Wednesday, 29 September 2010


An older lady with a diagnosis of schizoaffective disorder was admitted to our acute district general hospital down the road. She lives just out of area and was brought to our local acute hospital through the vagaries of chance. She was maintained on depot flupentixol decanoate (depixol) which had kept her well for a number of years.

She was having this injection every 2 weeks, without any side effects or problems, sought to continue it and both the patient and her psychiatrist/mental health team wished for it to continue. Her mental health team were remarkably helpful, faxing over depot cards and loads of relevant material for me. Continuity of care can work.

On the ward, her mental health was stable. Not a surprise. She'd been stable in the community for a few years, now.

She was referred because the nurses couldn't give her the depot injection. The ward nurses (RGNs) within the district general hospital are trained and competent to give injections, of course. But apparently the technique and administration of oily depot antipsychotic medication is something that mental health nurses (RMNs) are trained to do, but RGNs are not. So the acute hospital referred the lady to my door, for one of my nurses to drive over just to give the lady her injection. She did, shes a helpful soul and wanted the patient to get the right care.

But it struck me as odd. As a doctor, my training in procedures was p'raps more cavalier than it is now, being of the see one/do one/teach one school of practice, so I just assumed if you can give an injection, and you know the drug, you're fine to do it. I vaguely recall discussion about what the differences in practive between an RGN and RMN are, but since both nurses do injections, I'd not appreciated that the nurses can each only do certain types of injections.


cellar_door said...

An RGN trained tutor at uni tried just to teach us sub cut injections, as we "wouldn't need to give IM's". Obviously the class full of mental health students shouted her down and we got taught both eventually...

Nurse Anne said...

Yes RGNs are trained to give IM injections and often give IM drugs. I never heard of the drug that you mention or ever given it.

Therefore unless I had in house pharmacy for advice (yeah right) or another RN working with me (ha ha yeah right) who had experience with it I would have held off on it.

If it said in the instructions that it was simply IM and I was able to find it in the BNF and wasn't overwhelmed with other stuff I might have given it. But there is always the possibility that you don't know what you don't know and if something went wrong you would be in deep shit for giving a drug you had no experience with.

The hospital doctor would need to prescribe it on our forms as well. It doesn't matter if the patient had been on that drug every week for the last 600 years as prescribed by her GP. If it isn't prescribed by the hospital doctor on the hospital drug chart then it isn't prescribed in our view and we are not allowed to give it.

Was it a z track injection by any chance? I did one of those once 10 years ago and wouldn't do another one with supervision by a Nurse who was current with them?

We had a patient's husband bring in an injection from home that her GP has her on every two weeks.

We wouldn't give it until the hospital doctor prescribed it FOR OBVIOUS REASONS. The GPs script doesn't mean shit once you are in hospital. It was a weekend and we had to wait 7 hours for the junior doctor to get to the ward to deal with such a non urgent issue. The husband was having a shit fit because we wouldn't just give it. "She's always on it at home and the last one was two weeks ago so it's due now blah blah blah".

You would think it would be obvious why we the hospital Nurses can't just administer your usual stuff without a hospital docs sig but people are idiots.

Nurse Anne said...

Oh and when the junior doctor got there he refused to prescribe it and said "let the team sort it on monday or let the GP sort it out post discharge". So we couldn't give it.

It's not laziness. These juniors are the only ones doing ward work, they are covering multiple wards and they don't have time for non urgent shit.

But in the patient's view it is always going to be "The nurses couldn't be bothered or didn't know or didn't care or whatever".

Mark p.s.2 said...

Of course its the drug that made her well, not her own choices. (Sarcastic)
How do you know it was the drug that is/was making her "well"?
Circular logic works...

The Shrink said...

CD, would you give a general injection, like 3 monthly vit B12 injections then? RMNs in my corner still wouldn't, which seems fair enough!

Nurse Anne, yup, it's an oily long acting drug that needs deep im injection which our Trust policy requires use of Z tracking. And you're right not knowing what you don't know, the drug has a raft of short term and long term side effects and can cause permanent damage.

Mark, I believe the medication helped her for 3 reasons. Firstly, the patient told me so, in detail, with positive changes experienced on use of the drug and was confident in this. This richness of detail from the patient is compelling. Secondly, her clinical team evidenced how she was before the drug, how she was on the drug, how she was when it was stopped (she was on holiday abroad for 4 months) and how she was back on it. It was clear that off the drug she was more described herself as more distraught and was seen opbjectively to be more distressed, she improved on medication and was worse on stopping (then got better when started again). Lastly, her husband was very clear indeed that she was in his words "mad as a lune" (a phrase I'd never heard before!) off this drug and "normal and fun" on it, again giving detail of what that meant, and detail of timing on/off the drug.

For the patient, the clinical team and the patient's husband all to have seen her off drugs, on drugs, off drugs then back on them, all to have the same view and all to share that is compelling.

As I said, she's not my patient and, after improving mediacally she'll go back to her home town and her own clinical team. 've no proof it's medication (and not other factors) that correlate with her wellbeing. But for now, I've sufficient conviction that it's helpful for her and of merit to continue.

Eileen said...

He probably spelled it "loon" and mixed the "mad as a March hare" of GB with "crazy as a loon" of the US. The loon is a bird with a call that sounds like a mentally afflicted person. And loon also could be a contraction of lunatic. You only ever think abiut these words when you hear them questioned in some way but "loony" for acting not normally or sensibly has been around in our family for years.

cellar_door said...

Hmm...if I wasn't sure of the correct method or effects/interactions of the drug then I wouldn't give it until I found out, obviously. I'd have a read up and chat to the prescribing doctor about it. Ultimately, if it was a fairly standard SC or IM administration though I wouldn't be averse to giving it.

We give insulin regularly, so I always think that if we can handle that we should be ok with other routine jabs. Wouldn't touch an IV with a big stick, mind, because we have had nothing to do with them in the training. Similarly, I've never seen a ventrogluteal IM done in real life, so wouldn't do anything in that site.

Maybe I'm just too keen to stick needles in people :)

Quacktitioner said...

I am RMN not RGN but we are giving more and more injections that aren't depots, including sub cut heparin and insulin and the odd tetanus, b12 and the flu vaccine is just on it's way round now. It does seem to be a confidence thing both ways, I have known practice nurses and RGN's happy to give routine depots.