Sunday, May 17, 2009

It's Not an ER, It's a Safe Injection Site

I wish, oh how I wish I could take credit for the title of this post. But alas I cannot.

It baffles me, the number of people in this town who have standing orders for IM or IV narcotics. I have never worked in an ER with so many drug addicts who come in on a regular basis for their RN given, doctor ordered fix.

There are a couple of people here who you can set your watch by. Who needs a sundial when you have a Demerol 100mg q4h patient coming through the door?

One of my colleagues remarked today as we were both drawing up narcotics for patients with such standing orders, "its like this place isn't an ER, it's a safe injection site".

The statement made me howl with laughter but then sent me down a more introspective rabbit hole.

Ok. So why should I care if someone is a drug seeker? It doesn't affect me in any way, I am just carrying out the orders. I should be able to give it as impassively as azithromax. Right?

Well except for it does affect tax dollars pay for each visit. I run on the streets that she drives on after her injection.

What if I am the RN that gives the dose that finally puts him in to meperidine toxicity? Am I responsible because I am supplying a drug which has clear guidelines regarding its dependency and possible toxic side effects...supplying that drug waaaaayyy above and beyond the recommendations.

Should I just be pleased that this patient is getting clean pharmaceutical grade narcotics in a safe environment?

Why do I support real safe injection sites and harm reduction initiatives but get irritated every time I see one of the 'standing order' patients in the waiting room?

Is it even ethical for me to enable a prescribed drug dependency?

I've been doing some reading on meperidine use for headache management and it seems to only be recommended if the patient has perfect renal/hepatic function and is getting less than 600mg/24h or for only a 48h window of time. Yeah, no, no, and no in some of these cases. I feel like refusing to administer next time...but that isn't right either. What some of these people really need is a rehab clinic, a support network, a different childhood, coping mechanisms, withdrawal protocols...none of this comes if a self-important RN withholds a dose of medication.



Keet said...

You are so right EBSCO... What these people need are the social and psychological interventions that are not prescribed in an ER. You may want to check out brief interventions using motivational interviewing, as it has been shown to be helpful for people with dependency in ER's, just to get them thinking about treatment. Otherwise, maybe the doctor that's prescribing these narcotics should take a methadone prescribing course, so you could save some taxpayers $$$ and administer once a day? Stories like this make me rage, as it is irresponsible use of limited resources, and its not helping the people using the drugs, or the people giving them. I would take it up with the manager and medical director. There are better ways to run your ramshackle harm reduction clinic by the sounds of it.

Albinoblackbear said...

Keet--I like your use of the word 'ramshackle'. :) It is just not used enough, like 'bamboozled'.

I have talked to said MD about methadone and his response was "I'm not going down that road". I have to be delicate with things because I am an outsider that has just dropped onto the scene. What do I know? I am going to see when I next work with the doc that is re-ordering the prn doses...and maybe then I will bring it up again with some demerol toxicity articles that I can now site. I actually really like the guy--we've already had some interesting chats about palliative medicine, pain management, oncology...he's very smart and very sympathetic to his patients. So I don't want to be seen as 'that pushy broad from who knows where that is telling me how to practice medicine'!

There is no medical director, he resigned. So it would have to be my manager. And yes, I have also though of approaching her about it. One of the RN's said last night--every single agency nurse that has come here has commented on how inappropriate this is. We're such sh*t disturbers!

Well you remember the good ol' days from psyche eh? Every time I see one of the narc seekers I feel like I am back on the crisis unit working a 16h shift with Linda. hahahahahahaha :P

Keet said...

Dear God...
We had some good times didn't we... Remember mr "I-am-allergic-to-everything-and-have-been-abusing-my-epi-pen"? He was getting prn EPI for the love of!
Come to europe NOWWWW! I miss you.

Albinoblackbear said...

Oh RIGHT! I totally forgot about that dude...ahhh, the RAH. If only Wanda could see us now! The little ENS' that could! hahahaha

Trust me, I am anxiously awaiting the big move too. Can't wait 'til I hit the rocky shores. I've been in touch with a few Canadian IMG's that are now back in Canada after training over there. The theme to their training: Ireland is amazing, you'll have a blast.


Can I go now? How 'bout now? Now? How '

Bostonian in NY said...

I recently became good friends with a heroin addict...I'll write about it soon.