Friday, June 24, 2011

The Great Divide

So, I've noticed a great issue of debate among ER nurses lately- one that will surely go along with other important controversies such as abortion, dark chocolate vs. milk chocolate, and the Rolling Stones vs. the Beatles- whether to deny or provide the med seeker fix.
Other than a select number of ballsy doctors who just don't play with these people, just about anyone who comes into the ER with generic abdominal pain and a multitude of allergies acting a fool will get some Dilaudid prescribed. Since a bullshit complaint against a doc is still a complaint in their eyes, the powers that be at Hood Hospital pretty much force them into it.
This is where the nurses come in. You can't just say no to an order because you believe your bi-weekly-call-light-happy visitor's complaint is not legit, but you can deliver it in a way that is not ideal to them.
Yup. If I have a patient I know to be a drug seeker, I sure will give that 2 mgs of Dilaudid in about 200 ccs of saline over about 10 minutes. Lots of nurses I genuinely respect will give it fast as requested, give the people what they want, and hope they will STFU and stay off the call light. This often works, but I won't do it.
Here's my logic- first, I'm not here to get you high. I give pain medicine slowly, as I was taught to in nursing school. If you wanna complain that I did things by the book and pushed your narcs too slow, I believe that is actually one issue that my gutless management will actually back me up on. And second, I do not reward foolish behavior. If you come to my ER, lie to me, take time away from my other sick patients, act abusive and generally unruly, I do not want to give you any motivation to come back by giving you your fix. And I don't wanna teach you that you'll get what you want by being demanding and rude. I don't know if this will actually deter anyone in the future, but I do know that it satisfies the idealistic part of me, as well as the passive-aggressive asshole part of me.
So, other nurses. Where do you stand on this issue? Discuss with your coworkers on your next lunch break (ha). I guarantee it's more interesting to them than your opinion on abortion.

17 comments:

  1. That's great! My sister used to work in the ER and she ALWAYS talked about the people you just described.

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  2. TOTALLY back you up! I just got fired last week.... she wanted her fix... (see my latest post http://mmoon55.blogspot.com/2011/06/dear-pt-who-fired-me.html). I'd say my floor is 75/25. 75% don't want to fight with them and just give in. The others are like me and are sick of the bologna.

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  3. I'll mix it in a 50 cc minibag and give it slow as shit, for all the reasons you mentioned. And also because I, too, am a passive aggressive asshole sometimes.

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  4. I'm not an ER nurse but I have definitely done it to the frequent flyers a time or two!

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  5. I have no problem diluting a pain med in a 10 cc syringe and pushing it slowly with fluids....and if you tell me to push it fast, I will only go slower!

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  6. I wish our mgmt would back us up on this...but having pts "wait" just isn't part of our "culture"; I guess doping people up is- fancy that.

    My 1st place of work did Phenergan in a 50cc bag. IV narcs were NEVER given on that unit any more frequently than q4h. If the pt needed more pain meds, our INCREDIBLE CNL would tell the MDs to order PCA pumps. God, I miss that place so much. The grass is never greener...

    If it's a "10/10" walkie-talkie, where-are-my-clean-sheets and the-food-here-sucks and I'm allergic to everything EXCEPT Dila-la, I say GO FOR IT. I wish I could experiment and just slow-push 10cc of NS. I'm curious to see if the placebo effect would make itself known.

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  7. Good for you!
    Nurses are not stupid, we know who is there and needs the pain meds, versus who is there and wants the pain meds.

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  8. I agree with you whole-heartedly. I do the same thing.

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  9. I'm a pre-nursing student, so this may be a dumb question - but why aren't there any protocols in place for obvious drug seekers? It seems to me that if hospitals in a given area were in agreement (and nurses were mandated to "slow push" the drug seekers), in time, drug seekers would eventually "get it" and stop trying to take advantage. Too pollyannish a suggestion?

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  10. I heart this. Very much. In fact, I believe I will be incorporating it into my practice starting....now

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  11. In speaking with my favorite nurses up on the floor, this is what we have decided is our collective course of action. If the meds are ordered and the patient is alert and awake and BP is acceptable, give it. However, you always push the drug according to policy. No fast pushers among our group. One or two day shift renegades will make this harder for the others to enforce but the patients do learn quickly which nurses will cater to them and which ones won't.

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  12. @ pre nursing student- short answer is the hospitals and management are gutless, long answer is a little more complicated. We have a few that we are pretty much sure are seekers, and we see a lot more that fall in a grey area. Most of these people jump from hospital to hospital, and there is really very little coordination between the hospitals, nor can there be with privacy laws. A lot of the saying no really falls on the doctors, since they order the meds, but the hospitals, at least mine anyway, don't back them up. Hospitals are really big into patient satisfaction scores, particularly since the future of reimbursement is based on these scores. So if someone is dissatisfied, they don't look at the circumstances to see whether or not the complaint is reasonable or whether the patient was displaying warning signs of drug seeking behavior, they just see a ding in their Press Ganey scores and the target the recipient of bad feedback- the doctor or the nurse.
    We have a doctor here who is an excellent physician, and obviously knows when he's being lied to. He would straight call people out for their bullshit, and refuse pain meds to people who were obviously liars. I once saw him tell a lady who was faking seizures "I believe you are having pseudo seizures, so please stop now, thank you." Anyway. Got complaints for being legit, he saw other doctors basically get fired for the same thing, so now he orders at least 2 of Dilaudid for EVERYONE. It's sad, but it's a lot easier and a lot more job security for them to just give in to these assholes.

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  13. My friend put 2mg of the D drug into a liter bag of normal saline one time. I've not been that ballsy, but I have put it in a 10cc syringe and pushed really really slow at the top port. Passive-aggressive yes, but it makes me feel good! We had one come in 3x today acting the total fool. Doctor #1 gave him 2mg of MS and d/c'd him. 1 hour later he's back, doctor #2 gave him Dilaudid 1mg, a KUB and d/c'd him. Came back around 2p and doctor big work -up did a ct abd with contrast, another KUB and gave him Dilaudid 2mg x 2 and d/c'd him. That makes about 4 ct scans for the month and many KUB's. Unbelievable, but they say they get yelled at my administration for complaints and some have gotten fired. It's just ridiculous.

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  14. I got "fired" by a patient a couple weeks ago who claimed I was lying to her & not actually giving her any pain meds because she didn't "feel it going in." Fine, whatever. Nursing supervisor basically kissed her ass, gave her to another (less nice, seriously) nurse & told her to slam the stuff. She did, but she didn't get her her jello & crap as quickly (or at all) like I did. She probably would have "fired" nurse #2 if she hadn't fallen asleep. The patient that nurse traded with me was awesome, by the way. I always tell people, before I give them IVP anything, that I go slow, per policy.

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  15. I swear, when I see these descriptions and patient behavior it's hard not to think about the similarities I came across dealing with a toddler, and the teenager.

    My children don't display that behavior for the general public though, so if I have to bring them to "your" ER, chances are they will be pleasant and grateful. At least I've got that, right?

    How frustrating for you all.

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  16. I think I HEART you, New Nurse! I guess I'm one of the queens of paSsive aggression. As a travel agent, the client is ALWAYS right, and I can't afford to voluntarily lose a single sale, but I can tell you that the bigots and racists pay Much Higher service charges! This only makes me feel better because I know I've hit them where it hurts them most.

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  17. This is an old post (first time reader here), but I throw it into a 10cc syringe and put it on our syringe pumps which take ≈20 mins to infuse. I don't really have a stance on doing it to drug seekers per se, I just don't typically like to hear them whine about whateverthefuck if I stand @ the bedside for the slow IVP. So I prep it, prime it, and throw it up and promptly leave the room. If I'm asked why I'm not pushing it "like the other nurses do" (which 9/10 I am by the druggies) I mumble something about time management and critical patient and get the fuck out of there. If someone is acutely in pain, I'll push that shit as fast as my guide book says and maybe even a little faster. Having an MI? Yup. Push. Just broke your leg/arm/face/head etc..? Push. Your q3ยบ dilaudid for your chronic back pain/fibromyalgia/psych disorder? Nope. 20 minutes.

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