fentanyl, you are dead to me.

my patient is in for pancreatitis, which is ridiculously and notoriously painful.  unfortunately my patient, although very nice, is no stranger to narcotics.  therefore no normal medication doses were helping his pain.  as a result, the generous doctors at my day spa hospital decided to give him a fentanyl PCA with a basal dose.  first of all, you can take your basal rate and shove it, to me it screams "get the narcan".  secondly, fentanyl, really?  it's more sedation that medication, and i've had more than one bad experience with it.

so i went to this patient's room to obsessively check his breathing, and found him with a heart rate of 45.  i didn't love this, so i called the doctor and after a very typical patronizing conversation (where she insisted that fentanyl does not cause bradycardia...ha, and it doesn't cause hypotension or respiratory depression either...), we decided to take the basal out of the PCA.  naturally i didn't want to tell the patient that we were giving him less narcotic than before, so i sneakily reprogramed the pump and returned to check him again.  this time the heart rate was in the 30s.

weeeeeeell, we seem to have a little problem here.

this time, we decided to DC the PCA altogether and put the patient on some percocet and toradol (apparently the spirit of generosity in pain meds had left the building).  unfortunately, the fentanyl was still hanging around in my patient's system and his low heart rate in combination with his high blood pressure was wreaking havoc.

he started to complain of blurred vision, chest pain, dizziness, and shortness of breath.  i spent the better part of an hour running around pushing blood pressure meds, getting stat labs, and coordinating the EKG and chest xray.  i called the doctor who by this point was very sick of me, and suffered through another condescending conversation about how my patient was fine.  (funny, how an hour ago fentanyl did not cause bradycardia and now all of these very concerning symptoms are "just the fentanyl".)  then i called the STAT RN to come to assess.

of course by this time, the chest pain and shortness of breath vanished, and i was left looking like a big exaggerator.  but no matter!!  the crisis had passed (as had any hope that i would ever get a lunch break) and i returned to the issue at hand: pancreatitis patient now has crap for pain meds.

the saga continued on for a few more hours, ending with the patient dramatically vomiting up all of those great oral pain meds he was on.  at this point the patient was begging for that "Dilontin...it works for me!!" and i was pretty much at the end of my patience.  i called the doctor and got his pain meds switched to dilaudid and finally there was peace in the world.

i kid you not, 10 minutes later my phone rang.  it was my tech.  "he wants to get disconnected from his IV so he can go outside".  oh hell to the no, i know you DO NOT THINK you are going outside to smoke after everything that happened in the past five hours.  so i did what any good nurse would do.  first i avoided him until i thought i could interact with him and not rip his head off, and then i guilted him into staying in his room for another hour before i finally caved and hooked his IV machine on his wheelchair.

this situation has reminded me of several key nursing truths:
*they always want dilaudid.  ALWAYS.
*people can be half dead and still drag their nearly lifeless bodies outside to smoke
*medicine doctors are mean
*just because a patient is nice doesn't mean that they're not manipulative

and most importantly:
*fentanyl is evil and never to be trusted