Recently, this standing order set was suggested to my hospital’s ER (after some discussions with another ER’s director of nursing about ways to raise patient satisfaction scores):

“STANDING MEDICATION ORDERS

Emergency Department nurses may administer the following medications for pain or fever at
their discretion before an ED patient has been evaluated by a physician.

§ Acetaminophen 1000mg (or approx. 15mg/kg), or ibuprofen 600mg (or approx. 10mg/kg),
po x1 prn pain or fever.

§ Percocet-5, or Vicodin, 1 po prn moderate pain to a patient ≥ 40kg; may repeat once prn.

§ Fentanyl 50 mcg IV q 5 min. prn moderate to severe pain to a patient ≥ 40kg, to a
maximum of 250 mcg.

The nurse will consider such factors as the degree of pain, medications recently taken by the
patient, likelihood of the patient needing to go to the OR, and whether or not an IV may be
necessary for other reasons. Generic equivalents are acceptable.”

Excuse me. Did I just hear FENTANYL IV can be given to a patient in triage by a nurse with no provider evaluation?!?!?!?! To a maximum of 250 mcg?!?!?!And then they can just go back to the waiting room and sit there until they are called in?

W…..T…..F…..!!!!!

This is the stupidest thing I have ever heard.  Not only is it totally dangerous (people being given super high strength narcotics IV are then going to sit out in the waiting area with no monitoring at all – I can see having at least one to two respiratory arrests per month), but it creates a perfect situation for drug seekers.  They can just come in, get their fix and elope from the waiting room!  Probably with the IV still in place!  Hell, even if they just get pain pills like Percocet, that is bad enough!  I bet they’ll never even get registered!  They’ll get their drugs and leave!

I don’t give a crap if my hospital started this policy, I would absoultely refuse to follow it and would document on every chart that the RN gave these drugs expressly without my knowledge or approval.  Thankfully my director thinks the same way and there is no plan to go in this perverted direction.

A heated fist-fight discussion has been going on on three mediblogs – White Coat’s, Happy Hospitalist’s, and Nurse K’s. It started when White Coat bemoaned the fact that Michael Jackson’s doctor is possibly being charged with manslaughter in connection with the singer’s death, allegedly from the drug, propofol. He (and then Happy echoed it) is very concerned that if the doc is successfully prosecuted for this crime, it will set a precedent to charge doctors with all sorts of criminal acts if patients have bad outcomes from the off-label use of drugs. Doctors have been doing this since the dawn of medicine – usually appropriately and safely (after all, pharmaceutical companies cannot petition the FDA for every new indication of every drug that is discovered – it costs jillions of dollars to do so, and for what? We will prescribe them regardless if with think something will work and is safe). Here is my two cents.

I agree with them IF such a horrific precedent were to be set in this case, the practise of medicine would be egregiously harmed. As Happy (paraphrased) says, doctors will have to stop giving neurontin for diabetic neuropathy, and lasix for ascites (both are common off label uses for them). However, I agree with Nurse K that such an outcome is extraordinarily unlikely – mostly because what Dr Murray did (or allegedly did) was very different from what Happy describes. Propofol is a HEAVY duty anaesthetic induction agent. It induces deep levels of anaesthesia in higher doses, allowing us to safely put people “to sleep” for operations (and then maintain them on inhaled agents like Sevoflurane until the operation is done). It does not take a rocket scientist to realise that such a drug could kill you – it makes you completely lose the ability to protect your airway at higher doses. Thus, even when given at LOW doses for “conscious or moderate sedation”, one must strictly monitor the patient. It should not be given to anyone (except in the most emergent of life-threatening reasons) who has eaten or drunk anything within the last 6 hours (to avoid aspiration). The patient must be on a cardiac and oxygen saturation monitor. Airway equipment must be present (intubation supplies, a ventilator, oxygen, etc), and well as access to ACLS drugs (epinephrine, atropine, etc) in case the patients crashes. This occasionally happens and as a result, the person giving the propofol must be able to resuscitate the patient – and this does not mean just to do CPR. He or she needs to comfortable intubating and be ACLS certified. At my hospital these are the BASIC prerequisites to perform conscious sedation. We have an additional level of certification as well. You have to be either an idiot, a cavalier cowboy, or beyond uncaring to just bolus someone with propofol in at home (unless MJ’s house was basically set up like an ER and Dr Murray was properly certified with an attendant RN as well). Giving someone lasix for ascites or neurontin for diabetic neuropathy is not much different than giving it for it’s original use. Both drugs are pretty damn safe and dosed similarly for these off label conditions. I find it hard to believe that doctors will be prosecuted if someone so happens to die from lasix – induced hypkalaemia JUST because they gave it for an off label use. I just don’t see how that would be manslaughter just like they are proposing MJ’s death is a case of. It’s like apples and oranges. That said, I am very interested to see what happens – and I wonder if the government will make propofol a controlled substance finally.

Well, at first I could not believe it. It was one of the those “if pigs could fly” things. The pharmaceutical industry is supporting the Obama administration’s health care reform efforts. How could this be? Did they not fight tooth and nail against “Hillary Care” back in the early nineties? Now they are supposed to spent 100 million bucks on ads that support it! WTH?!?!!

Simple. I think they see the writing on the wall with SOME sort of reform coming and they don’t want to be seen as the bad guys. Thus they are throwing their support in – IN EXCHANGE for some plum deals.

A. Banning importation of less expensive drugs from Canada

B. Preventing the government from further meddling in setting the price of drugs (something I think the government HAS to do eventually and evidently many Democrats agree with)

Thus, they are going to look good while getting these good deals plus a huge new pool of patients with insurance! Voil`a! Makes them look good AND keeps them rich!