Doctor vs Nurse - page 6

I work in a nsg skilled facility and rehab at the same time. Our medical director always orders continue to monitor when I report something to him. One time I reported an extremely high blood glucose... Read More

  1. Visit  CapeCodMermaid} profile page
    3
    Vicedrn....I am one of those "ltc folks". At any facility I've run, we did NOT call 911 for "absolutely everything". In fact, we try absolutely everything we can to keep our patient in the facility....labs, xrays, ultra sounds, IV therapy,nebs...what we don't do is shoot a confused elder full of Haldol like you ER folks do.
    LTCNS, BrandonLPN, and tyvin like this.
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  3. Visit  VICEDRN} profile page
    0
    Quote from CapeCodMermaid
    Vicedrn....I am one of those "ltc folks". At any facility I've run, we did NOT call 911 for "absolutely everything". In fact, we try absolutely everything we can to keep our patient in the facility....labs, xrays, ultra sounds, IV therapy,nebs...what we don't do is shoot a confused elder full of Haldol like you ER folks do.
    The facilities in my area absolutely do not do IV therapy or new neb treatments. I can tell you this as a fact. I recall one night hearing in report that our facility disciplined a nurse for discharging a patient to LTC with an iv access. The LTC called 911 to take the patient back to the hospital and have it removed. I am NOT MAKING IT THIS UP!!!!

    They absolutely won't do nebs on a new onset wheezing. Every patient has to have his or her own neb machine and they expect it at their facility before we discharge patient.

    We aren't permitted to give Haldol to pts with acute confusion anymore. I miss the days greatly. I think the reaction to the use of haldol in confused elderly is overblown and mostly cultural. We just can't associate little old grandma with a schizophrenic! oh no! that would be so not right. Haldol is not, in my opinion, the end of the world under certain circumstances. In fact, sometimes I think its the only humane thing to do.
  4. Visit  DeBerham} profile page
    1
    I've worked both sides (ltc and er) and I think not of you have fundamental misunderstandings about what the other does. In ltc you are often working with patients who are relatively stable but need some more help with adl's. The nurses in this environment are carrying between 15 and 30 patients depending on the facility. With these patients you are expected to medicate, do wound care, ensure that feeding and toileting take place etc. If a patient begins to go south there is frankly little time to sit and monitor them to see if their condition changes. You go with your gut and call the md. As an er nurse now I have much respect for what they do because I've been there and know how hard and stressful that work can be. My shift, start the finish, was basically a medication pass... God help me if anything came up.

    From an er nurses standpoint pts come from ltc's in all sorts of conditions. From basically nothing wrong but being sent out because the family insists that grandma with dementia who they haven't bothered visiting in a year is acting more confused needs an er eval to patients who are satting in the low 80s gasping. We don't just give them "haldol" and send them back. All of the patients have to be worked up, and unfortunately the history that we get from the nursing homes leaves a little bit to be desired.

    Both of you need a reality check... Walking a mile in the others shoes might be helpful
    Altra likes this.
  5. Visit  DeBerham} profile page
    0
    Quote from VICEDRN

    The facilities in my area absolutely do not do IV therapy or new neb treatments. I can tell you this as a fact. I recall one night hearing in report that our facility disciplined a nurse for discharging a patient to LTC with an iv access. The LTC called 911 to take the patient back to the hospital and have it removed. I am NOT MAKING IT THIS UP!!!!
    Would you dc a patient home with iv access? It's a HUGE risk for infection. I pulled ivs out of patients we received from the ER but they should not have been left in the first place as ltc's do not typically give iv drips. Your coworker screwed up.

    They absolutely won't do nebs on a new onset wheezing. Every patient has to have his or her own neb machine and they expect it at their facility before we discharge patient.
    This isn't a hospital that you're dealing with, it's not like they have a supply of nebulizers that can just be pulled from, if the pt needs nebs it would be prudent to have the equipment on hand, wouldn't you say?

    We aren't permitted to give Haldol to pts with acute confusion anymore. I miss the days greatly. I think the reaction to the use of haldol in confused elderly is overblown and mostly cultural. We just can't associate little old grandma with a schizophrenic! oh no! that would be so not right. Haldol is not, in my opinion, the end of the world under certain circumstances. In fact, sometimes I think its the only humane thing to do.
    Haldol is overly sedating and can exacerbate existing confusion. You do realize that haldol has a black box warning r/t administration in elderly dementia patients, right? As it turns out there is a higher mortality rate in those who receive it. The problem with elderly psychotics is that it is near impossible sometimes to differentiate organic deterioration vs psychotic symptoms.
  6. Visit  LadyFree28} profile page
    2
    In OP, she works at a skilled nursing and rehab....in my area, when there is a "rehab" component, they do IV infusions-including TPN, nebs, etc, especially if it is designated as a LTAC (long term acute care). More and more of LTC is becoming sub acute....the "rehab" part now is truly "rehab"! And you still have 25 patients. When I worked in rehab, you didn't send them out for new onset wheezing...you can take an x-ray, there's a pharmacy on site, respiratory therapy, etc. I may be making an assumption, but what I gather from the poster, this facility has the capabilities of handling this, but from her novice experience, she wanted to send out the pt, also for concern for her license, despite misleading the doc and charting incorrectly.... We have to remember depending on where we work geographically, there are many aspects of nursing care that may be changing, especially in LTC, and even facilities still vary.
    Altra and VICEDRN like this.
  7. Visit  VICEDRN} profile page
    1
    Quote from DeBerham
    Would you dc a patient home with iv access? It's a HUGE risk for infection. I pulled ivs out of patients we received from the ER but they should not have been left in the first place as ltc's do not typically give iv drips. Your coworker screwed up.


    This isn't a hospital that you're dealing with, it's not like they have a supply of nebulizers that can just be pulled from, if the pt needs nebs it would be prudent to have the equipment on hand, wouldn't you say?


    Haldol is overly sedating and can exacerbate existing confusion. You do realize that haldol has a black box warning r/t administration in elderly dementia patients, right? As it turns out there is a higher mortality rate in those who receive it. The problem with elderly psychotics is that it is near impossible sometimes to differentiate organic deterioration vs psychotic symptoms.
    I understand and respect that you have had both experiences and that makes you more sympathetic to the LTC nursing side of the equation but frankly, I think this makes your response more emotional and less insightful. As an ER nurse, it is not my fault that your job basically consists of a long med pass. I get that that it is but frankly, and I am being really honest, I don't care and it doesn't give you an excuse to abuse the ER for what is otherwise, a nursing activity well within the scope of your practice.

    Do I pull my IVs on discharged patients? Yes, I do. Did my coworker screw up? That's rushing to judgment. She actually thought she was helping. She thought the nurse might need the IV on this difficult stick. Did the LTC nurse screw up by calling 911 to REMOVE A FREAKING IV? Are you kidding me??? I have to say one is more ridiculous than the other.

    I am not stupid. I realize they probably have a machine that belongs to another patient but having a massive patient load, any excuse not to take their patient back is a good one. If you don't have one, get someone to phone one in for you. LTC would like the ER to babysit their patient until they can fill a script. Unacceptable. We have a waiting room full of sick people to take care of. Just because you abuse us because of EMTALA doesn't mean you should.

    Finally, I am aware of the warning on haldol. Thanks. In health care, we have lost touch with reality. We don't use phenergan in our ER anymore either because of the potential for necrosis. In the two years I did use, we ran it in 50 ml bags and I never not once saw any irritation and an MD I spoke with said he went years and years without problems. We continue to jump through hoops to avoid uncommon side effects when there is a very real risk to the patient if we don't treat them for their confusion. If you don't like what we do to your patients, convince the family to keep patient in the facility but then that doesn't lessen your work load and would require some effort. The ER is simply easier for most people. Maybe you weren't like that but I think most people are. Sorry. True story.
    ♪♫ in my ♥ likes this.
  8. Visit  anne919} profile page
    0
    Ltc wouldn't send out their resident to ER as much as possible. But when the md wouldn't give appropriate orders and we see the pt deteriorating that is the only time we send them out.
  9. Visit  psu_213} profile page
    0
    When, from the ER, I have called report to a LTC facility I have heard both "you are going to leave the IV in just in case" and "you're going to take that out...she can't be here with that." Obviously it varies from facility to facility if they are able to do IV therapy. Either way, an RN needs to be able to remove a peripheral IV, and it is just more strain on the healthcare system to send residents into the ED by ambulance for a simple IV removal.

    I worked as a CNA in LTC and I worked with many great nurses, including one I still have as a close friend. However, working in the ER, I have had some less than stellar interactions with nurses. For example, calling report: "His labs were normal, chest xray was normal, UA showed no infection, so we are going to be transferring him back to your facility." Nurse: "Umm, OK." Me: "Last set of vitals were heart rate 72, respirations 18, BP 110/48." Nurse: "What? You can't sent him back like that. I cannot not accept a pt with such a low, unstable blood pressure!"

    On the other hand, while I would never make a big deal about this BP, having never been an RN in LTC, I don't know how good of a job I would go at caring for that many residents at once. Therefore, I can't criticize on the day-to-day workings of a LTC nurse.
  10. Visit  marcos9999} profile page
    1
    Quote from anne919
    And as soon as I got the order I hung up on him.
    I see a problem right there. Assuming that you just ended the conversation without reaching a conclusion that satisfy both parties, regardless weather the doctor was wrong and you were right is not ethical therefore I would fix that first before fixing anything else.
    psu_213 likes this.
  11. Visit  LadyFree28} profile page
    0
    Quote from anne919
    Ltc wouldn't send out their resident to ER as much as possible. But when the md wouldn't give appropriate orders and we see the pt deteriorating that is the only time we send them out.
    Maybe because your LTC is designated to intervene FIRST...if the pt's sats decrease, BP looks unstable, change in mentation, THEN I would send out. Your LTC has a criteria that you must adhere to, and do the best you can, BEFORE sending out a resident. Do you have a pharmacy on site? Respiratory supplies??? IV pumps??? Then your facility is CAPABLE of caring for the pt, even though it is not a hospital. I bring this back to you and suggest reading that clinical thinking and nursing judgement and start sharpening those skills, as well as trusting your MD, you are going to have to work with many of them as long as you are a nurse. I have worked with many MDs that could have better judgement, however, I gave them the same respect as the highly competent MDs, and everywhere in between.
  12. Visit  BrandonLPN} profile page
    0
    I work in a facility that is strictly LTC, not subacute or rehab. In other words probably lower acuity than most LTC nurses here. I have 40-49 residents on 3-11. But even in my facility we at least try to treat illness before just sending someone out. We can give PO or IM abx and neb treatments, push fluids and monitor vital signs. And when you think about it, this is sufficient in most cases. If something goes beyond what we can handle, we call the doctor. A wheezy resident who denies SOB does *not* seem to justify calling 911.
  13. Visit  CapeCodMermaid} profile page
    1
    It seems this thread is deteriorating into an us versus them thread.As an aside, Haldol has fewer side effects than Seroquel and works wonders in small doses for end stage agitation.Ps.at the risk of violating TOS, the next time someone says walk a mile in their shoes, I might have to take said shoes and kick them.
    tewdles likes this.
  14. Visit  Anna Flaxis} profile page
    0
    At the risk of contributing to the complete derailment of this thread, I will add that I have never worked in LTC as an RN (only as a CNA), but I have worked as an ED RN, and in my experience, not all LTCs are created equal.

    I have received LTC patients that I had no earthly idea why they were sent. The EMTs could not tell me either, and the paperwork that came along with the person was signed off by a Med Aide. We would have to call the LTC and sit on hold for fifteen minutes until an LPN or RN could free themselves from whatever they were in the middle of, and even then, they often weren't exactly sure of the reason for transport. This happened regularly.

    I have also received LTC patients with a POLST stating DNR, Comfort Measures Only, Do Not Transport, for various things like pain or labored breathing or decreased LOC; all things that an LTC facility should be able to handle.

    On the other end of the spectrum, I have received many LTC patients that were in septic shock by the time they were sent.

    These are all frequent occurrences here, and we learned which facilities were the worst offenders, that we would not send our worst enemy to.

    I have also received LTC patients who were transported appropriately, and when speaking with the nurse on the phone, really got the sense that that nurse had their act together. This was significantly less frequent.

    In other words, there is a wide range of variation from one LTC to the next. CapeCod, it sounds like you work at one of the better ones, and you are one of the better nurses. Just know that from an ED nurse's perspective, you are a rare gem!
    Last edit by Anna Flaxis on Dec 30, '12 : Reason: to compliment CapeCod


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