17 year old boys...

Okay... I have now decided that I will NEVER have 17 year old boys... I don't like them... they suck... and they're rotten patients!!!!

So here's my story...
I get report for a 17 year old boy who broke his leg in a motorcycling accident. Okay, fine. So my CNA comes to me half an hour later (as I'm getting all my meds in order) and tells me that his temp is 38.9... okay... sounds like he needs tylenol... hmmm... no tylenol ordered, but he's got vicodin, I'll give him two of those because they've got tylenol in them... so I walk in the room with the vicodin (still in the packaging fortunately), and immediately smell something foul... I approach, and take a closer look, and there's something brown on his sheets... both top and bottom... and it's kinda chunky... ahhh crap... he threw up all over himself... (and didn't even bother to wake up, mind you...)... and then I realize that's what I smell (there's definitely a difference between post op vomit and sick vomit... *gags*) and want to throw up myself. I manage to resist the urge and go get help to change his bed (and put the vicodin back in lockup) and do the magic icepack trick (one ice pack behind the neck and one under each armpit... works every time). *sigh* The kid will hardly wake up to hear us while we shove the sheets under him, much less take off his shirt, or even lift his ass to give us a little bit of help!! Okay, so he's slightly snowed from the 25mg of demerol he's used from his PCA. Kinda keep a wary eye on him... and his dad shows up around 11pm. So I'm in talking to the dad, kinda letting him know what's going on while the aide takes the vitals... oh wow... his sats are only 56% on room air!! (he's completely asymptomatic aside from being lethargic, which will be explained in a future paragraph)

So as a nurse, my first instinct is to put him on oxygen (duh!), and on 2L per NC manage to get him up to 73%.. woohoo... but I don't think that's good enough... I mean, I'm just an LVN, but I'm certainly not stupid!!! So I see if he wakes up any with the oxygen... and he does... and when he wakes up, he's completely uncontrollable and combative and agitated and WILL NOT (even after repeated attempts) let us put ANYTHING on his face! At this point, he hasn't had any demerol for about 5 hours. So the only thing left to do is to crank up the oxygen and do a blowby via mask. The catch is that someone has to hold the damn mask for him to get any! So I stand there for two hours... yes... TWO BLOODY HOURS... holding this mask with the oxygen cranked up to about 12L, and if we're lucky, we get his sats up to 84 before he wakes up and starts thrashing again!

So I go out and talk to the doctor (whom my charge nurse had already spoken to) who obviously knows that it's because he got so many narcotics during the day (and he hadn't voided yet). So I'm just about in tears, totally exhausted, explaining to the doctor what exactly is going on, that I don't think it would be a good idea to give him any narcan because then he'd just be absolutely and totally uncontrollable with little hope of turning back, but that giving him ativan to calm his bursts of non-lucid consciousness would be counter productive. I'd already explained all this to the father, who was fortunately very helpful and understanding. So he says that we could give the narcan WITH the ativan only if ABSOLUTELY necessary. (countered with some side remarks that this kid needs to grow up and act like a 17 year old instead of a 2 year old and let the doctor sleep if he wants his leg fixed later in the morning)

Now here's the bit about the narcotics. When this patient was in the ER at another hospital (don't know which one), he was in 'so much pain' that he was getting 50mcg of fentanyl and 1mg of dilauded every 30 minutes for about 4 hours before they transferred him to us. All fine and dandy, that was more than 20 hours prior. So, after he was transferred to us two nights ago, he was getting 2-5mg of morphine IVP q2hours, which wasn't even holding him... so the doctor decided to give him a morphine PCA set at ... I don't know... it was probably 2mg every 10 minutes without a 4 hour limit. This kid used 48.2mg of morphine just during day shift yesterday, until the PCA was changed to demerol (12.5mg every 8 minutes without a 4 hour limit) around 4pm. Apparently he pushed the button twice (25mg total) before I came on shift and then was out cold after that. To top it off... he hadn't voided since he's been at my hospital... so just imagine all the fentanyl, dilauded, morphine, vicodin (of which he'd gotten 20mg), and oxycontin (40mg) all snowballing in his system... I think it all just hit him at once!

The fabulous thing about this situation is that at 7pm, when I came on shift, his sats were 93% on room air! When his sats were down in the 50's, he looked absolutely fine.... his color was perfused, he was warm and dry to touch, lips and nails were pink with good cap refill... no way anyone would have known except to check his vitals!

So anyway... the doctor called back after saying that there's nothing we really could do except keep him on the oxygen, and gave the order to STOP all the narcotics (and the soma), and only if necessary, resume the PCA after 4 hours...

In the end, the kid came around, peed twice, finally let us put the nasal canula back on him and at 4L of oxygen, we kept his sats between 88-98%!!

Needless to say, I told my charge nurse that I will not accept this patient back tonight, because I spent more than HALF my night caring for him and ignoring the rest of my patients! I didn't get my second break because I STILL had to do my chart audits, my dare charting, and check my MARS (which resulted in having to write up pharmacy twice), as well as collect urine from a foley for a q6hour urine serum sodium and potassium.

I have a headache, and I'm going to put on a good movie and go to sleep....