Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

What is a Nursing Dose?

I was assisting the ED staff with restraining a patient. The emergency physician gave orders for some lorazepam (Ativan). A whopping dose of 1 mg, although I was not aware of the dose at the time. I was busy trying to keep Mr. Agitated from doing anything other than setting off vital signs alarms.

The nurse gives an injection.

RM – What did you give?

Nurse – 1 mg. Nursing dose.

RM – Huh? This line was delivered with my most intelligent befuddled expression. 1 mg isn’t going to do a thing for this guy.

Nurse – Nursing dose, heavy dose, we hit a bump, . . . . You know what I mean.

What she meant was that the entire 2 mg in the syringe was administered, rather than the 1 mg ordered by Dr. Inadequate.

Now, we could criticize the nurse for exceeding her orders by giving a dose that is less inadequate than the ridiculously inadequate dose ordered by the doctor. I have much more of a problem with Dr. Inadequate depriving the patient of appropriate care, just because a doctor can get away with inadequate pain management and inadequate sedation.

What are the risks from the actions of the nurse?

Respiratory depression. Since Mr. Agitated is breathing at an alarmingly high rate, a bit of respiratory depression is actually needed.

Just to amuse the Dr. Inadequate defenders, what if the respiratory depression becomes a problem? Talk to the patient. If this is an iatrogenic respiratory depression due to any remotely reasonable dose of sedative or opioid, talking to the patient should be more than adequate to keep the patient breathing. Such high tech treatment might confuse Dr. Inadequate, but any ED tech is capable of handling this BLS intervention.

A talking patient is a breathing patient.

Why would anyone think otherwise? Because there are too many Dr. Inadequate clones giving orders. They don’t understand, so they give a dose that does not have much of an effect. They only see the risk from too much medication, not the more significant risk from not enough medication.

Drop in blood pressure. sedatives can lower the blood pressure. Treating Mr. Agitated’s blood pressure by sedating Mr. Agitated is probably the least dangerous method of dealing with his alarmingly high blood pressure. As with respiratory depression, lowering the blood pressure is expected and is a good thing

Just to amuse the Dr. Inadequate defenders, what if hypotension does become a problem? Since it is unlikely that there is a significant bleed, it is perfectly appropriate to give some fluids. Low blood pressure secondary to sedation is not something that should encourage anyone to panic. If this does encourage panic, the answer is to sedate the panicking person, too.

Change in mental status. Not really a problem. We are hoping that Mr. Agitated’s behavior will change. Mr. Agitated already has altered mental status. A more cooperative, more sedated, altered mental status would be better.

Does sedation equal a change in mental status?

We hope so.

If Mr. Agitated is now sedated to the point where he only responds to voice, but now answers all questions appropriately, isn’t that the goal of sedation? Isn’t that a dramatic improvement?

I wrote about the problems with bad orders/protocols in EMS Needs to Be a Separate Medical Specialty – Now – Part I. This is a little bit different.

Has the nurse endangered her patient/Dr. Inadequate’s patient?

No.

I think that I have made it clear that Mr. Agitated is at much greater risk from Dr. Inadequate, than from the appropriate dose of lorazepam given by the nurse.

Has the nurse done anything wrong?

She exceeded her orders.

She has not done this for herself, but for Mr. Agitated, who probably cursed at her and hit her, or tried to hit her. She is doing something that could get her in a lot of trouble, but she is doing this for one of the least pleasant patients. Will she get any credit for this? More likely she will get in trouble for this if anyone finds out.

Dr. Inadequate will assume that his ridiculously low doses are adequate.

This is the real problem.

I apologize to all of those who will claim that Dr. Inadequate has some sort of sacred right to mistreat his patients, just because he has a medical license. He does not.

An interesting article addresses appropriate use of opioids, just not from the point of view of Dr. Inadequate.

Avoiding trouble when using opiates to treat patient pain.
June 2003 ACP Observer, copyright © 2003 by the American College of Physicians.
By Jason van Steenburgh
Article

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Comments

  1. Or a politically correct way is to say that you administered 2 doses of the order 😀