Doctor vs Nurse

Orange Tree · Dec 30, 2012

Am I the only one who thinks this is completely made up? All of it?

SionainnRN · Dec 30, 2012

Am I the only one who thinks this is completely made up? All of it?

I hope it is but I doubt it. I am beginning to wonder if English is the OP's second language and that's contributing to the misinformation.

tyvin, BSN, RN · Dec 30, 2012

Is it regular charting to put down the side effects? Nurses cannot make diagnosis...did you write flu in the chart? So you were making a prediction...that's not nursing. You should have learned this in school. You need to brush up on your charting.

As far as the doc just work with him and stop taking everything so personally. If you call have prepared what you want and then proceed from there. Relax, they're not the enemy.

violetgirl · Dec 30, 2012

You lied...

I am not a nurse, but only a student.

Wrong tread.

VICEDRN, BSN, RN · Dec 30, 2012

Why in the world would you call 911 for wheezes??? As another ED RN that is an extreme reaction. Your patient has wheezes and poss pneumonia on an CXR, and guess what? The MD started abx and breathing treatments and O2. What in the world do you think we could do that isn't being done? The only reason to call 911 in this case is if the pt couldn't maintain their O2 sats and was going into resp distress. Otherwise give the abx some time to start working, geez.
And this is in NO WAY unethical or unlawful. It seems to me you have your panties in a bunch about the doctor and are trying to find anything you can to make them look bad.

I don't see where she said breathing treatments were ordered. You can't ignore audible wheezing. Lets be really honest here folks. The ltc folks call 911 for absolutely everything including a fever with no other symptoms. Expiratory wheezing bears addressing in my opinion as a nurse.

CapeCodMermaid, RN · Dec 30, 2012

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.

VICEDRN, BSN, RN · Dec 30, 2012

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.

DeBerham · Dec 30, 2012

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

DeBerham · Dec 30, 2012

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.

LadyFree28, BSN, LPN, RN · Dec 30, 2012

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.

VICEDRN, BSN, RN · Dec 30, 2012

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.

anne919 · Dec 30, 2012

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.