Ventolin now indicated for low pressure

The patient presented to the emergency room with an Spo2 of 80% on room air, and he was taking rapid deep breaths as though starving for air.

The respiratory therapist was called to duty and placed an NRB mask upon the patient's face, improving the SpO2 reading to 95%.  The air hunger of the patient immediately subsided.  The RT then auscultated the patient and heard rhales in the bases, a sign that the patient was probably wet.

Right then the good doctor came into the room and, before listening for lung sounds, he told the RT to give a Duoneb to the patient.  The RT said, "No problem."

While giving the treatment the RT pondered as to why the physician ordered albuterol, especially when it was obvious the patient was wet.  He wondered how adding 0.5cc of albuterol solution, 2.5 mg of ipatropium bromide solution and 3cc of normal saline to the the fluid already present in the patients lungs would resolve this man's heart failure.

He looked away from the patient and at the monitor, where the vitals showed a heart rate of 112, a respiratory rate of 32, and a blood pressure of 90 over 20. That is when the aha moment occurred.

The therapist slapped himself alongside the head, and thought:  "Duh!  I should have figured this out earlier. The physician figured the low pressure could be treated by the side effects of albuterol  This made sense.

In this case the albuterol was lowpressorolin.  This made sense considering low pressure is best treated with lowpressorolin.

The RT snickers, and the nurse in the room looks at him funny.  "What's so funny?" she asked.  "Oh, nothing," said the enlightened RT.  He then rushed up to the RT cave and added yet another 'olin to the long list of Ventolin Types.

To call the Dr. or not to call, that is the dilemma

Here's something you will come across from time to time if you work nights. Of course as all RTs may have noticed by now, there often seems to be no rhyme or reason to "some" doctor orders, nor consistency to how a doctor will respond to a request to change the order.

Consider the following example:

The patient is a 75 YO non-COPD post operative patient with a registered SpO2 of 88% at 3-o-clock in the morning. Mind you, I did say three a.m. The patient is in no respiratory distress, and has no respiratory history. Otherwise, his vitals are normal. The order is for 2lpm. What do you do?

1. Call the doctor and wake him up
2. Increase the oxygen to 3lpm and have the RN call the doctor in the morning
3. Ignore the spo2 and pretend you didn't see it as the patients SpO2 probably always drops while he is sleeping
4. Since the SpO2 has an accuracy of plus/minus two, assume actual reading is 90%

Okay, what's your guess?

Day #1: This night the RT decides to use his common decides "b" is the best solution. The patient is stable and no harm done. If the patient's SpO2 was at a critical level, then a call to the doctor would be warranted, but not in this case.

The next day when the RT arrived at work he was lectured by said doctor who said, "Why do I write orders if you're not going to follow them?"

Day #2: Different patient but same information; different doctor, but this doctor is the spouse of the doctor in the scenario above. What does he do now?

Using the same choices above, since the RT now knows option #2 is not good, he decides to go with option #1 and wake up the doctor. The doctor says, "Why the hell are you waking me up at 3 in the morning to tell me this?"

"Um," says the RT, "Because yesterday, same scenario, your husband told me that I have to call before I increase oxygen to get an order."

"Oh," she says, "Well, then increase it to 3lpm and leave it at that."

"Well, then can we..."

Click. The doctor was no longer available.

"...get an order for protocol just in case... oh, what the heck.

So, what is the best thing to do in a scenario like this? Well, based on my experience, you're damned if you do and damned if you don't, so you might as well wake the doctor up and let her lecture you about how idiotic you are.

Thus, RN Cave Rule #72:

If you think you better call the doctor you better call him. If you think the doctor might yell at your and tell you you are an idiot because he doesn't want to be irritated in the middle of the night, call him anyway.

Here is a case study for you guys

After Dr. Krook assessed the mild-SOB out-of-town smoker who so happened to be camping at one of Shorelines parks, he ordered 3 Q-20 minute treatments. How does he know that a second or even a third treatment will be indicated when I haven't even given the first and reported the results?

Later, before she or I even went into the patient's room, Dr. Krane ordered me to do Q1 hour breathing treatments. Upon assessment the patient was was a smoker, but her chief complaint was mild dyspnea and a cough and nasal drainage. What's wrong with this picture?