Life Saving Initiative of the Month
We have been notified of a new policy which was obviously developed by the pencil-pushing meddlers up on the twenty-eighth floor of a shiny new building far far away from the hustle and bustle of the emergency department. We are now required to order a rate on our IV fluid boluses. If I wanted a rate, I'd have ordered a rate. There are only two rates of fluid administration I ever really need to order in the ED.....wide open or none.
Anything else is just jerking off.
I want my patient to have a liter of normal saline intravenously. If the patient is stable, I really don't care if it goes in over 10 minutes, 30 minutes, or an hour. Just give them the dang liter and re-assess them for me please. I might order another one later. If the patient is unstable, your fancy machine won't pump fluids fast enough for me. I want two liters infused yesterday.
When all is said and done, nobody gives a damn what rate the fluids went in. The only thing that matters is did the patient live, and if so, the accepting team might ask "how much fluid did he get in the ER?"
Not "how fast did it go in?"
posted by scalpel at 2:01 AM
16 Comments:
I thought bolus pretty much meant "wide open". If you order any other rate on an adult patient you can be sure that nobody is computing the drips. In the ER there are two rates: fast and slow.
OH, that reminds me of the newest torture that JCAHO has inflicted on us via pharmacy -- I'll blog it later when I have time.
Ummmm, I agree with anonymous, bolus means as fast as it will go in, duh. that is dependent on a lot of factors, for instance the size of the IV catheter.
I wonder if they would accept the following notation in the chart, next to the IV order, "...with the nurse squeezing the hell out of the IV solution bag to make it go in faster..."
"The only thing that matters is did the patient live"
Sadly, not to the pencil pushers who are on the 28th floor in a building far away from the action. They're far too busy sniffing pencil shavings, wondering how else they can hinder docs' from doing what they do best.
JCAHO strikes again. Is there any way they can be
ousted from power? Hey, JCAHO, you're fired!
MJ
Ditto! I have quit fighting the pencil pushers though. I am a beaten man. I order drug screens for psyche patients and blood cultures on pneumonia patients and it barely bothers me anymore. It's like getting mad at an elephant... what the hell are you going to do to an elephant absent a very large gun?
OK, when infusion pumps have a rate setting of 25,000 ml/hr, I could see having a rate specified.
Til then, the comment about the nurse standing there squeezing is good enough
"It's like getting mad at an elephant... what the hell are you going to do to an elephant absent a very large gun?"
I would probably blog about its unwieldly girth, elephantine speed, incoordination, and massive production of excrement, while hiding behind my cloak of anonymity.
I mentioned this to my EMS intructors today. They laughed. "Rate? As fast as you can get it the hell in, that's the damn rate."
I wonder scalpel, have you ever seen CPM? I have, thanks to an ER doc who dumped several liters of NS in a patient with a low sodium...Food for thought.
I have never personally caused a complication by giving a patient either too much IV fluid or by giving fluid too fast. But I'm aware that such a thing can happen.
Actually as a hospitalist I can't tell you how many times I have had to lasix the heck out of new admits in florid CHF because the ER didn't bother to think about somebody's fluid status. Just dump in the IVF and let the admitting doc sort it out.
Thanks for agreeing with me.
It's the total amount of fluid that matters...not the rate.
The irritating problem with ER drip rates, besides having them at all, is that we have a limited supply of pumps in the department. Even if we call for more pumps 3 or 4 times, sometimes we can only muster up one here, one there. So wasting a pump on the myriad of 22 year old gastroenteritis patients just hurts the future guy-with-an-MI who needs 3 pumps going with very exact does of nitro/heparin/integrelin.
So, in other words, you can order the drip rate, but we're not going to charge the patient for a pump nor waste the pump on the patient. I'll just eyeball it and fit it into the categories of "TKO, medium, or wide-open."
The only time I have to deal with the concept of "rate" on a truck is if I have a drug hanging. Other than that, if the patient needs fluid (and fast, at that), WO is the way to go. If it's really bad, I've been known to put a blood pressure cuff around the bag to get the fluid in faster.
Sometimes "faster" is just not fast enough.
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