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sandyfeet, ADN, MSN, RN 5,976 Views

Joined Jul 26, '10 - from 'CA'. sandyfeet is a RN. She has '5' year(s) of experience and specializes in 'Emergency Nursing'. Posts: 422 (41% Liked) Likes: 406

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  • Oct 19

    We genuinely worry and care about our patients that it often consumes us. When a patient codes or expires, we are crushed. I once had a patient who got stuck at least 15 times by various staff members, including physicians, to get IV access. The patient took those sticks like a champ, but I still went home and boo-hooed because I hated to see him go through that. We hurt when our patients hurt.
    To me, this is the root cause of your issues.

    Personally, I do not worry about my patients. I assess them and intervene as I'm able. After that, I accept that things will run their course and I do not fret about it.

    When a patient dies, I generally remains dispassionately detached from the occurrence. I have had a couple of experiences with children that have made me sad and for which I've shed some tears but even then, I keep it at an arm's length... and I am never 'crushed' because I don't let myself care too much about it... because... this is my *job* and my job is to provide nursing care, not to become emotionally connected to what's happening. Sometimes I do begin to care more than I should and I actively nip it in the bud.

    And I certainly do not hurt when my patients hurt, even when we must poke them time and again, or when urology struggles to place a catheter, or difficult intubations, or chest tube insertions, or all the other invasive and painful things that we do to patients in order to treat them.

    I always recognize my role and that is of the professional nurse who is being paid to provide a service, one which I take very seriously and strive to perform at the highest level. My heart is my own and is reserved for my personal life.

    I would encourage you to seek counseling in an effort to learn to separate yourself from your work.

    Nursing is not a calling nor a mission; nursing is a job... and one which will chew you up if you get too close to it.

    Professional detachment...

  • Sep 5

    Seriously though,

    I get real twitchy about the whole "lunch" break thing and what it is.

    If you get a free, totally uninterrupted thirty minute break from your duties, that is an unpaid lunch break. You are able to do whatever you wish during that time: Tai Chi in the parking lot, driving to and from Walgreens to fill a prescription, stuffing your mouth in the cafeteria--doesn't matter what you want to do, this is _your_ time.

    If you take your zone phone with you and it rings and you answer it, and the call is related to your patient, you did not get a thirty minute lunch break. You get paid for the whole thirty minutes.

    If your patients are unstable and you run back for ten minutes ten times to nibble during your shift, that is paid time.

    If you are working through your lunch break and you are not getting paid for that, you are contributing your time to your employer. Here is the math for what you are contributing:

    36 hours per week, 1.5 hours per week unpaid lunch equals 78 hours for one year. You are contributing over an extra two weeks per year to your employer by taking unpaid lunch breaks. You could have gone on a fabulous vacation with this time. Instead, you are at work, unpaid. You are essentially gifting your employer two weeks of your time every year.

    On a unit that employs 30 RNs, that 1.5 hours each day for one year becomes 2,340 hours. Gosh, it's almost as though the facility could afford to hire a break RN, right? Wonder why they don't?

    For all of those RNs pressured by their managers to work off the clock either during their "lunch breaks" or after their shift has ended, your State Department of Labor in your state is a great no-cost resource. Most DOLs will take anonymous complaints.

  • Aug 25

    I've found that a little sarcasm or a little humor works with these sort of folks. The thing is, I can't plan it -- it just sort of pops out.

    There was a renal attending who had a reputation for being nasty, and we all used to dread renal consults in the CCU. One morning he showed up at 7:07am (after the consult was placed at 7:01) and started yelling (raised voice, offensive language) about the fact that I didn't have an hour's worth of urine collected for him. "It's been six minutes," I said. He continued to rant about the fluid orders, labs that hadn't been sent (because they hadn't been ordered) and various and sundry other issues. Finally I snapped.

    "I'm SURE Dr. Smith ordered this consult to ruin both of our days."

    "Oh," he said, taken aback. "Right. I'm sorry."

    And I never EVER had another problem with him being nasty to me.

  • Aug 20

    You really haven't defined any behaviour by the nurses that is bullying. The techs, maybe a bit unprofessional, but not bullying. Then there's the fact that a doctor had to correct you on a medication. You're one month in, so where was your preceptor for that? Were you asking the appropriate questions or researching your med before he had to correct you?

    Respect to a human being is basic. Nobody will respect you as a nurse until you prove yourself. Respect as a nurse is earned. That's ER culture.

    As for watching trauma, if you have nothing better to do with your time, I dont blame the techs for asking you to grab equipment. You're standing there doing nothing. Nobody in the department needed a single thing? Put your head down, get to work. You will be oriented to trauma in due time. Then, you will see what you need. Offer to start IV's, draw blood, splint, make a bed, grab vitals, do an EKG on that new chest pain. Just don't get caught standing around watching. It makes you look lazy.

    This process will not be fun, but don't give up before a year. Never be afraid to ask questions or ask if you can jump in and help with something you've not done before. This, too, shall pass.

  • Aug 20

    Respect is EARNED.

  • Aug 11

    There are some days when I read posts here and say OMG!!!! So I switch over to Facebook and say D***!!!! So, I get in my car, go for a drive and say WT*!!!! So, I go back back home, pick up the remote, start channel-surfing, and say sonuva*****!!! Then, it's time to go back to work! So I say, Lord, forgive me for ALL that I've said and please, if You help me get through this ******** at work, I promise I'll watch what I say tomorrow.

    ......just trying to put a smile on a few faces here.

  • Aug 11

    Quote from tara07733
    Point lost yet again by many (not all).

    ill leave this tidbit here and then I'm done. NO ONE (I repeat, no one) is saying not to give down-to-earth opinions or advice. There are quite a few ladies and gents here (I won't name names but know that tou are appreciated even if you're out off by this post) who do just that all or most of the time --they know how to be helpful without the condescension. Now, I am 46 years old (like you I grew up in a different era) and I don't need hand holding, smoke exhaled into any of my orificies, or any of those other cliche sayings. I admit I had a not nice moment but who doesn't.

    I however won't back down about the snark. And this begs to be said: My original in the other post was a 2-sentence reply to a 2 word response. It's very funny how snark allows for such short, terse responses but when people want to garner some sort of sympathy from the masses there are all sorts of qualifiers about what was was said, hints about wanting to leave the board because "I just can't deal with this sometimes", etc. All I'm saying is that if as much thought was put into your overall responses, Roser, as the one's in this particular thread maybe I'd think differently. And maybe if I truly believed if some responses were to actually help many times I'd feel differently. And MAYBE if it were someone else that I saw some other type of response from I'd be able to take that stuff and run with it, because no, I and most other people don't need constant reassurances. But at least be respectful because no, I'm sorry, you don't have to come off that way to teach people about work or about life.

    Roser, I hope you don't leave and that you live a long virtual life here in AN. There are obviously a good many folks here who really appreciate your breadth of knowledge and candor. My opinion is obviously just one but, just as many people have no qualms about expressing their in-the-moment feelings, I expressed mine. By the way, thanks for the call out. I feel pounds lighter now that I was able to get some of that out.
    I've said plenty in real life and on this site that missed the mark. I prefer to admit my own short coming, apologize and move on. There's just no rationalizing statements such as must have had fingernails ripped off as a child.

  • Aug 11

    Quote from tara07733
    I'll bite. That was me who posted that response. As an FYI, that response wasn't just about that particular post as much as what I see is a recurring behavior from you. It has nothing to do with 'new nurses/students these days', as I'm neither young, naive, not entitled. I took that response of yours in the way that I see many of your responses and, honestly it chapped by hind parts. Yes, algebra is an excellent place to start but I'm old (and smart) enough to detect snark when I see it.

    There are obviously times when many others here have been very tough love. There is a time for all of that; it's needed often. But sometimes it's all about the delivery. Maybe it's just about bring able to decipher tone in the written word but there were too many examples and too much history in this case. Maybe it was uncalled for but people get annoyed by things every day on this site so my response to you was no different than any other 'Mary Alpha-Nurse' response so...
    1. I have not said anything whatsoever about "new nurses these days." And the only reference I've made to students is that they ask us questions.

    2. If you can detect snark from "Algebra 101," when Algebra 101 is a perfectly appropriate answer, then you have indeed provided an outstanding illustration for this thread. Thank you for that.

    3. No one should attempt to decipher "tone" from the online written word. That will get you into trouble every time.

    4. If you truly believe that asking me if someone tore my fingernails out as a child is "no different than any other response," then you honestly have my sympathy. I am sorry for anyone whose mind goes to such extremes over a one-word answer. I am sorry for anyone who even thinks of those things.

    5. Please do us both a favor and refrain from reading any of my posts, given that you don't care for my "recurring behavior." We will both rest easier for it. I will indulge myself in some snark and say that I'm not sure who made you the judge, jury or parent of anyone's "behavior" on an online forum as we have sufficient moderators who do that in a much less judgmental way. At any rate, that is a topic for another thread......

  • Aug 11

    • 12Our patient population is tough - many people with chronic health problems but also lots of (too many) people playing the system. They're demanding, most likely drug seeking, malingering.

      I find myself driving to work telling myself I'm going to give my patients my best. Then I'm assigned some frequent flyer who either shouldn't have been admitted or is back because they continue their self destructive behavior or they've been totally non-compliant. And I could deal with any of that (I'm not a perfect person and I don't do everything I should most of the time) but they're so manipulative. And demanding. I hate the drama. I feel like I'm running up and down the hallways all day, administering PRNs to people who tell me they have 10/10 pain who, while they may have some discomfort, are nowhere near 10/10.

      I know I'm teetering on the edge of burnout and I do have some time off scheduled. Meanwhile, how do I find a way to compartmentalize my frustration and anger? I need to find a better way to cope with this now and after my very much needed vacation. I know many of you struggle with the same frustrations. How do you keep it from eating at you? I'm tired of being tired and angry.
      jk2185, NotYourMamasRN, Cola89, and 9 otherslike this.

    From Samuel Shem, in "House of God" -- The patient is the one with the disease.

    Remembering that has helped keep me from burning out completely. It isn't MY disease, it's theirs and although they aren't dealing with it the way I'm sure *I* would, they're dealing with their own disease. Or not, as the case may be.

    I used to work on Med/Surg, and we had some frequent flyers that came back with their GI bleeds, esophageal varices and other issues of alcohol abuse on what seemed like a weekly basis. Between them, the diabetics who thought an 1800 calorie diet meant 1800 calories three times a day and the girl my own age who came in with DVTs over and over again because the only activity she engaged in was walking from the sofa to the bathroom, I was a walking ball of anger. Then a wise old woman (who was younger then than I am now) told me "They're the one with the disease, not you," and told me about "House of God."

    One of the things that has helped me the most is journaling. When I'm particularly angry or upset about some situation, I sit down and write about it for 20 minutes or 500 words or some other pre-defined length of time. Sometimes, I can't think of anything to write and at those times, I just write "I can't think of anything to write" a few times and then find myself writing about whatever it is that's bothering me, often before I even realize I have something to say. Oftentimes, what I find myself writing about isn't the same thing I THINK I was angry about. It's enlightening. You don't have to save your writing -- save it, shred it, burn it -- whatever makes you feel best. Sometimes burning or shredding your words helps to let go of the anger.

    Good self-care is important, too. I like to walk and one night after an especially traumatic shift, I walked my dogs eight miles or so without even realizing it. Or I swim in the creek behind our house, or go to the gym or something physical. Eat well, make time for friends, make your home comfortable -- whatever else you do to take care of yourself. Alcohol works once in awhile, but you have to be careful there.

    Hope there's a kernel in here that helps.

  • Aug 8

    Since the purpose of the Emergency Department is to rule out/stabilize life threatening injury/illness, we are concerned primarily with acute pain.

    The numeric pain scale is one dimensional. It only evaluates the patient's verbal report of the intensity of their pain. Since the goal in the ED is to determine the cause of the acute pain in order to treat the cause (i.e. appendicitis, myocardial infarction, bowel obstruction, long bone fracture, etc.), a multidimensional pain assessment is appropriate.

    A multidimensional pain assessment includes the patient's subjective report of the intensity of their pain, but also the quality, the clinical progression, any alleviating or exacerbating factors, as well as objective observations such as splinting, grimacing, moaning, crying, etc. as well as abnormal vital signs.

    It is the multidimensional assessment that should be guiding the prescriber's decision making regarding appropriate analgesia, not simply a number from 1-10.

    Treating pain related to a long bone fracture is different than treating pain from renal colic. Treating a migraine is different from treating a small bowel obstruction.

    There is no one-size-fits-all pain management strategy.

    When you triage a patient who presents to the ED for a pain related complaint, it only takes a few minutes to perform a comprehensive, multidimensional pain assessment. Part of this means that when you ask the patient to rate the intensity of their pain on a 0 (no pain at all) to 10 (the worst possible) scale, it is completely appropriate to explain the scale to assist them in selecting the appropriate number to represent their experience. For example, 1-3 is mild pain that can be ignored and doesn't interfere with their activities of daily living. 4-6 is moderate pain that is difficult to ignore and interferes with concentration. 7-9 is severe pain that interferes with activities of daily living. 10 is the worst possible pain that requires bedrest. Obviously, if they drove themselves in and are calmly sitting in an upright position with no grimacing, splinting, tearfulness, and with normal vital signs, then they cannot be a 10.

    Keep in mind that I am speaking of acute pain only. I'm perfectly aware that chronic pain is different. But again, in the ED, we are not in the business of treating chronic pain. If a person with chronic pain at baseline presents, it is appropriate to ask about their chronic pain, but also to explain that we're concerned here today with what is new or different from their baseline. We are not going to adjust their oxycontin dose or prescribe a fentanyl patch- that is for their primary care provider or pain specialist to do.

    Having said all of this, I would say, Emergent, that if the providers in your ED are prescribing analgesia based only on the unidimensional, subjective, verbal report of the intensity of pain and not taking into account the physical exam, objective signs, differential diagnosis, etc, to select the most clinically relevant pain management strategy, then it's probably due to a host of factors such as pressure from administration to speed up throughput and increase patient satisfaction.

    Honestly, it might feel like what number you plug into the computer under the pain score really matters, but in the end, that's not what the bean counters are auditing. They're looking at things like how long it took for the physician to order pain medication for a long bone fracture, or how long it took to give antibiotics to a person who met sepsis criteria, or whether a repeat lactate was drawn within six hours, or how long it took from the time the decision to admit was made until the person finally got to the floor, or how many patients a provider saw in their shift. Providers are under so much pressure to meet these demands, that they just click the boxes and give the patients what they want because they don't have time to actually practice medicine- i.e. dilaudid for a pinky toe sprain.

    In other words, it's bigger than you or me or the stupid 0-10 pain scale.

    Does that answer your question...sort of?

  • Aug 8

    In response to the OP-
    Yes, it probably has a small role in this disaster.
    When you ask in those terms, and are told 8/10, it develops an expectation that you are going to do something to lower the pain rating. By "something", I mean give narcotics. When you re-asses, and it is still 7/10, the person has a reasonable expectation that you are going to do "something" more. I try to avoid re-assessing when I know we aren't going to give more narcotics.

    As a nurse, providing appropriate pain control is important to me. But, the 1-10 scale is only occasionally helpful, and often just a box to check. I might advocate for a gram of tylenol for a pt with 12/10 pain, and 2 mg of dilaudid for 3/10 pain. I use my judgement and experience, as well as developing a rapport with my pts.

    The scale itself has lost meaning- it has fallen victim to inflation. We all know nobody walking/talking/eating has 90% of the pain possible. Dousing that person with gasoline and lighting it would easily double that pain, and taking a weed whacker to their head as they burned would bump it up even more.

    I don't even know what number I would use if I wanted to get narcotics for pain for myself. The one time the issue came up was for an injury that was too painful for me to walk or move, so I ended up in an ambulance. Trying to get up to pee left me wincing, unable to move. At the time, I rated it 4/10. Not trying to be macho, I am just mathematically inclined. I believe that experiencing 50% of the pain possible would be agonizing.

    But, when I hurt my back so badly I knew narcotics would be the only thing to help, I had to think "what number should I give to get narcotics."

    So, as a one size fits all assessment tool, I think it has outlived it's useful life, and probably has a minute role in a colossal problem.

    And on another note:

    As nurses many of us want to help people. When you give a medicine to somebody, you either help them or hurt them. Many of us believe that providing narcotics to drug abusers, or narcotics that will be subsequently sold to abusers hurts them.

    These threads always bring up the same themes about not being judgmental. Some folks will chime in on on how they experience pain differently, etc, etc. Outlier examples and cultural differences always come up. This is never what these OPs are originally about. We all get that somebody could be in agony, and not express it in a way we understand.

    "How can you know how much pain......" Yup. We get it. Pain is an individual experience.

    But- if, for example, you actually believe that somebody is allergic to NSAIDS and mild narcotics, but can tolerate mind altering, commonly abused drugs, then you are incredibly naive. Nursing requires good assessment tools and an ability to read people.

    These threads are really about these PTs:

    Common Characteristics of the Drug Abuser:

    • Unusual behavior in the waiting room;
    • Assertive personality, often demanding immediate action;
    • Unusual appearance - extremes of either slovenliness or being over-dressed
    • May show unusual knowledge of controlled substances and/or gives medical history with textbook symptoms OR gives evasive or vague answers to questions regarding medical history;
    • Reluctant or unwilling to provide reference information. Usually has no regular doctor and often no health insurance;
    • Will often request a specific controlled drug and is reluctant to try a different drug;
    • Generally has no interest in diagnosis - fails to keep appointments for further diagnostic tests or refuses to see another practitioner for consultation;
    • May exaggerate medical problems and/or simulate symptoms;
    • May exhibit mood disturbances, suicidal thoughts, lack of impulse control, thought disorders, and/or sexual dysfunction;
    • Cutaneous signs of drug abuse - skin tracks and related scars on the neck, axilla, forearm, wrist, foot and ankle. Such marks are usually multiple, hyper-pigmented and linear. New lesions may be inflamed. Shows signs of "pop" scars from subcutaneous injections.

    Modus Operandi Often Used by the Drug-Seeking Patient Include:

    • Must be seen right away;
    • Wants an appointment toward end of office hours;
    • Calls or comes in after regular hours;
    • States he/she's traveling through town, visiting friends or relatives (not a permanent resident);
    • Feigns physical problems, such as abdominal or back pain, kidney stone, or migraine headache in an effort to obtain narcotic drugs;
    • Feigns psychological problems, such as anxiety, insomnia, fatigue or depression in an effort to obtain stimulants or depressants;
    • States that specific non-narcotic analgesics do not work or that he/she is allergic to them;
    • Contends to be a patient of a practitioner who is currently unavailable or will not give the name of a primary or reference physician;
    • States that a prescription has been lost or stolen and needs replacing;
    • Deceives the practitioner, such as by requesting refills more often than originally prescribed;
    • Pressures the practitioner by eliciting sympathy or guilt or by direct threats;
    • Utilizes a child or an elderly person when seeking methylphenidate or pain medication.

    We shouldn't label people. But the DEA does.

  • Aug 8

    Quote from CanadianAbroad
    Unsophisticated and low level of education? My god is this a generalization. Here is the thing, instead of passing judgment on these individuals, how about taking addiction courses to learn how to help these patients? Most of the time, a great deal of these individuals have no where else to go; especially in inner city hospitals. They are not seeking these meds due to being a junkie. Most of the time, they are in pain. They are masking other symptoms and are using as coping mechanisms. Yes they clog the ER, but they need help. Get some empathy and put yourself in their shoes. I used to be like you, until I had an injury and a chronic pain condition. It was hell, but I eventually pushed through it and am back to work. Am I a junkie if I go to the ER because I cannot manage my pain properly? I work in part of the ER, and I can tell you that our pain seekers are of all classes and education levels. There was no need to even mention that in the first place, and it comes off very ignorant. I am not sure if you intended this or not. Here is some advice from someone who has been in their shoes. Ask the pain level, look at their facial reactions and ask them to describe the pain. Most pain specialists go by the description of the pain, and not the number. I used to attend a pain clinic for years, and my experience has made me understand just how easy it is to get dependent on a drug and even when you do not intend to. I do highly suggest addiction courses online. McMaster University in Hamilton has an excellent program. I do think it will help in the ER, and then help stop patients from being transferred to Clinical Decision Units to investigate their pain.


  • Aug 8

    Quote from blondy2061h
    I hate the pain scale.
    Here's one I find a little more realistic from Hyperbole and a Half by Allie Brosh:

  • Aug 8

    I had a serious injury last year, with 8 severed nerves, 5 severed tendons, and a very, very painful recovery. I have lingering limitations and pain.

    Yes, I understand pain.

  • Aug 8

    Several of the hospitals I work for have a place to document the patient's behavior next to their stated pain level. One even asks for the nurse's "total pain impression."