most of us strive to do our best to get our alloted tasks done in the alloted time to the best of our abilities. and what we are unable to complete, we pass it on to our colleagues following us with a sincere apology - "hey, i really tried to get this pt. work up going but i kept getting hit with one thing or the other and i never could. i'm sorry".
those of us on the receiving end blanch initially but accept it as part of the game and proceed to play catch up the best we can. often times, it works. sometimes, it doesn't.
but the merry-go-round doesn't stop. patients keep pouring in, their numbers and their needs inexhaustible. and the "thin white line" of nurses and aides struggle to hold the front and manage the deluge.
what helps us immensely, is our shared understanding of the attitude that "nursing is a 24 hour profession".
but some times, our attitudes clash.
a 'vignette' from last night:
case:: giving report on a (now) stable ffff presenting with a chief c/o of "ruq pain" also presenting with mild r chest pain (non reproducible pain increasing with inspiration) and sob.
pt. was worked up as a "chest pain" (which meant cardiac workup - because of prior cardiac history). eventually, the cardiac labs came back negative and abd. ct returned positive for gallstones. pt. was admitted to med-surg post surgical consult.
report -
"why do you ed people always put ivs in the ac? don't you know how uncomfortable it is when the pt. comes to the floor?"
"i'm sorry but yo..."
"yeah you're sorry all right! you just stick 'em down there where you please and we have to chase after the pump when pt. gets to the floor!"
"ma'm, if you'd jus..."
"whatever. is there anything else? when are you bringing the patient up?"
i started to say something but just swallowed my thoughts. "nothing else ma'm. unless you have any questions for me."
"no".
and she hung up.
i wanted to feel mad and angry - but i chalked it up to someone who'd been having a bad day and let it go at that (but it gives folks the right to take out their frustration on me?) besides, i had two patients on ventilators who needed my attention as well and a fresh "chest pain" brought in by ems to assess.
but there's a "reason" why...
because the ed doc was more concerned about the inspiratory chest pain/sob, i stuck the iv (18g) in the right ac while drawing initial labs - in the off chance that the doc would also order a cta to rule out pe. it's happened more than a few times to me, where i've started a line on patients who ended up getting cardiac workups - where i'd have to stick them again because of wanting to do cts.
why stick the patient twice? if you were the patient, would you prefer to be poked 2-3 times or once?
besides, when pt. presented to the ed, pt. was hypotensive and tachycardic - even if the cardiac angle was ruled out, pt. was atleast apparently hypovolemic. which meant pt. would need fluid resucitation (if not more. pt. was also running a temp. who the heck could tell if pt. was septic at that point or not?)
now, put yourself in your nursing shoes (no matter the department) - when you have to start an iv, wouldn't you go with your best shot? even if it was in the ac? or hand, or thumb, or pinkie for that matter? access is better than no access, right?
it's all well and good to grouse at me after the patient has been here for 4 hours under our care about the placement of the iv - did you see the patient when they initially got here? pale, dehydrated and retching and shaking all over? did you see the patient's veins when they got here? i'm not saying i'm "mister iv and i can draw blood from a rock" - but neither am i an oaf.
just as it's a "pain in the butt" to have patients with antecube ivs on a pump, it's just as much a pain in the butt to have a patient in the ed with no venous access, no way to draw labs, no way to administer meds/fluids... heck, no way to do anything!
fact of the matter is, unless it is absolutely required or an emergency - i first offer the patient the choice of where they would like the iv (which arm and where). if i can meet their choice somewhere between my requirement (e.g.: i need an iv in the antecube while pt. would prefer an iv anywhere in the non-dominant arm), i'll do my best to get one in the non-dominant antecube. if neither need nor emergency is a criteria, i let the pt. pick a site and i'm more than happy to oblige.
blood transfusions (or in critically ill patients), i'll strive to get 2 (if not more) large bore lines - with at least a 20g/18g in the forearm if possible. because i know what havoc an antecube iv site can play with blood transfusions through a pump. how do i know this? because i'm not speaking from ignorance. i worked a ridiculously short-staffed floor before i switched to the ed. i've lived the 'floor life' (and i quit not because of the patients but because of management).
i'm very tempted at times to tell folks who complain about my iv placements that "ok, i'm pulling this one out. please do as you please when the patient is your responsibility. after all, you know how to start ivs too, right?"
i don't question how you do your job - what makes it ok for you to question how i do mine? this isn't a question of "gross negligence" or "unsafe standards", is it?
on some nights, when i actually have a few minutes to spare and based on the admission orders of the pt., when giving report i'll even offer to start a new line on the patient in a less 'restrictive' area to the nurse accepting report and depending on their response, i'll start a new line if i can find a spot and i'll leave it up to the accepting nurse's discretion as to which line s/he wants to discontinue (or keep).
i guess all i'm trying to say (besides blow off some steam), is that "things get done in the ed the way they do for a reason". we are nurses just like you - we have to deal with similar pressures and expectations of the job just as you do. we aren't lazy and we aren't out to make your jobs harder than it already is.
but please - don't dismiss what an ed nurse has to do or say without hearing the "why" part of it. it makes it that much harder to defend your actions (why you can't take report right away, why the room isn't ready etc.) when the shoe is on the other foot.
a tired and mildly irritated,
roy fokker
ps: please - this is not a thread about ed nurses versus the rest of the world. let us not turn it into that. this is just one ed nurse semi-ranting about some recent unpleasantness at work.
pps: for the record - most of the nurses i give report to are professional, co-operative individuals. i would never dream of disparaging them - no matter what time of the shift i find myself giving report, they've always been courteous and respectful.
addendum: if an ed nurse seems apologetic about giving you report on a patient close to shift change, please understand it's not because we're 'mean', 'want to hold onto our patients' or whathaveyou. we have no control over the issue (this issue was addressed somewhat in depth here). we understand that you have morning meds, accuchecks, lab draws, vital checks and your own report to get through...
please don't laugh derisively over the phone and dismiss my genuine feelings on the matter - i'm not an idiot and i mean what i say.
