I'm trying my best, but seriously stop putting me down on the phone

VICEDRN, BSN, RN · Feb 18, 2012

I'll find your first post, oh, here it is.Hmmm, I see NOWHERE where you said anything even resembling, "I definitely agreed that one if not both of her patients should go to ER." Your implication was clear, you capitalized "non-emergent," and related a story of another patient with a fever who was simply given Tylenol, despite the fact that the OP's statement pointed to another cause for the fever, which you so obviously missed.I also see no mention of "Glucose would have been nice but as STATED, not necessary." The word "glucose" doesn't even appear.So, I am sorry that YOU can not read what YOU have clearly written, you made a mistake, then kept down the path of said mistake, and now you're trying to dig your way out by claiming you never made the mistake.Then you go on to say,Well, allow me to inform you opinion a bit more, I've worked in LTC, and I can assure you, when you call that MD at 2am, once he tells you to send the patient out, he hangs up on you. Sure, you can call him back, but that will result in your getting screamed at, and your having to argue with him to be able to "clarify and explain what you think." When I worked night shift in LTC, I was responsible for the direct care of 60 patients of my own, plus I was supervising LPNs that covered another 120 patients. You don't have the time to argue with an MD about that one patient, especially knowing the MD is also overworked, at my facility, we were one of 5 that our MD covered, the smallest of the 5 (with 180 total patients at our facility). I get that LTC staffing is not your problem, but blaming the LTC RN won't fix the problem, if you're tired of being the dumping ground, contact your legislators, impress upon THEM the problem, because telling the LTC RN that you "know" they can do something they actually can't do won't fix a damned thing.

I stand corrected. its my second post (#23 in this thread) where I state in the last paragraph that the first patient didn't bother me. In another post, I also state it depends on the second patient. In #23, I state I don't have enough information. Apologies for confusing my first and second post. Will have to look back and edit this post to find references to glucose which I know are there.) EDIT: its post 65.

Let me fill you in on a reality in my job that's similar to yours: I get screamed at too. I screamed at by ER docs who can't believe I am requesting prescriptions for patients that have been discharged, by hospitalists who don't care that the patient is still awaiting a bed in ER and don't want to be awoken (just like your MDs).I've learned to have a thick skin and that advocating is my job and while not glorious, it requires me to often take abuse from people who are frustrated.

As I said in post #23, it is your choice NOT to "argue" with the MD and to continue providing care to the other patients in your facility. Do not hide behind the "MD orders" thing. As mentioned, don't blame the ER RNs that they resent being the dumping ground for overworked LTCs RNs.

I will also note the irony in your statement: it is your problem as much as it is mine. Sending your patients to the ER does not result in better care for these patients (as a general rule but of course, the obvious exceptions apply).

TygRNoef · Feb 18, 2012

Let me fill you in on a reality in my job that's similar to yours: I get screamed at too. I screamed at by ER docs who can't believe I am requesting prescriptions for patients that have been discharged, by hospitalists who don't care that the patient is still awaiting a bed in ER and don't want to be awoken (just like your MDs).

Let me fill you in on another reality of my job. I no longer work in LTC, I clawed my way out of that field, because it IS pure hell for an RN that actually cares. I now work in cardiac critical care, and while I still get yelled at by MDs, I now have 5 patients to deal with on most days, I CAN now argue with the MD without worrying about whether or not my other 179 are still breathing. I don't know what staffing is like in your particular ED, but in ours, the ratio is 1 RN to 5 patients in most of the pods, and 1 RN to 2 patients in the trauma pod.

As I said in post #23, it is your choice NOT to "argue" with the MD and to continue providing care to the other patients in your facility. Do not hide behind the "MD orders" thing. As mentioned, don't blame the ER RNs that they resent being the dumping ground for overworked LTCs RNs.

It IS my choice, and I'd say it's a damned good choice. I NEVER once sent a patient to the ED that didn't get admitted, so I'd say I have a right to feel like I've never used an ED as a dumping ground. When I make that choice not to argue with the MD who asks that the patient be sent out, I do it knowing I have to get back to the business of keeping the remaining 179 patients in the facility from being sent to you as well. I also never ONCE blamed ED RNs for resenting that they often ARE a dumping ground for overworked LTC RNs, what I said is that blaming the LTC RN is the wrong strategy, it won't make them less overworked, and they can't make themselves less overworked.

I will also note the irony in your statement: it is your problem as much as it is mine. Sending your patients to the ER does not result in better care for these patients (as a general rule but of course, the obvious exceptions apply).

It may not result in better care for that ONE patient, in some cases, but it nearly always results in better care for all patients involved. Sending you that ONE patient that is exhibiting signs of possibly going bad allows the LTC RN to take care of the rest of the LTC patients more effectively and keeping them in the facility.

MJB2010 · Feb 18, 2012

The same could be said for you since you clearly display a judgmental attitude about people you don't know that you read a few posts from but don't really pay attention to on the internet but I don't judge you that way.
I frequently edit my posts because I catch typos or I want to clarify a point that isn't well stated in my original posts. On some of my devices, its hard to read the post until its posted.

Yes I am very judgemental. But only to bullies, or those that put others down. I have zero tolerance for that kind of crap and if I see someone putting down a new grad or treating them badly, I will step in. You know why? Because I remember what that feels like. You seem to have forgotten.

TygRNoef · Feb 18, 2012

I've been steaming about this a bit, and I'd like to address another couple of points you made.

In another post, I also state it depends on the second patient. In #23, I state I don't have enough information. Apologies for confusing my first and second post.

Why don't you have enough information? What information are you missing? The OP stated, in the opening post that the patient had a temp of 101.5 that spiked to 103 AFTER being administered Tylenol. The OP also said that the MD asked to check the wound packing. What is your suggestion for a patient with a fever that doesn't respond to Tylenol and a possible source of infection? X-rays and blood tests in the AM? Sepsis IS an emergent situation.

Again, the symptoms of sepsis are:

Fever above 101.3 F (38.5 C) or below 95 F (35 C)

Heart rate higher than 90 beats a minute

Respiratory rate higher than 20 breaths a minute

Probable or confirmed infection.

The OP did not mention the HR or RR, but based on the information provided, sepsis is a pretty obvious possibility.

Will have to look back and edit this post to find references to glucose which I know are there.) EDIT: its post 65.

Go back and read everything written here, post 65 is the post that I quoted you claiming you earlier said the glucose wasn't a big deal, which you NEVER claimed until post 65.

TygRNoef · Feb 18, 2012

Yes I am very judgemental. But only to bullies, or those that put others down. I have zero tolerance for that kind of crap and if I see someone putting down a new grad or treating them badly, I will step in. You know why? Because I remember what that feels like. You seem to have forgotten.

I find myself in the same boat. I don't know everything, and I know that no one else does either. All of us will, at one time or another, miss the obvious, and make mistakes. Some of us more than others of us. As a new nurse, I missed a lot of things, and made a lot of mistakes. Some of my colleagues were understanding, some were not.

Today, when I see others make a mistake, I try to see myself in their position before I pass judgement. What were they seeing when faced with the situation? What were they thinking when faced with the situation? What pressures were they under when faced with the situation. Could I have done better? How much better could I have done? Would I have done better? Did they do the best they could with what they had?

Sometimes, even I forget myself and need to be told I'm being a jerk.

In just the last week I yelled at an ED RN that was sending me a critical patient, but all she could tell me in report was that the patient had an elevated BNP and an elevated Troponin, information that I already knew, because as soon as the patient's name appeared as admitted on our unit, I looked up their labs and X-rays. When I got the patient he was in rapid A-fib with Cardizem and heparin running, information I couldn't know because our hospital doesn't have the ED notes on the same system as the rest of the hospital. I shouldn't have yelled at her, it did no one any good. I was that jerk.

VICEDRN, BSN, RN · Feb 19, 2012

I've been steaming about this a bit, and I'd like to address another couple of points you made.
Why don't you have enough information? What information are you missing? The OP stated, in the opening post that the patient had a temp of 101.5 that spiked to 103 AFTER being administered Tylenol. The OP also said that the MD asked to check the wound packing. What is your suggestion for a patient with a fever that doesn't respond to Tylenol and a possible source of infection? X-rays and blood tests in the AM? Sepsis IS an emergent situation.
Again, the symptoms of sepsis are:
Fever above 101.3 F (38.5 C) or below 95 F (35 C)
Heart rate higher than 90 beats a minute
Respiratory rate higher than 20 breaths a minute
Probable or confirmed infection.
The OP did not mention the HR or RR, but based on the information provided, sepsis is a pretty obvious possibility.
Go back and read everything written here, post 65 is the post that I quoted you claiming you earlier said the glucose wasn't a big deal, which you NEVER claimed until post 65.

Because viral fevers often peak in the evening hours. Patients frequently present to the ER with a temperature, get treated with tylenol AND the fever still goes up because...viral fevers peak in the evening. Does the patient have a new onset of cold/flu symptoms?

As for the sepsis, as you said, no other vitals are mentioned or the patient's baseline neuro status? Some neuro patients frequently have FUOs. As for the probably source of infection, did the wound smell? What was her wound assesment?

Of course, I don't expect all of these subtleties to be listed in the post and so I tried to give the OP the benefit of the doubt because I wasn't there as I am frequently not when these folks get reported on to the ER...which is why...I am always polite.

I ahve discharged more LTC patients than I have admitted and I don't necessarily blame any particular group (RNs in LTC, MDs in outpatient setting or ER RNs or MDs) for that.

As for yelling at ER nurses, I have frequently been yelled at by ICU RNs. Since I am also married to one, I understand that we have different mindsets and sometimes, its an unbreachable gap. I certainly don't enjoy it but as I said, if you are advocating for your patient, then that's the price you pay and I have paid it many a time to the ICU. ;-)

VICEDRN, BSN, RN · Feb 19, 2012

Yes I am very judgemental. But only to bullies, or those that put others down. I have zero tolerance for that kind of crap and if I see someone putting down a new grad or treating them badly, I will step in. You know why? Because I remember what that feels like. You seem to have forgotten.

I haven't forgotten. In fact, I am a bigger believer in new knowledge and practice then in experience.

In my first post, I told the OP no one has the right to be rude to her and I have told you several times that you have no right to be rude to me but you seem to think you have been endowed with some special right to well, bully people. ironically enough.

TygRNoef · Feb 19, 2012

Because viral fevers often peak in the evening hours. Patients frequently present to the ER with a temperature, get treated with tylenol AND the fever still goes up because...viral fevers peak in the evening. Does the patient have a new onset of cold/flu symptoms?

Would you be willing to keep that patient in a LTC facility to wait and see if that's the case?

As for the sepsis, as you said, no other vitals are mentioned or the patient's baseline neuro status? Some neuro patients frequently have FUOs.

Not many of them carry themselves to the bathroom.

As for the probably source of infection, did the wound smell? What was her wound assesment?

I've seen more than one infected wound that had no noticeable odor.

Of course, I don't expect all of these subtleties to be listed in the post and so I tried to give the OP the benefit of the doubt because I wasn't there as I am frequently not when these folks get reported on to the ER...which is why...I am always polite.

The OP probably didn't report them to the ED RN either, but in this case, with the information provided, I still think it's pretty clear that sending the patient to the ED was the best course of action.

MJB2010 · Feb 20, 2012

I haven't forgotten. In fact, I am a bigger believer in new knowledge and practice then in experience.
In my first post, I told the OP no one has the right to be rude to her and I have told you several times that you have no right to be rude to me but you seem to think you have been endowed with some special right to well, bully people. ironically enough.

Whatever helps you sleep at night.

Editorial Team / Moderator · Feb 20, 2012

Please debate the topic, not the poster ... consider this the official warning shot. Thanks.