PITA ED patients - how to handle?

[kmoonshine, RN]

Lately I have become really annoyed by patients, and I'm looking for advice on how other RN's handle similar situations.

Sunday night I had a patient who was complaining of a "10/10" headache, along with nausea/vomiting for 3 weeks, and was screaming at me "get me something!" Another RN actually had this patient first, but begged me to switch with him because the patient was so rude.

We put in an IV and drew labs, and I hung 500 ml NS w/o. I had an order for phenergan IV and morphine IV (I know, I know...I hate phenergan; I had a talk today with our nurse educator about looking into the whole phenergan risk/benefit - I'm a big advocate for zofran myself). I first pushed the phenergan, and the family kept on asking me "what's going on" (obviously, after 15 minutes in the department, we won't know). I explained "right now, we're running some blood work, which will help clue us into what may be wrong". One of the pt's visitors got a cell phone call and she said to the caller "she's just the nurse and doesn't know anything".

Excuse me? Just the nurse? :angryfire Without this nurse, your loved one would still be in pain and nauseated. But anyways...

We did a full workup on this patient - CT, labs, EKG, urine, and so on. We ruled out lots of things it "could" be. The patient wasn't happy and refused to be discharged. We really needed the room, and the charge RN was nagging me to discharge this patient ASAP.

During this time frame, I had a SOB patient with sats in the low 80's; once I stabalized them, we had a trauma level 1 come in. I was one of the RN's on the trauma team and I had to go help out. Pretty serious too - multiple GSW's to the torso, arms, legs, back...the patient was losing lots of blood, and we had to send him to a nearby trauma level 1 facility for emergency surgery to save his life.

So, after the whole trauma ordeal, the headache pt's family is pissed because nobody is "paying attention" to them. I just wanted to scream. Nobody seems to care that this is an emergency room, and "surprise", we do get emergencies. Therefore, their headache that they've had for the past 3 weeks will have to wait.

I've also had people ask me "can i get a prescription for an antacid?"; I explain to them that they can pick up prilosec OTC or other OTC antacid products, which should carry them until they can see their PCP. Their response is "I need a prescription becaue I can't affort it OTC". I try so hard to respect patients, but at times I feel like this is abuse of the system. It is already strained as it is, and we're just digging the hole deeper and deeper. Is it that unreasonable to shell out $10.00? And yet, you can afford that nice purse, expensive shoes, and cell phone?

Please offer me some advice. I hate being bitter.

On a side note, the trauma went well, the SOB was admitted to the ICU, and I had already admitted 3 patients to the floor during my shift: GI bleed, active CVA, and endometritis. Busy, busy, busy...

You know, you feel awesome about being able to do a good job, but it really wears at you to hear "I've been waiting 10 minutes to see the doctor"; "I've had this toe pain for the past year"; "NUUUURSSSEEE, I need something to eat now"; and "Is that medicine you have there morphine? Because if it is, it doesn't work for me - but dilaudid does. I told the doc, and he said he would give me dilaudid." (which he didn't)

[NorthpoleRN]

Your frustrations are totally normal! Sometimes I wonder why in the world I do what I do??? We are in a stressful and a challenging profession, but very rewarding. I know no one can pay us enough for what we do or go through.

I noticed you mentioned something about pushing phenergan. Does your facility still do that? My facility stopped all IV-push phenergan a few months ago due to recent studies that have shown that it is a vescicant that causes a lot of damage to the veins and surrounding tissues. We only give it IM or IVPB. just curious???

[Larry77, RN]

I think all of us feel the way you are describing from time to time but I just try to focus on the patients that appreciate what I do for them (sometimes few and far between), we actually do get to save lives for a living.

I have so many stories that are similar to the one you describe but we shouldn't dwell on them and yes those type of patients who pay nothing for their visit to the ED and take beds away from patients that are "really" sick will always be around. Maybe if they had to pay $20 up front to come to the ED for a non-emergent need they wouldn't be so free to give up their cigarette money to take up space in our dept!

I don't know about your insurance but mine charges me $100 to come to the ED, do you think I'm there weekly like a lot of my patients...

Larry

[kmoonshine, RN]

NorthpoleRN: Yeah, I hate pushing phenergan. I talked about instituting a policy with my nurse educator today; I see no need to use it with all the other wonderful anti-emetics available.

I usually try to persuade the MD to order something different. I had a different doc order morphine and phenergan IV last week...I said "how about zofran ODT in place of phenergan?" He wanted to know why, since phenergan was, according to him "less than a buck". My reply "zofran odt is available generic now, and while the drug itself is more expensive than phenergan, you have to factor in the cost of administering the drug too." I then informed him that administering phenergan costs much more than administering zofran ODT.

As for why I didn't ask to change it for this patient: they had a running IV line and an 18 gauge in the AC, plus we were super busy; also, the MD prescribing the med was in a room putting in a central line. Sometimes you have to pick your battles, right?

I wish the FDA would ban IV phenergan. I requested my nurse educator to find out an exact cost analysis. We should be using the least invasive route, right?

[RunnerRN, BSN, RN]

Deep breaths? That's truly the only way I know of to handle these people!

There will always be those self-centered patients who don't understand that anyone but them is having pain. And there will also forever be those people who don't understand what nurses REALLY do. I guess next time that person would rather their family member sit in the WR until the doc can get them back, put in that IV, and find time to push those meds PLUS be compassionate and understanding. RIGHT.

We were incredibly busy last weekend, and I had several of the same situation. I just explain again and again that this is an ER, we have 25 people waiting in the WR with an over 4 hr wait, so the simple fact that "you" are in the treatment area in less than an hour is pretty amazing. I also have no problem explaining that because we are so busy, there are a lot of very critical patients, which means if we aren't getting to you really fast it is a GOOD THING. Same thing if we put you in the hallway beds....95% of the time it means we don't think that pt is critical (the other 5% of the time we're just screwed because we have no beds!!!).

This is getting long. Mainly, I remind myself that I only work 12 hrs, so in x number of hours I'll be going home. That's when it becomes less of a passion and more of "just a job." Those difficult pts get the bare minimun of my energy. (I don't deny any aspect of care to anyone, I just do what I need to do and leave the room). Plus, every ER patient has to go someplace sometime! Either they get admitted or sent home.

And then I remind myself why I don't work on the floor :) I think floor RNs are wonderful people, but I could NEVER do that.

[pkapple]

When I have a pt complaining about d/c, I can usually just smile sympathetically and get them out. Now if they are really obnoxious or insistant, I get the doc to go talk with them-that way if they have a question or concern he can adress it and/or tell them that's all ya get buddy-go home. I also document that doc adressed concerns in nurses note and hopefully it was reflected in doc notes.

As for the phenergan cost basis: we charge for the drug, so no matter how its given there is a drug charge, needles, syringes and saline are not charged out. I really cant see saline dilutant and a flush costing much.The least invasive route for a pt with an iv is iv push, we always put an iv in if we draw blood-so a better argument is the vesicant effects not cost this time around.

[momdebo, BSN, RN]

Amen! this is everywhere. I have the luxury of working in a cardiologists office and thought I would escape this stuff, but alas, no. I get people coming into the waiting room diaphoretic, sob, nauseated with crushing chest pain wanting to know if we can work them in today, or they cancel thier appointments repeatedly and then have an "emergency" and they must get in right away, or call to see if we have any samples and when we don't they get mad and want me to "find some" and call them etc. etc. etc. I feel your pain. Keep your chin up, sister and just remember all those you touch who really need you!

[greenjanell]

there is a thread on here somewhere called "rules for the ER" or something like that. You should read it. Its under the emergency nursing forum , and has everything you just went through put into a humours light, humor helps in times like these. we have all been there.