may not know all the automatic substitutions we have. Again...a learning curve - just ask & we'll tell. Better yet - ask your attending why the xyz drug or lab test wasn't done. There is usually a reason which is based in reason - not always, I'll give you that (sometimes orders are just overlooked or misplaced - it happens) - we're not perfect, but usually there was a reason, however, if we've made a mistake, I'll be the first to admit it & move on from there.

But...remember, we have perhaps 6 new anesthesia residents that started July - can you imagine how many other residents we have which are new on July 1 on all the services? We are working the same on July 3 as we did on June 28 - the difference is - you weren't there! Between July & Sept...we have lots of pissed off residents who seem to think we are just ignoring their orders - we're not....we're just trying to keep to the hospital policy which was designed to try to keep our budget & all sorts of other issues in check all the while trying to figure out why you are ordering what seems odd to us (altho it may have been the norm at the Mayo Clinic, Duke or wherever you came from...(that was not meant to disparage those two insituttions - they are just far from CA!) You have to learn within the constraints of a very large & expensively run corporation that you are currently in & unfamiliar with. You also have to learn the politics, the heirarchy, the prioritization, etc... - its a lot for the first few months. If you're beyond your first year & you still have issues with the pharmacy - why don't you stop one of us & ask? We are always around - just ask why thus & such wasn't sent or done or whatever? We'll tell you quite honestly. We are very open & have all sorts of data of what drugs we keep, antibiograms, time from order to delivery, drug level draws, etc...

Now...when you came from the University of whatever where you went to medical school - they had other contracts.....they taught you that prevacid was the very best proton pump inhibitor (or take any other drug as an example) when actually...that is what worked best for their contract. There is nothing wrong in believing that...but the education you are receiving as a resident is to learn that many things work (drugs, procedures, techniques) - and many folks can contribute to your patient care. You can order one thing & get another and it still works. When you work in an institutiton which has a monthly drug budget which runs in the millions of dollars...you don't just get what you want just because you write it.

I can honestly say I have never refused an order I do not understand & I have worked as a pharmacist for 29 years. Every order I have refused to do I have understood clearly & I have also cleared it thru many channels BEFORE I have refused it (believe me - I've had middle of the night coversations with the chiefs of service & hospital administrators!) This is the not pretty part - it goes on for hours & hours & there must be documentation. It very rarely happens & never with residents - I can tell you that! The attending is always the first person called. Your attending is usually the one overriding you, altho you may not know that. It only gets bad when an attending writes for something similar to what jet's situation was which can compromise a lot of people & mostly the patient.

However, if you choose to write orders which are subject to misunderstanding, make sure you are on call and available. Otherwise....and this happens to me weekly during the summer months....I call a resident to clarify & that resident is off call....I call the guy who is on call & he doesn't have a clue. I call the attending & he/she says cancel that order & do thus & such. So....the order has been cancelled thru all the proper channels of authority & the reasons there are no repercussions are because there has been so usurption of authority at all - just a series of people who could not understand what you wanted in the first place. You, however, just see on the order sheet - "cancel ........& start ........." so you feel we ignored what you wrote when we actually didn't do that at all,, but felt the chart was not the place to document all the calls which went on to actually get the order changed.

Again, volatile, I do not discount your unfortunate experience with the patient & the fentanyl drip - that is inexcusable. However, your resident experience is filled with learning your speciality. Learning hospital administrative regulations & policices, particularly when you might have come from one environment to another, are beyond what you should be expected to have to learn. Ask Jet or Mil or other attendings who have changed institutions...it takes a while to learn who the players are & where the power lies & what factors force decisions (sometimes therapeutics, sometimes money...)

I hope you accept this information as just that -information only - not aggression nor threats to your authority or abilities. It is imperative we learn to work well together. I wish you all the best in your residency years and hope your experiences with pharmacists improve!

 

[Chronic Student]

That was possibly the best post I have ever seen on SDN. Well written, informative and tactful. I have learned a lot from your different posts.

Thank you sdn1977.

-Mike

 

[VolatileAgent]

How do these threads on this forum degenerate into such anger when it involves someone else trying to do their job?

Volatile - I appreciate your experiences - I do and don't discount they really happened exactly the way you presented them. However, if indeed a nurse (I'm speculating here) or pharmacist (I'm not speculating at all here!) actually disobeyed an order or "ignored" or cancelled an order - let me tell you as a pharmacist, my ass would be on the carpet the next day before the sun set! I cannot speak for the experience you related with the nurses you spoke of, however, I have had the experience of refusing orders & they are never pretty!

However....let me tell you a bit about residents & how teaching hospitals really work, from the employee side. I've worked at two....you may have heard of them....UCSF & Stanford....I'm within spitting distance of both. A resident may write an order...and at this time of year - August....the poorly written or outright incorrectly written orders are rampant. We understand that...its a teaching hospital - you're learning. We know that.

We also know that you don't know that there are some things we can do automatically without checking with you - my previous example...you order ranitidine, we give famotidine. We write the order to change it & we write as per P&T - we don't call you, your on-call buddy or your attending...its just done. We do this with lots of stuff - antibiotics, proton pump inhibitors, etc.. & you may not know all the automatic substitutions we have. Again...a learning curve - just ask & we'll tell. Better yet - ask your attending why the xyz drug or lab test wasn't done. There is usually a reason which is based in reason - not always, I'll give you that (sometimes orders are just overlooked or misplaced - it happens) - we're not perfect, but usually there was a reason, however, if we've made a mistake, I'll be the first to admit it & move on from there.

But...remember, we have perhaps 6 new anesthesia residents that started July - can you imagine how many other residents we have which are new on July 1 on all the services? We are working the same on July 3 as we did on June 28 - the difference is - you weren't there! Between July & Sept...we have lots of pissed off residents who seem to think we are just ignoring their orders - we're not....we're just trying to keep to the hospital policy which was designed to try to keep our budget & all sorts of other issues in check all the while trying to figure out why you are ordering what seems odd to us (altho it may have been the norm at the Mayo Clinic, Duke or wherever you came from...(that was not meant to disparage those two insituttions - they are just far from CA!) You have to learn within the constraints of a very large & expensively run corporation that you are currently in & unfamiliar with. You also have to learn the politics, the heirarchy, the prioritization, etc... - its a lot for the first few months. If you're beyond your first year & you still have issues with the pharmacy - why don't you stop one of us & ask? We are always around - just ask why thus & such wasn't sent or done or whatever? We'll tell you quite honestly. We are very open & have all sorts of data of what drugs we keep, antibiograms, time from order to delivery, drug level draws, etc...

Now...when you came from the University of whatever where you went to medical school - they had other contracts.....they taught you that prevacid was the very best proton pump inhibitor (or take any other drug as an example) when actually...that is what worked best for their contract. There is nothing wrong in believing that...but the education you are receiving as a resident is to learn that many things work (drugs, procedures, techniques) - and many folks can contribute to your patient care. You can order one thing & get another and it still works. When you work in an institutiton which has a monthly drug budget which runs in the millions of dollars...you don't just get what you want just because you write it.

I can honestly say I have never refused an order I do not understand & I have worked as a pharmacist for 29 years. Every order I have refused to do I have understood clearly & I have also cleared it thru many channels BEFORE I have refused it (believe me - I've had middle of the night coversations with the chiefs of service & hospital administrators!) This is the not pretty part - it goes on for hours & hours & there must be documentation. It very rarely happens & never with residents - I can tell you that! The attending is always the first person called. Your attending is usually the one overriding you, altho you may not know that. It only gets bad when an attending writes for something similar to what jet's situation was which can compromise a lot of people & mostly the patient.

However, if you choose to write orders which are subject to misunderstanding, make sure you are on call and available. Otherwise....and this happens to me weekly during the summer months....I call a resident to clarify & that resident is off call....I call the guy who is on call & he doesn't have a clue. I call the attending & he/she says cancel that order & do thus & such. So....the order has been cancelled thru all the proper channels of authority & the reasons there are no repercussions are because there has been so usurption of authority at all - just a series of people who could not understand what you wanted in the first place. You, however, just see on the order sheet - "cancel ........& start ........." so you feel we ignored what you wrote when we actually didn't do that at all,, but felt the chart was not the place to document all the calls which went on to actually get the order changed.

Again, volatile, I do not discount your unfortunate experience with the patient & the fentanyl drip - that is inexcusable. However, your resident experience is filled with learning your speciality. Learning hospital administrative regulations & policices, particularly when you might have come from one environment to another, are beyond what you should be expected to have to learn. Ask Jet or Mil or other attendings who have changed institutions...it takes a while to learn who the players are & where the power lies & what factors force decisions (sometimes therapeutics, sometimes money...)

I hope you accept this information as just that -information only - not aggression nor threats to your authority or abilities. It is imperative we learn to work well together. I wish you all the best in your residency years and hope your experiences with pharmacists improve!

you seem a bit hung-up on the substitutions issue. i'm not talking about substitutions. likewise, i get called by the pharmacy all the time about other apparently "wrong" orders too, sometimes they are and sometimes they're not. no problem. you seem to be taking this a bit too personally, as well. i have very little problem with the pharmacy/pharmacists, in fact i hang out with a couple of them outside the hospital.

i just want to be called when an order isn't going to be done, and i want a reason why. this does not always happen, and sometimes it impacts patient care. this is a fact. the post-call issue is valid, but why not email me? (as a pharmacist that works with us routinely does.) it just often seems that, more than occassionally (as is implicit in your message), many ancillary staff's knee-jerk reaction is that the ordering physician must have made a mistake when this happens. and, the attending issue you raise i can't really comment on, because i'm not ever aware that this happens - at least to me - and, if it did then we have a way to record the override in our ordering system, which the overriding person should document.

we're all human. i concede that. some orders are inscrutable. but, here we have an electronic ordering system at my institution. there is no excuse for disobeying a clearly written and legible order (with the appropriately pre-defined computer logic checks) - which does happen here - without calling the ordering person.

you can get off your soapbox because you'll never convince me otherwise. fortunately, this is the exception rather than the norm, i'll admit, and most do call when something isn't clear. still, in addition to this issue, there are also on occassion other things that are done by ancillary staff - backtalk, unprofessionalism, etc. (things i would never do to a nurse/tech/pharmacist) - that are equally inexcusable, and this seems to go along with the often pre-emptive attitude that the resident is a ***** that needs to be "shepherded" to the right action, whether or not it is truly the right action that would've been arrived at with or witout their "help". point is, there never seems to be repercussions (if there was a job glut right now in nursing/ancillary staffing, i'm sure this would be different).