Emergency Nursing

NuGuyNurse2b · Mar 26, 2018

NuGuyNurse2b:
Thank you for your reply! I suppose there's good and bad to every job. Would the bad days mainly consist of patients dying?
What is med surgery like? I didn't realise that there were customer surveys. As far as bedside requirements go do you mean caring for patients for the long term as opposed to treating patients for a shorter time?

Bad days can include patients dying, but for me, a bad day is anything from having multiple chest pains to multiple strokes that come in. You really can't keep up with those cases, especially if the stroke is within the time frame for giving clot busting medication - that is a complete 1:1, but obviously you can't just get rid of your other patients. And sometimes you won't have additional staff to help you in cases like that.

There are customer surveys even in ER, but Med Surg is now becoming more about customer service than it is about nursing care. it's something that is turned me away from bedside nursing and if it continues to a place like the er, i may just leave the hospital setting altogether and go elsewhere where I can do nursing care without the bureaucracy.

Mary3010 · Mar 26, 2018

Bass catching nurse:

Wow you can have a lot of people in the waiting room!!So basically you might have to give patients things like morphine as you said when they don't necessarily need it (just to make them quiet/happy). I can't believe that customer satisfaction is linked to reimbursement! Really they should be thankful that results come back negative!!

Wow I can't believe even a fractured hip from patients. I guess you have to be physically strong then to work in emergency. I've heard paramedics being attacked but I didn't think of that. I think they should be taken into lockdown or security guards should be present...something should be in place.

So do you triage all patients in the waiting room (even the 30-40 you would normally have) before prioritising who needs treatment first? Thank for sharing!!!

BassCatchingNurse · Mar 26, 2018

Yes, narcotic pain meds are given to patients due to patient satisfaction reasons. It is sad and partly to blame for the current prescription drug problem.

Yes, patient satisfaction is linked to reimbursement. That's the government in action. Not to be political, just stating facts, this is one of the "gifts" from Obama's administration. It is one of the reasons that budget cuts were made and healthcare cost went up. Again, I'm not trying to start a political argument. It is just a consequence to putting out such policies. In my opinion, it is a bad policy.

We have security in my ER. But, when a patient "lashes out", it might be too quick to do anything. You might be assessing the patient or giving a med when it happens. I did work at one ER where we had one security guard, and they would tell us that they couldn't touch the patient as we were fighting the patient trying to get them in restraints.

You do not triage everyone first. You triage every person individually as they come in and assign a priority (1-5). "One" meaning that they will die right now if I do not do something and "Five" being they should not even have come to the ER. Now, if I am about to triage an earache and someone with chest pain comes in, I will skip the earache and checked out/do an EKG on the chest pain patient. You will have multiple levels out in the waiting room, "ones" will not be there - they go straight back, as it is a true emergency. I might have 3 "level 2s" and 30 "level 3s" out in the waiting room. I will then call the "lead nurse" and tell them which of the "level 2s" I am most concerned about and think should be brought back next. Someone might be a level 2 for a reason other than "they are going to die if we don't do something within the hour." Triage is a skill. There are a LOT of people that act like they are dying or have chest pain to get to the back. I've had patients fake seizures and fake passing out in the waiting room trying to get back to the back. You have to be knowledgeable enough to recognize serious signs and symptoms. You have to be knowledgeable enough to ask "the right questions" to figure out if this is potentially serious or not. And, you have to be confident in your critical thinking. If not, you might let a person with a chest cold that is lying on the ground clutching their chest go before that patient that has a pulmonary embolism and is not being dramatic, but concentrating on trying to breathe.

PeakRN · Mar 27, 2018

PeakRN:
So in emergency you have less serious cases overall?
So it's not that it's looked down upon for not having breaks...it's that you physically can't. Would that depend on how many staff are put on? Wow charting must take a long time to do. Do you have to do that at your nursing station?
That's good to know that you can have some down-time moments since you must work so hard. The hospital you work at sounds really nice in that you can admire the city from the top of the building. You've got an interesting story, thank you for sharing! So do you frequently change wards to help out other staff?
I suppose you have plenty of time to think about which one you would prefer then if you need experience before advancing in nursing. Wow, I thought that to be a doctor it would be the same amount of pay for pediatrics and adult medicine.

We certainly have a lower average acuity than most of the hospital, the vast majority of our patients get discharged to home with basic symptom management. The caveat to that is that you never know how sick a patient is until someone actually sees them and you never know what is going to come through the doors. Statistically most admissions come in via ambulance but that certainly has not stopped the countless homie drop off GSW, stabbings, and narcotic ODs. We also have a very limited history on most of our patients and we have to do all of the detective work on every patient ourselves (there is a reason the ED has a reputation for having the shotgun approach to diagnostics), and when you have a truly sick patinet you need to figure out which interventions are going to save their lives and which can wait for a bit.

Some days there just isn't time for breaks regardless of staffing. If we are fully staffed but running 200% of our average daily census a 30 minute lunch isn't going to happen.

In my opinion charting is either to provide a legal document if we go to court later or to communicate findings for other health providers later (the billing aspects are far less important than on inpatient units, we bill a facility charge regardless of how much is charted). As long as those two things are done we are good to go, I think that a lot of nurses have a tendency to over chart in the ED but I guess that is more of an opinion. I definitely chart a the nurses station, I chart at the beside for certain things but generally I find that I can personally chart faster if I have fewer distractions.

Our hospital is always trying to develop good interdepartment relationships, and certain units are certainly more skilled at some things than others. For example if I cannot get fetal heart tones on a 10 week gestation pregnancy I call the labor deck and ask on of the OB nurses to come down and help, they certainly have far more practice at that then I do.

Similarly there are certain skills that the ED either performs more often than other units or are the only nurses allowed to perform certain skills. For example in our hospital EJs can only be placed by competencied ED nurses or credentialed medical providers regardless of where the patient is in the hospital (even the PICC nurses are not allowed to place EJs, and I have yet to see a non-ED provider actually attempt an EJ). We have a couple of ultrasound guided IV trained nurses on other units however they certainly use the skill less frequently, and none of them are allowed to use ultrasound to guide IV placement in kids under 13. As a result it is not uncommon for the ED to get called by peds, PICU, or a myriad of other units to help with IV placement. We will also go to assist in a slew of other things, even though we don't pull shift on those units.

As far as the physician pay: our PEMs make less than our general ED docs, or pediatricians make less than our adult hospitalists, the neonatologists and pediatric intensivists make less than the adult intensivists, and the peds surgeons make less than the adult ones. This is not unique to our hospital by any means nor limited to hospital based medicine providers.

Mary3010 · Apr 2, 2018

NuGuyNurse2b:

I suppose it would be pretty chaotic with having multiple people who have chest pains or who are having strokes all at once. That makes sense because it would be stressful!!! Does that happen often? And obviously you only have so much time before the patient would only get worse.

It seems as though this must be a common issue as far as these customer surveys go. You could always consider clinical nursing or school nursing if like you said the customers surveys play a bigger role within the ER.

Mary3010 · Apr 2, 2018

BassCatchingNurse:

That's so bad that the health system is like that (giving narcotic pains medications due to patient satisfaction reasons).

That makes sense in that patients will unexpectedly lash out without giving you time to call security. If you suspect that a patient might lash out because they are abusive, are drunk/high etc. can you prepare a security guard to be on standby just incase? I guess the patient could really injure you or worse still kill you. I mean if they can break walls, doors and the ceiling like you say. It's not just that, they could even have a weapon. I could be completely off here.

That is actually so ridiculous!! I thought a security guard would help you restrain patients down if they are violent etc. There is no way I could restrain a patient like that by myself. Hopefully you didn't have a hard time trying to restrain patients at that ER you used to work at!!

This sounds so interesting!!! So am I correct to say that when patients first arrive and let the front desk what is wrong, you assign them a number between 1-5 but don't treat them all just yet. All level one patients are treated first because they will die any minute if they are not. These get divided between however many nurses there are. Once they're done you treat them in order from level 2-5. Wow three level 2's at once sometimes!!!

Wow...people actually fake being sick in emergency!!! That's exactly right you have to find the one's who aren't putting it on. I guess it comes with practice knowing who is faking it and who isn't. Thank you for your response!!

smonty1025, BSN · Apr 2, 2018

I am an emergency RN with about 10 months of experience. I work in a level II trauma center in Indiana and I started fresh out of school.

1) It is a crazy environment that always keeps me on my toes. Every day is different yet still has somewhat of a routine in a sense of my job duties in given scenarios.

I had the benefit of a fantastic team of managers and coworkers who are all very supportive. My preceptor was very knowledgeable and really helped me to see the 'why' behind what I was doing, not just doing things robotically. You have to critically think as a nurse to anticipate your next course of action.

2) I work 3, 12 hour shifts each week (7a-7p) and I have the option of picking up more hours if I want to. We have 4 different shifts in our ED, 7a-7p, 11a-11p, 3p-3a, and 7p-7a.

If you are interested in a career as an ED RN you need to be flexible. Things can change in an instant and you need to be able to roll with it. You will be on your feet for hours and probably not have a structured break/lunch schedule. (Desk? What is this desk you speak of? lol)

We have a 3:1 ratio with our patients and we triage them based on severity of symptoms and resources they will require (trauma bays typically are 1:1).

3) There is a very broad spectrum from paramedic to MD. Honestly, I don't think I would categorize paramedic into nursing because they work in different arenas.

Paramedics and EMTs are your first responders, they provide care in the field and bring the patients to the hospitals to continue that care. While they are an important part of patient care, nurses don't typically work in the field with them or vise versa.

Nurses are the bridge between the patient and the healthcare provider (MD, DO, PA, NP). We assess the patients and administer medications as well as some treatment (within our scope of practice).

This being said, if you are considering a career as an RN, there are so many different areas you can go into if the ED doesn't sound right for you.

smonty1025, BSN · Apr 2, 2018

I was a part of a transition program while in nursing school that allowed us to work as student nurse/techs in the hospital until we graduated and passed NCLEX. I started on a med surg unit and I HATED the whole patient survey thing. We had meetings called "8 to great" that specifically focused on getting those 8 ratings to a 10. The whole idea aggravates me to no end. Its not a hotel, its a place to heal. I'm so glad to hear someone else had this issue. Transferring to the ED was amazing. I dont think I could work anywhere else.

BassCatchingNurse · Apr 2, 2018

BassCatchingNurse:
That makes sense in that patients will unexpectedly lash out without giving you time to call security. If you suspect that a patient might lash out because they are abusive, are drunk/high etc. can you prepare a security guard to be on standby just incase? I guess the patient could really injure you or worse still kill you. I mean if they can break walls, doors and the ceiling like you say. It's not just that, they could even have a weapon. I could be completely off here.

Yes, we can/do get security standing by; however, someone can strike you quicker than they can be grabbed by security! Also, some people seem perfectly "normal" before they aren't!!

BassCatchingNurse:
That is actually so ridiculous!! I thought a security guard would help you restrain patients down if they are violent etc. There is no way I could restrain a patient like that by myself. Hopefully you didn't have a hard time trying to restrain patients at that ER you used to work at!!

I'm a big guy and can hold my own. That being said, I just do not think it should be part of my job!! It makes it more difficult to "build trust" and help the patient after having to physically restrain them!

BassCatchingNurse:
This sounds so interesting!!! So am I correct to say that when patients first arrive and let the front desk what is wrong, you assign them a number between 1-5 but don't treat them all just yet. All level one patients are treated first because they will die any minute if they are not. These get divided between however many nurses there are. Once they're done you treat them in order from level 2-5. Wow three level 2's at once sometimes!!!

After triaging the patient you will assign them a number between 1 and 5. Of course, a "1" will not need much of an assessment to know they need to go back NOW (think...patient gets dropped off outside with two gunshot wounds to the chest). Yes, you are correct...1's must be taken care of immediately. We can have more than 3 level 2's in the waiting room. I work in a VERY busy ER.

BassCatchingNurse:
Wow...people actually fake being sick in emergency!!! That's exactly right you have to find the one's who aren't putting it on. I guess it comes with practice knowing who is faking it and who isn't. Thank you for your response!!

Yes, people fake being sick!!!

Editorial Team / Moderator · Apr 3, 2018

There is a very broad spectrum from paramedic to MD. Honestly, I don't think I would categorize paramedic into nursing because they work in different arenas.
Paramedics and EMTs are your first responders, they provide care in the field and bring the patients to the hospitals to continue that care. While they are an important part of patient care, nurses don't typically work in the field with them or vise versa.

Some states have prehospital RNs, and don't forget flight nurses - they are very important in the field. And some EDs have paramedics whose scope inside the ED is not too far from the RN scope. Just depends where you are! And deployed? Those medics do just about everything, and so do the nurses. I have worked in several EDs since 2005, and each one has been a little bit different as far as roles go. :)

PeakRN · Apr 5, 2018

3) There is a very broad spectrum from paramedic to MD. Honestly, I don't think I would categorize paramedic into nursing because they work in different arenas.
Paramedics and EMTs are your first responders, they provide care in the field and bring the patients to the hospitals to continue that care. While they are an important part of patient care, nurses don't typically work in the field with them or vise versa.
Nurses are the bridge between the patient and the healthcare provider (MD, DO, PA, NP). We assess the patients and administer medications as well as some treatment (within our scope of practice).

Some states have prehospital RNs, and don't forget flight nurses - they are very important in the field. And some EDs have paramedics whose scope inside the ED is not too far from the RN scope. Just depends where you are! And deployed? Those medics do just about everything, and so do the nurses. I have worked in several EDs since 2005, and each one has been a little bit different as far as roles go. :)

I am going to agree that paramedics, in the US with the current education standards, are not nurses and do not perform a nursing role. We train and treat our EMS (especially EMRs, EMTs, and entry level Paramedics) as technicians. Paramedics who have their critical care, flight, or other more advanced training may have a more advanced scope of practice but they ultimately are still trained as technicians within those specialties.

I work with medics in the field and while the majority of what we do is the same, the way that we do it is very different. I look at the patient and their disease process and plan how to manage the patient. Medics see emergent medical problems and treat those conditions. This means that in a trauma my medic is typically performing most of the procedures while I'm thinking about how we are going to get the patient to the appropriate medical facility. They are tubing the patient while I'm thinking about if we need to pit stop at a community hospital to place central access, pick up blood, et cetera before we continue to a trauma center.

I work with a lot of great medics and I have no intention of depreciating what they do, but they are not nurses. There is a reason why most medics continue their educations and peruse nursing, PA school, medical school, or a myriad of other professions within just a few years of starting in EMS.

Editorial Team / Moderator · Apr 5, 2018

My point was that contrary to what was posted, some nurses work in the field, and some medics work in fixed facilities. And then the military is a whole 'nother animal! As someone who started in EMS 19 years ago, went to work in the ED 13 years ago and went into nursing 10 years ago, I am well aware that paramedics are not nurses. :) Valuable roles, varying goals.