Trau·ma  Junk· ie  ( 'trau-m&  'j&[ng]-kE) n. Slang
  1. One who has an insatiable interest, devotion or addiction to responding and assisting people with serious injury or shock to the body, as from violence or an accident.

Does that patient *really* need another neb?

(credit to KeepBreathing for the pic)

It's that time of year again. Everyone and their friend and brother is catching pneumonia, bronchitis, or even...H1N1. Which means, for some reason which is beyond the RT (or RT student), 99.999% of all patients in the hospital and emergency department will be given SVN treatments. Okay, so maybe that's a slight exaggeration. But not really.

Due to the seasons changing (or God smiting the lowly RTs-- one of those), everyone's asthma also starts to act up. This, in turn, means that we get to give a lot of nebs. (It's what we do, ya know.)

I have no problem with that. I love being busy. I love getting to use my assessment skills. I love being able to help people breathe better. But the problem comes into play when you have a particular doctor that overuses neb txs. You know what I'm talking about. Case in point:

I'm working ER yesterday at clinicals. A 5 year old male presents to us. No past medical history except asthma. On assessment, he is in distress. Intercostal retractions, tachypneic, coarse rales on inspiration and expiration. Auditory wheezes. Okay, this kid needs a neb.

Doctor orders 0.63 Xopenex (x2) and 0.5 Atrovent (x2). I don't really agree with this, but being the student, I give the treatment anyway. Post-tx, he has improved aeration and clear breath sounds, but he is still tachypneic and now slightly tachycardic (go figure, right?). It's not rocket science to figure out that the kiddo needs some steroids. Maybe Solumedrol IV?

An hour later, I'm called back to the ER. Xopenex .63 (x2) and Atrovent .5 (x2). Yes, an hour later. BBS are clear pre-tx. I give it anyway. My kid's HR increases from 136 to 180. I notify the ED MD and suggest politely that we hold off on more nebs or even consider a continuous neb, since they run at a lower flow and won't affect the HR as much. I also suggest we don't add Atrovent. He nods.

About an hour and 20 minutes later, ER is blowing up my phone again. Another Xopenex .63 x2. (Did I mention the kid took five albuterol treatments at home before coming to the ER? And yes, they're aware of this.) Again, HR goes through the roof. Now the kid is complaining of nausea. Instead of considering that maybe the SVNs are causing this, the doc orders some Phenergan IVP and orders another neb an hour later.


Don't get me wrong, I respect doctors to no end. But wow. How could this have been handled diferently? Just my suggestion:

1. Obtain a CXR
2. Draw an ABG to evaluate the patient's acid-base status (he was, after all, hyperventilating)
3. Steroids? Yes please.
4. Admit to inpatient for observation

Just sayin'.

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