Emergency Department Environment

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I am a Clinician at a small community hospital.  I was covering the ED during an illness of a coworker and received a phone call asking for assistance. I went to the department to find that an intubated patient was not responding well to Propofol and the MD did not want to titrate higher but wanted to add a paralytic agent instead. I requested trying pressor support first with increased titration of the Propofol, but was shot down. I inquired as to the paralytic agent and the MD wanted to utilize Norcuron, even though our hospital had an order set for Cisatracurium, complete with titration tables, assessment guidelines, etc.  I worked with the primary nurse who then began to argue with me regarding using Norcuron.  We utilize the Gahart IV Medication book as our resource and any med that is listed within Gahart is on our formulary and therefore usable. I worked closely with the primary nurse on the titration tables and had one other nurse double check our math. It required much coaxing on my part to finally get the primary RN to hang the Nimbex and begin titrating the drug.  It took several minutes to do this, meanwhile the patient is biting, pulling, bucking, you name it. At this point he did not require any pressor agents because whatever anxiety he was feeling was causing HTN and tachycardia. After performing baseline neuro testing, we finally hung the med with effect. I am still baffled at the stance of the RN in regards to using this medication. She stated that she did not feel comfortable with the work required to mix, titrate and then monitor for effect. I stood slack-jawed for a few minutes, but did get some satisfaction because in the end there was a positive outcome for the patient.  Working with nurses is difficult, but in the ED environment, lack of trust in oneself can lead to disaster.

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