August, 2007 Archive

my jaw literally dropped. then, i uttered the all so common: oh. my. goodness. word for word. then i self righteously declared: “i will NEVER do THAT!”

the boys and i were walking home. on a narrow street, we had to pause to let an suv pass. in the driver’s seat was what looked like the dad, and sitting on his lap was a little girl who looked like 2 or 3 years old. he was driving, but the girl’s hands were on the steering wheel. by the looks of it, she was definitely having a  blast. the guy who was driving looked equally pleased.

he should be ashamed of himself!
what was he thinking?
how stupid!
what a terrible example!

i was endlessly bashing the guy for doing such an unthinkable thing when i realized something.

i did take the kids to the park so they can play, but we did not go home right after their countless stints at the slide. we passed by carl’s jr and they feasted on french fries while i gobbled a whole in your face burger. why? because i, the self proclaimed perfect mother, the best example, the one who will never do the unthinkable, found it easier to shove greasy, fatty food  to my toddler’s and preschooler’s mouths, just so i gan give in to my laziness in preparing a healthy dinner.

for all i know, there was a very good reason he did what he did. and for all i know, he probably never feeds his kids unhealthy foods.

there is so much hypocrisy in my system, it literally makes me sick.
it is difficult to admit it, but there are a lot of times when i am truly beyond disgusting.
this is one of those times.

some things NEVER change.
when will i ever learn to mind only my own business?

he winked at me.

this was when, after getting report, i pointed out to him that he has been giving the patient just 1 mg of dilaudid. the order was 2 mg every 2 hours, and i saw that in the chart, twice, he gave the patient 1 mg.

i understood the wink. without asking, i knew that the wink meant he has been telling or not telling the patient the whole truth, that he was only giving him half of the dose, instead of the full dose he knew he was getting. i know a few nurses who do this, and although i will not be hypocritical here and say that he was doing something that was completely wrong, i will not lie and say i was totally comfortable about it too.

these are the supposed warning signs: when  patients watch the clock and ask when they can have their next pain shot even before you have actually finished giving him one. when five to ten minutes before the next pain shot is due, the call light goes off, and you get a request for pain med “just so it will be ready at the time when it is due”. when patients ask: “can you push it faster?” or this classic request: “can you give both my phenergan and dilaudid at the same time?” these requests/behaviors send most nurses to a definite conclusion: drug seekers.

while it is true that there are drug seekers being admitted in the unit (i say this because a few patients actually confessed or admitted it), i will not say all of those asking for pain meds regularly are drug seekers. not everyone agrees with me on this one, but this is my stand and i will defend it if i have to, even if it makes me miss unpopular.

i will not open a can of worms that will generate an endless debate on where we draw the line. there are patients who are literally too drugged up because they are seeking pain and anti-anxiety meds like they are gasping for air, just because they like the high. there are patients who ask for pain med because their pain is genuinely and literally killing them, and they really need it. sometimes, it is not easy to spot who is who. there is a line somewhere, but that line is difficult to draw, and even when drawn, it is extremely difficult to decipher.

i will not go there because this kind of debate is sort of never ending. pain is very subjective, and one’s behavior towards those who complain of being in pain is even more subjective.

what i’m curious about is the supposed white lie that a lot of nurses willingly commit in situations like these. or can this be considered half lie because the true dose given is actually documented in the chart? when is it alright to say, :”yes, i am giving you 4 mg of morphine” when the truth is it is only 2 mg? when is it alright to say “i just gave you your pain med” when in fact it was a different IV med you just slowly pushed?” i guess what i really want to know is, if it is actually alright in the first place.

when after lying, the patients thank their nurse for giving him the pain meds, then they show the same behavior of relief as when they get them the real dose, is that enough reason to keep “lying” because their behavior perfectly matched the drug seekers label?

if you have met nurses who practice this without a flinch, what are their reasons for doing so?
          is this some kind of a personally waged war against drug dependence, and they believe they can alter the present addiction by doing this apparently simple/harmless intervention?
          is this something they have been doing ever since they were a new nurse, or is this something that one develops with experience?
          is this something they keep on doing even if the same patient keep on coming back for the same reason?

i do not intend to offend nurses who do this, i am just curious as to what goes on their mind. i am well aware this is none of my business because i’m pretty certain no patient has been harmed by this. to be honest, i just want to know if i should actually embrace this practice and do it without questions.  

i was raised in a very religious environment and guilt is something i deal with all the time. it is very possible that there are good reasons in doing this, but the guilt will eat my spirit away if i try it. if there are arguments that will convince me that i will be doing my patients good in the end by “lying” to them as far as pain meds is concerned, i am definitely willing to change.

let’s open the floor for a mature, honest, sensible discussion.
let me know what you think/feel about this whole thing.
i will really appreciate it if you share your thoughts, no matter what they are. 
thank you. 

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a follow up to answer questions/clarifications after reading 7 comments:

in our unit, the doctors write the orders of pain medicine this way: dilaudid 2 mg IV every 2 hours PRN (as needed) for severe 8-10/10 pain. this is a legal order and you cannot give a dose more than 2 mg. BUT, it is the nurse’s responsibility to assess the needs of the patient and decide how much to give. there are certain things you consider when giving pain medication. most of the times, the weight and age are big factors, and it is not unusual that doctors miss these by just ordering a certain dose. another big thing is the patient’s pain med relief history.

what i’m saying is: you cannot force me to give an 80 year old, 90 pounds patient 4 mg of dilauidid, even if it was ordered, without seeing first what 1 mg can do for her. i’ve given the smallest amount of Xanax (a relaxant) to a 68 year old female before, who was very anxious. a few minutes after, she was totally unarousable we had to give her something to reverse the med’s narcotic effect. i am not taking chances and will not jeopardize my patient’s safety by following an order that could possibly harm my patient by depressing their repiratory function. even if the doctor’s order is within the approved or recommended dose, only the nurses see/know first hand how a patient will react to a specific narcotic. therefore, it is my responsiblity to be very cautious. the approved/recommended dose is from the book, but every patient reacts differently. this is where nursing judgment comes in handy.

let me clarify further by explaining what i usually do when a see an order like this, if the patient is oriented: i ask the patient about his pain level. i will then ask if this kind of pain is new. if it is not, what has helped relieve it in the past. i will then ask the most crucial question: “have you ever been given dilaudid before?” if the answer is no, i USUALLY would give just half a dose and then reassess the pain.

i will tell the patient the truth: “the doctor ordered that you can have 2 mg, but since you’ve never had it before, i will be more comfortable in giving you just 1 mg now, and see how it works for you. this pain medicine is pretty strong, and patients react to it in different ways. i will come back in about 10-15 minutes and see if you still need some, but even before i come back, if you feel that the pain is getting worse, don’t hesitate to call me so i can give you the other half. i will then document in the chart that i only gave 1 mg, and waste (with a witness) the other mg, if there was no available 1 mg vial from the Accudose (the med/narcotic machine).

this has worked for me all the time, because there are a lot of patients who don’t really need that much pain med. the doctors then see the chart in the morning and find out that the patient has only been getting 1 mg, yet, his pain is managed. they will then adjust the dose and we will continue from there.

we are not required to let the doctor know that we gave a smaller dose than what was ordered, especially at night, because this is not an emergency that needs to be addressed. sometimes, in the middle of night, there are doctors who actually call and ask how the patient’s pain is, then they will know. if not, they will find out about it in the morning, and most, if not all of the times, they appreciate what was done. i have never heard a doctor get mad or question the act of giving a smaller dose of pain med if that dose managed the pain as expected.

it is another story if the patient has been in the unit for a while and have been getting the same pain med for days or weeks. by looking at the chart, i will see how the med worked. for example, if i see that in the past two or three days he has been getting 4 mg almost every 4 hours, there is no point in giving him 2 mg first, just to see what happens. because duh, i already know that 4 mg is what works for him.

there is no lying in the chart or the Accudose. the nurse i mentioned in the post charted truthfully in the MAR (medication administration record) that he only gave 1 mg. with a witness, he wasted the other half. the lying was the fact that he never told the patient he was just giving him half. all the while, as he was used to in the past few weeks that he was with us, the patient thought he was getting 2 mg. the nurse said that the patient  actually acknowledged him a couple of times, saying: “thanks man, that pain medicine really helped.”

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i hope this answers the questions raised in the comments. if there are other questions that will come up, i might end up just doing a follow up post next time. thank you so much for your inputs. i hope to hear more.