Setting: Emergency department, side desk, away from the nursing station in front of a computer workstation.
Dr. Smart: So, what is remarkable on this chest x-ray? (Pauses only a second before answering his own question.) The answer I am waiting for is that the mediastinum looks wide. So this patient is going to need an urgent CT angio to rule out an aortic dissection. I don't suppose either of you have the remotest idea on how to order a CT scan? So I'll have to show you ...
Louise: Dr. Smart, I'm sorry to interrupt, but the 74-year-old patient in bed 3 is having more back pain. He says it's up to an 8 out of 10 now. Can he have something more for his pain?
Dr. Smart: Just give him morphine 5 mg IV, Louise
Louise: He's received a total 10 mg of morphine over the past 2 hours and it doesn't seem to be working. What about giving him hydromorphone instead?
Dr. Smart: Hmmm, I am not used to ordering that, so let me check (pulls out his smartphone). Let's see ... hydromorphone ... (becomes annoyed after scrolling for a few seconds). Ahh great, the subscription on my app ran out. Well listen, just give him hydromorphone 5 mg IV.
Medical students: (looking at smartphone and whispering to each other)
#1: Hey, that dose seems really high for this patient.
#2: Yeah, you're right. You should say something about it.
#1: Not me. Maybe the nurse will say something?
#2: No, you looked it up, you should say it.
Louise: (re-reads order) All right, so we're going to give him hydromorphone 5 mg IV. I'll let you know if I need anything else. Thanks, Dr. Smart.
Dr. Smart: Right, now back to more pressing matters. Let's get on with ordering that CT scan. Now could one of you page the radiology resident? It's 209.
Med student #1: (hesitantly) Excuse me, Dr. Smart. I was checking my drug reference, and it says that the recommended dose for hydromorphone is lower than what you ordered.
Dr. Smart: (somewhat dismissive) It's going to be fine. Listen, that patient just got 10 mg of morphine and didn't touch him. Let's just hope that radiology resident calls back quickly so we can book our CT scan.
Concluding facilitation question: What alternate courses of action could the students and nurse have taken?