Monday, September 17, 2012

Verbal orders in the ER are a source of never ending fun.  Health care pundits and poobahs would vehemently disagree and say that there is nothing fun about them.  They are easy to misinterpret, often inaccurate, not documented, an abusive manifestation of the physician-nurse relationship, and major sources of patient harm.  All of which I suppose are true to some extent, but it is equally true that in the hectic pace of the ER you simply can’t survive without them.

I think I like verbal order because unlike written ones, which are very much cut-and-dry, copy-and-paste sorts of things, virtually every verbal order is an exercise in negotiation.  There are many factors involved in the request, the issue, and the acceptance of verbal orders.  These include primarily the patient’s clinical condition, but also the nurse’s drive to get exactly what they want (know full well they can’t) and the physician’s impulse to prove they’re really in charge (knowing full well they’re not).  The wild card in the negotiation is something will call the General Annoyance Value of the patient.  The GAV is calculated by multiplying the subject’s  Chief Complaint (like “chest pain starting thirty minutes ago” or “painful rectal itch for three months”) by the Actual Clinical Severity of the patients.  This total is divided by the  number of times (factorial) the patient or an accompanying relative pushes the call button in a 20 minute period multiplied by the number of seconds it takes before the patient requests pain or anxiety medications upon arriving in the ER.  (The latter number is squared if a specific narcotic is requested by name).  The resulting equation looks something like this:

GAV = (CC)(ACS) / (BUTTON!)(Request)2

The reason patient volume (measured by volume in decibels times type and variety of profanity) is not included in this equation is that if you’re spending that much effort to yell out we know your airway is intact, you’re moving sufficient air past your vocal cords, and you’re getting enough blood flow to your brain to allow you to perform the higher functions of acting out.  In a general sense people who are really sick, who have problems with breathing and blood pressure, don’t do that.  So we can block you out and make the noise a non-factor, unlike the call button but which we are mandated, by administrative policy or State Law or religious duty or United Nations Mandate… keep getting those mixed up… obligated to respond. 

Once the AVS has been calculated, then the negotiation begins.  It’s kind of like “Name That Tune.”  You want to have the best chance of success with the least amount of drug, the lowest risk of respiratory depression, and the minimal amount of effort.  Here’s how it goes:

(For the uninitiated, Haldol is an antipsychotic drug and Ativan an anti-anxiety agent.  Both are used as sedatives in the ER.)

RN:  “The patient in Room 36 is acting up again.”

MD:  “I can snow that patient with 10 of IM Haldol.”

RN:  “I think we should use 5 mg of IV Haldol.”

MD:  “He’s too wild.  I don’t think you can get an IV.”

RN:  “I can if we give 2 mg of IM Ativan.”

MD:  “But if we give 2 mg of IM Ativan why not just give 10 mg of IM Haldol?

RN:  How about we give 5 mg IM Haldol, then start an IV to repeat if needed?

MD:  “Snow that patient.”

(Personally, I have come to the belief that once we get to this point, the health care system has failed the patient.  The actual solution to the problem is the Ativan lick.  Just like a salt lick, you put one of these in each patient room.  When the patient feels anxious, they take a lick.  If they don’t calm down, eventually they will take enough licks that they will fall peacefully to sleep, which stops them from taking any more meds into their system.  An alternative would be Ativan lollipops, but unfortunately the dose cannot be as well controlled, especially they’re treated like Tootsie Pops and no one can take more than three licks before biting through to the oh-so-relaxing center.)

Unlike most arguments in life, this really is a friendly exchange that can be win-win for all.  The patient feels better and becomes quiet, the call button does not get pushed, nobody stops breathing so there are no complications nor the accompanying paperwork, and we carry on in peace until the meds wear off or it’s time to play the Golden Medley.


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