Stressing myself in the ER...do I suck or what??

CABG patch kid, BSN, RN · May 5, 2009

I don't really have a whole lot of advice, I just wanted to say hang in there! You are still new, things like confidence will come with time!

loricatus · May 5, 2009

It sounds to me like you are in the Southern part of the US because of the dynamics of your ER.

I have worked in both the South and the Northeast and there are major differences. For a primary example: In the Northeastern part of the US, you would have known it was a r/o ACS because you would have had protocols to have started the workup on the patient (drawn the labs, started the line, ordered all the related tests, etc) prior to the doc even seeing the patient. Most of the results would have been in before the doc saw the patient to do the assessment (except for the brief review of the 12 lead after triage). I recall a few times that we had tachy patients and went to the doc saying I saw a possible goiter and other s/s r/t hyperthroidism, so I had drawn for a throid panel----to have the doc thank me.

Now, in the South, if I do what I described, I would be up before the BON for trying to practice medicine without a license. Can't even start a line in most places without the doc giving me a VO. And, in some ERs, it is like doctors and nurses are in a different caste system. The only way I survive and not feel as if I am some slave to the doctors is to approach them with something like (relating to your scenario) "Would you like me to start the ACS protocol?" When I get a 'huh'? I respond with, "You don't want me to draw the cardiac enzymes, keep the patient NPO for possible cath lab, call radiology for CXR, put an 18G in..." Then I go to the chart and will write "Advised Dr Shmuck (making name up) of [s/s]-no new orders received. That will usually get me some orders.

So, if you are in the South, I suggest you take a more proactive appoach to dealing with the medical staff. Like for the r/o ACS, try saying back to the doc "Well, since you didn't give me an order to draw CE and it has been x hours since the 12 lead without the patient being advised that he is being observed for a heart condition, would you like to draw the cardiac enzymes, or would you rather have me do it? Oh, and are you thinking of trying a GI cocktail to see if the patient's CP is resolved with that, because I could prepare and administer that now, while we wait for the cardiac enzyme results to come back"

If you are in the North, you just have to be more take charge with the docs and would have to reply "So why didn't you tell me earlier pt. was a r/o ACS...I'm not a mindreader, you know...besides, when is someone going to get around to sending those labs..."

No matter what part of the country you are in, you have to keep in mind that you are the patient's advocate and have to facilitate the patient's care. It is just done differently in various parts of this country. Try to be more assertive (adapting to the regional differences) because I am getting the feeling you lack confidence in yourself and the docs may be picking it up and taking advantage of it.

drew9319 · May 5, 2009

the last post seems kind of critical of the south in general. did you work in every er /hospiytal in the south? if you did then i would wonder how you acheived that particular feat in only 4 yrs. now as to momvick. dont let the docs get you. be assertive. its ok to doubt yourself. that shows that you care about what you are doing. it allso will cause you to later go back and review.(thats whats going to make you better). If the staff you work with tells you that you are doing good, then take it at face value. dont worry about the other new grads either. you focus on what you need to work on and thats all. develope your skills and the respect from the docs will come. it will just take some time. keep your head up:smilecoffeeIlovecof

MassED, BSN, RN · May 5, 2009

So, I have been an ER nurse for about 8 months, in a busy county ER...I still feel like am getting the hang of things...but I haven't gotten the confidence I would like...I feel like Im really slow, cuz sometimes I get patient after patients and discharge after discharge and I end up feeling like I missed something by not being able to think 100% regarding a pts dx....its very high paced...I always second guess myself and feel intimidated by some doctors, who can be nonchalant about a HR of 39, Bright red emesis, hgb of 4, etc...I tell them, "can you write me something for pain," and they just stare at me with a blank face...Like yesterday, I had a pt who came in for CP, ekg was normal and no cardiac enzymes had been drawned. the doctor sees the pt, but doesnt order anything...an hours goes by, while am busy with another CP/SOB, and still no new orders....nothing I ask the doctor if the pt can eat, since hes been asking me every 5 minutes...and then the doctor loudly says, "god, dont you know hes a r/o acs and may need a cath...so no he cant eat...." I was so embarrased, but in my head I was like, "you are so stupid, you havent even ordered anything, even cardiac enzymes, a d-dimer, anything, and yet you already plan a cath..." but all i did was walk away....
and then my heart starts racing when i have super critical pts:redbeathe:redbeathe...like I start thinking, "omg, what if he codes, i dont know how to cardiovert, etc, etc..."
Ive been noticing that other new grads were allowed to go into trauma bay area (we are a trauma hospital and receive super critical pts, like GSW, cardiac/traumatic arrests, all those tier 2 pts)...before me and they started after me...This really took a blow to my confidence and now I feel really bad, like my nursing skills must suck.....they must if everyone can work trauma, except me...
I dont know what to do, other nurses tell me am doing good and that I am very directable, that I focus on what I gotta do and do it...but I dont know why i feel this way...Ive noticed other nurses are so calm and collected, and joke around with the doctors, etc...and then there I am, like I dont fit in...so im frustrated and dont know what to do...I would really appreciate some advice..:cry::cry:
THANKS!!!!!!!!!!!:heartbeat

Aw, hang in there! 8 months along is still fairly new to it all. Don't let the doc intimidate you. Is there a more senior nurse you can confide in that can be your go-to person for your critical patients? Those that are cutting up in the ER when you're working is so irritating. You're better off to keep your nose to the grindstone and work, keeping focused for what might come in next. I would recommend reading on your off time (I have a quick reference ER guide)- go over your defibrillator and practice that skill - do you have a skills lab you can go to and practice? Everyone feels somewhat like you are feeling at some point. Take a deep breath, ask questions from those that you know will be helpful and understanding when you're needing some assistance. Good luck to you, you can do it!!

MassED, BSN, RN · May 5, 2009

It sounds to me like you are in the Southern part of the US because of the dynamics of your ER.
I have worked in both the South and the Northeast and there are major differences. For a primary example: In the Northeastern part of the US, you would have known it was a r/o ACS because you would have had protocols to have started the workup on the patient (drawn the labs, started the line, ordered all the related tests, etc) prior to the doc even seeing the patient. Most of the results would have been in before the doc saw the patient to do the assessment (except for the brief review of the 12 lead after triage). I recall a few times that we had tachy patients and went to the doc saying I saw a possible goiter and other s/s r/t hyperthroidism, so I had drawn for a throid panel----to have the doc thank me.
Now, in the South, if I do what I described, I would be up before the BON for trying to practice medicine without a license. Can't even start a line in most places without the doc giving me a VO. And, in some ERs, it is like doctors and nurses are in a different caste system. The only way I survive and not feel as if I am some slave to the doctors is to approach them with something like (relating to your scenario) "Would you like me to start the ACS protocol?" When I get a 'huh'? I respond with, "You don't want me to draw the cardiac enzymes, keep the patient NPO for possible cath lab, call radiology for CXR, put an 18G in..." Then I go to the chart and will write "Advised Dr Shmuck (making name up) of [s/s]-no new orders received. That will usually get me some orders.
So, if you are in the South, I suggest you take a more proactive appoach to dealing with the medical staff. Like for the r/o ACS, try saying back to the doc "Well, since you didn't give me an order to draw CE and it has been x hours since the 12 lead without the patient being advised that he is being observed for a heart condition, would you like to draw the cardiac enzymes, or would you rather have me do it? Oh, and are you thinking of trying a GI cocktail to see if the patient's CP is resolved with that, because I could prepare and administer that now, while we wait for the cardiac enzyme results to come back"
If you are in the North, you just have to be more take charge with the docs and would have to reply "So why didn't you tell me earlier pt. was a r/o ACS...I'm not a mindreader, you know...besides, when is someone going to get around to sending those labs..."
No matter what part of the country you are in, you have to keep in mind that you are the patient's advocate and have to facilitate the patient's care. It is just done differently in various parts of this country. Try to be more assertive (adapting to the regional differences) because I am getting the feeling you lack confidence in yourself and the docs may be picking it up and taking advantage of it.

ACS guidelines or protocol, like you say, is only in some regions of the country. Where I work, we order protocols for almost everything (the nurses), since the docs usually don't see patients for hours - if it comes back that the doc didn't think that the person shouldn't have been R/O MI, well you have to be thinking worse case scenario. Most docs won't get on your back if you're critically thinking.

MassED, BSN, RN · May 5, 2009

the last post seems kind of critical of the south in general. did you work in every er /hospiytal in the south? if you did then i would wonder how you acheived that particular feat in only 4 yrs. now as to momvick. dont let the docs get you. be assertive. its ok to doubt yourself. that shows that you care about what you are doing. it allso will cause you to later go back and review.(thats whats going to make you better). If the staff you work with tells you that you are doing good, then take it at face value. dont worry about the other new grads either. you focus on what you need to work on and thats all. develope your skills and the respect from the docs will come. it will just take some time. keep your head up:smilecoffeeIlovecof

I had worked in the South and now am in the NE - that poster was correct about the differences - RN's generally have more autonomy in the NE. Just the difference I noticed, one of many.

Trauma Columnist · May 5, 2009

To the OP: 8 months isn't a long time in a busy ER! Hang in there - if you are getting positive feedback (and it certainly sounds like you are) you have to have patience with yourself. When I started in the level one trauma center I had been a nurse for 3 years already and it still took me 2 years to feel comfortable that I could handle whatever came thru the door. Don't give up.

As to the differences in ER care in the US: I gotta tell ya there are major differences even in the same area! I work in central IL - had 10 years experience in a level one trauma center where everything was protocol driven - the pt had an IV, EKG, CXR, labs, etc all ordered with results coming back as the MD was seeing the pt. However, in the community ER where I work, the MD is usually the first person to see the pt - the pt isn't even undressed, on a monitor, no IV, no labs, nothing!!!

maxthecat · May 5, 2009

If I were you, I would ask what skills I need to work on, whether I am progressing at the expected pace, why I am not progressing to trauma bay. I'd ask charge nurse, supervisor....whoever you think will give you honest answers and not either soothe your ego or destroy it. I must admit I would be somewhat concerned that newer nurses are moving ahead.

I'm not sure what to think about the doctor's response to you. It may simply be that you approached at a time when he was feeling stressed and he snapped at you---it happens, not that that's any excuse. But I have also seen doctors express similar frustration with nurses who they felt were not "up to snuff." My point is that rather driving yourself crazy wondering whether you are doing well enough, try to get some perspective from an objective source. I wouldn't go to co-workers--they tend to tell you you're doing fine even if they don't think so because they don't want to make you feel bad (at least in my experience).

Now, having said that, IF you find out that you are progressing more slowly, that doesn't mean you aren't going to make an excellent nurse. Some people are fast but superficial learners. Some learn more slowly but once they've "got" something they've GOT it! And, really, 8 months is a short time. I surely wouldn't expect a nurse with less than a year experience to react like a 10 year veteran. The fact that you've lasted 8 months is in your favor. If you were really awful you'd have been out after 3!

Good luck, hang in there.

crb613, BSN, RN · May 5, 2009

Bless your heart....it can be an awful feeling. I know.... I could have written your post. You are trying & you will learn but it takes time. Do you have protocols? If you do learn them....this alone will be a confidence booster. Get all the extra training you can PALS, ACLS, TNCC.....this will also help you.

Is there a nurse or a couple of nurses that like to teach? I can not tell you how much it will help to have someone like this that is willing to answer questions.....or give advice. I work with a nurse that I declare.....knows everything! She can have drips hung, procedures in process, before the doctor knows they need them....She just has a sixth sense for things & will not back down if she thinks a pt needs something & a doc is sitting on things. Is she right all the time? no....but I can tell you our doctors value her knowledge & she is highly respected...... I want to be her when I grow up!:yeah:She is my go to person & what I have learned from her....invaluable!

I look up everything I am not familiar with drugs, diseases, trauma related what to do, when, how. It is a constant learning process....ask your docs to explain things you don't understand in a less busy time. I am sorry you were embarrassed by you ER doctor in front of everyone.....next time tell them what you posted. (you might want to leave stupid out :lol2: ) Good luck & ease up on yourself.....stress shuts the brain down!

Editorial Team / Moderator · May 5, 2009

You don't suck, but wow ... that doc sure does! Our docs never criticize like that -- they all love the opportunity to impart knowledge, too. I've been pickin' their brains for years, they're used to my questions by now.

Is your preceptor still available to you for advice, or do you have a nurse educator in your department?

loricatus · May 5, 2009

the last post seems kind of critical of the south in general. did you work in every er /hospiytal in the south? if you did then i would wonder how you acheived that particular feat in only 4 yrs. now as to momvick. dont let the docs get you. be assertive. its ok to doubt yourself. that shows that you care about what you are doing. it allso will cause you to later go back and review.(thats whats going to make you better). If the staff you work with tells you that you are doing good, then take it at face value. dont worry about the other new grads either. you focus on what you need to work on and thats all. develope your skills and the respect from the docs will come. it will just take some time. keep your head up:smilecoffeeIlovecof

Travel Nursing and talking to a network of travel nurses can give you insight to things. Please understand that there are profound differences in culture between the North and South. I am not saying one is better than the other, just different. Sorry, I forgot how sensitive people can be and was just focused on trying to give facts.