WHAT is wrong with my ER??? Grrrr...

[Scavenger'sWife]

OK...major ranting about to go on here.

PUH-LEEZE explain what is happening to my facility's ER. Here are just a few problems lately.

We got an admit last night of a 51 year old male, N&V, diarrhea, dehydration. No co-morbidities. Labs were straight down the line, couldn't even prove the "dehydration" dx by them. Non-tele (thank goodness). Why was he admitted? He was "too sick to make it back home" (patient statement) and the wife said she "just couldn't handle him at home anymore". (I am serious - that was her statement) I am saying this guy was A&O - wife just didn't want to listen to his whining anymore. Guess what SHE does for a living? She is a Home Health RN at our hospital! Do ya think the authorities will have a field day w this admit? What about the "meeting criteria for admission"? We were told to admit on observation status b/c the wife wanted him admitted!!! Well....the next time *MY* hubby has the flu and I am tired of dealing w it, I guess I know what to do...

Crap - 3 months ago I was in to ER w what I found out later, was pyelonephritis and bronchitis. Had SEVERE lower back pain (Yes you dumb a$$ - it's a *FREAKING 10 ON A 10 SCALE*) had dysuria, hematuria w frequency. N&V w diarrhea. Fever of 103.4F oral. Know what *I* got in the ER??? A FREAKING TYLENOL and a po BACTRIM and a script for Bactrim, and got told to go home! Never even got my fever below 103 while in the ER, never got an IV for fluid replacement, etc. My MD was furious. I was asked, "Why didn't you tell him (the ER doc) you wanted to be admitted?" I nearly blew a gasket....I don't think that was *MY* call! I WAS TOO SICK!!!

The ER has sent patient w FUO and then orders *NOTHING* for a fever!!! WTF!!

Two weeks ago, I admitted a 93 year old female who had fallen at home. This is a very A&O lady who is actually a volunteer at our hospital. She had fallen at home and had this **HUGE** hematoma over her left eye. CT of head and Xrays revealed no fx, bleed, etc. She was there for observation. Well, we walked her to the bed from the hallway, stood her to weigh her, etc. Got her into bed. I went in and did my assessment......Lo & Behold: She has this *ENORMOUS* swollen, bruising, solid hematoma injury as big as my outstretched hand over her left hip. Ahhhhh jeez...I'm thinkin' hip fx here, and I allowed her to walk...NO ONE said anything to me in the report I took about a HIP injury. I looked at the records and there was NO note about it, nor were any xrays done.

I called the ER supervisor, asked who examined this patient. She said, "Well, actually, I did it and Dr. XYZ. Why? What's the problem?"

I tell her what I found, and she said, "Well, the patient never said she was hurt anywhere except her head."

HELLO????!!!

Has anyone ever heard of this new thing called an ASSESSMENT?? I said, "Since when do we just take a patient's word for what their problem is? (I can see it now: "Hey Doc? I believe I have an intracranial bleed here...") What about undressing the patient and doing a physical exam, for crying out loud?

And do ya think the fact that she is *94 YEARS OLD* that she FELL and that she is FEMALE and takes FOSAMAX just *MIGHT* tell ya to have a look-see at something other than her bloody head?? DO YA'THINK, HUH????

I had to call her MD and get orders for a STAT set of hip xrays. Thank God she had no fracture.

:mad:

These are just a FEW things......I could go on and on....

It is not just one MD down there. It seems to be mass stupidity. We have several new MDs working ER and everyone is talking about this. I have written several incident reports, but nothing seems to be changing.

All I feel I can do is to continue to assess my pts carefully when they present to my floor and to document, document, document...

Well, thanks for allowing me to go on and on with my diarrhea of the mouth. I will get off here now.

I love my job...I love my job...I love my job...

[NotReady4PrimeTime, RN]

HoooRAAAHHHHH KaroSnowQueen! I wouldn't have paid the jerk either. I've also had to take my kids to another facility when the ED doc made the wrong call. My daughter broke her elbow (medial supracondylar #) and was told, based on lateral view x-rays that there was no #, then sent home with instructions to take Tylenol if it still hurt. Four tearfilled days later, guess what... ecchymosis on the opposite side of the joint, grossly obvious edema, no sensation to half her hand and intense pain. Mom to the rescue... we went to a sports medicine center, I insisted on multiple views on x-ray and we left with T3's, a knuckes-to-axilla cast and an appointment with ortho. In the end she needed surgery on the tendons due to trauma and is still disabled. The first ED she went to got a nasty letter and no money.

[rjbryan]

Yup, ER suck, especially from the point of view of all you "experts" who are complaining here.

SO...try the ER for a shift or two. Attempt to triage the real emergencies from the drug seekers, those who want a work slip, and the "social admits" which we fondlly refer to as "pop drops" or "positive taillight signs" . Or from the mother who is upset becuase she has to deal with "just a nurse" and screams her "baby" is burning up with fever, but didn't bother to buy a therometer. Yup, just a nurse, but I'm smart enough to take a temp, hun.Or the elderly who take a zillion meds but cant be bothered to write them down or remember them because "you must have a record here someplace" or "you can call my doctor. He should know." Or take the blame because lab, or Xray, or whatever is swamped and can't do STAT on everyone and you haveta wait for your tests. Want a forum? How about "stupid floor nurse tricks" or "using the ER for primary care because I was too stupid to find a real doc" or "Primary care physicians who send their patients to ER to have all their tests run before being admitted because its easier than me having to actually come in and see the patient". Sure is nice hearing from all you ER experts. Yup. Sure is.

[avigail]

To go back to the original posting, I think that the ER md is really the problem in terms of admissions and treatment. I hate to say it but I've sent pt.s with kidney stones home with a RX for Motrin (and worse, but I fear to admit it). There are some mds who just fancy themselves as hard asses and they will not tolerate being challenged about their treatment or d/c decisions. Of course, I always document these failings in full (Pt reports pain at 10/10. Md informed. No further orders). On the other hand are those docs who have no diagnostic skills and can't make a decision without every test known to humankind. Then they admit the pt to top it all off. Unfortunately, I have to carry out these orders as well.

I think the hospital administration may bear some responsibility for the hard rump attitude. Medicare/medicaid will not pay any part of medical claims if the pt is a full admit and is released the following day-and other insurers are trying to follow suit. The doc may decide not to admit anyone if they've been ragged on by admin too many times. Mostly, however, I think it is a personality issue.

As for all the tales of pain and suffering and missed diagnoses and inappropriate treatment, etc., there is inadequate provision of healthcare in this nation. ERs across the country are forced to attempt to provide care for the under and uninsured, in addition to the emergent surprises. The demand is simply too great for us to meet. There are many times I feel terrible about making someone in pain wait - but I have no open bed to put them in. Every day people leave in disgust because of the wait. Pts are angry to the point of boiling over. Guess upon whom that anger is vented. This is one of the most unpleasant aspects of ER nursing: trying to placate enraged pts while explaining that the entire evaluation in the ER will also require hours. Fun, fun, fun! No one seems able to accept that someone else could be experiencing a more severe emergency than their own. I really hate trying to explain that to pts! (I'm going to move you into the hallway because I've got a CP coming in. Sorry, sorry, sorry). The missed diagnoses stem in part from this situation, and yes, some people are rushed out a bit prematurely - but heck! There are Chest painers waiting in the waiting room and though we'd like to close to EMS, all hospitals are on round robin and a GSW is on the way.

These problems need to be addressed on a fundamental level, even a cultural level. The answer does not lie with the ER but with the way medical care is funded and provided. It also lies with the willingness of nurses to stand together to fight for what we know is right on every floor.

[rjbryan]

I just reread my first post and it sounds bitter. Sorry.

Some days at work, I do make a difference.

Some days, I put toe tags on children.

Today was one of those.

[Dinith88]

Unfortunately, at my place of employment it's a quasi-hobby of floor nurses to ridicule ER nurses....(c'mon..you all know who you are!)

Of course this is misguided behavior....but some of the ER nurses i deal with deserve it! (for being rude, inconciderate, dumb, ...among other things...did i say dumb?)

Sure, you can't judge an entire department by the actions of a few....but...

I'm convinced a number of our ER nurses got into it for the wrong reasons (Awesome!..I get to work w/George Clooney..and sexy fire-police-ambulance-men...and live a soap opera-life full of tragedy and romance...and hot babes!!...YES!!)....

We can blame NBC for this i suppose....

anyway...a pompus nurse, stupid nurse, rude nurse, lazy nurse.. be he/she an ER nurse, ICU nurse, LTC, whatever...is worthy of ridicule(or to be laughed at) in my book.

(as an aside, if you REALLY want to work in a glamerous environment, full of well rounded,intelligent nurses with perfect attitudes and friendly demeanors..not to mention sexy-soap-opera-story-lines....come down to ICU! The waters perfect...c'mon in!)

[rjbryan]

AH. I see.

One of OUR favorite hobbies to to ttrash the dumb, pompous, anal-retentive (...did I say DUMB out loud?) ICU nurses. Actually, what we do is have them float to the ER for a day so we can send them back whimpering to the ICU where they belong and their idea of a huge patient load is 3 paitents.

("No toots, it never occured to me to get the patients dietary preferences. I was relaxing doing CPR and defibing his Vfib when he came in.")

Yeah. I look JUST like Clooney. And thats why we ALL became ER nurses, for the sex and glamour and I look SO FINE in blood splattered, puke splattered scrubs.

Buy a vowel, Vanna.

[fab4fan]

ribyan: LOL!

[Dinith88]

Whao now dude! Apparently you didnt read my post completely...

it was a slam at people who make rude comments about nurses just because they're from a particular department...( like you just did!)(with a little bash at a few nurses i know personally)..

Thats OK though...as you were probably too busy sticking your fingers into bullet holes and defibing peoples' brains out.

Sheesh...dont be so defensive.

And, as an aside..let me tell you about MY experiences being floated to ER...

-80% of ER patients are 'office' cases who're using the ED as primary care...

-15% have boo-boo's that need a stitch or a cast and some ibuprofen...and go home.

And of the other 5% (who actually need admitted)...most arent 'critically'-ill.

Oh, and as for the people who come through the ED and need CPR, defibrillation, whatever...MOST are already dead. The staff just goes through the motions...then call it. (ER nurses sometimes remind me of that kid from the 6th-sense "I see dead people...all the time...")...

And as for the trauma cases...There're about 50 people from every department waiting to 'do their thing' before the rig even arrives....makes any single nurse's job ALOT easier...not to mention the Doc's are all there and are making all the calls...nurses in these cases are 'doers' rather than 'thinkers'...

...although the nurses do get spatters of blood on their scrubs....which reminds me: You should change your scrubs if you're constantly walking around with blood, poop, and puke on them.

In my opinion the HARDEST thing about ER is dealing with drunks, psych-pt's, and neurotic mothers trying to 'protect' their kids...the other 'bloody stuff' is hard to see at first....but the 'team' takes over...making any individual nurses job a little less difficult.

(your point about an ICU nurse asking about a persons dietary preference is well put. that nurse was a goof.)

[rjbryan]

Nope. Not defensive. Just tired of defending my position as an ER nurse. There's a difference.

Well...that's why I chose ER. Your percentages are a little off, but true in most cases...long periods of sheer boredom being an office nurse broken up by moments of sheer terror and the adrenaline rush....and I think that's why I chose ER, to be honest...I'm an adrenaline junkie.

Most of the complainers on here had cases better served by a PMD, and then *****ed because they didnt get quick, efficient service. Gee, you present with symptoms to a doc that doesnt know you or your Hx and in 15 minutes he is supposed to Dx you? Yup sure. And the ER is suposed to be an ENT, OB-GYN, PMD, opthamologist, nephroplogist, psychiatirst and whatever you have expert? The reason you got 15 minutes is all your friends and neighbors were in at the same time because amazingly, the sore throat, earache and whatever they had all day is now an emergency at 10pm. If you DO come in with an emergency, THATS what we specialize in. And there's no where near 50 people waiting to do their thing. I usually end up drawing blood off off IV lines to speed things up, bagging and intubating you, and holding your hand.

I'm tired, sometimes defensive, and sometimes a bit bitter, yup, I suppose. I dont have TIME to change scrubs, sweetie.

I learned a lesson over 30 years ago, as a medic in Vietnam:

I can't save them all.

I save some.

I'm at peace with that.

Go on and trash ER. I'll be there over top you the next time you or yours come in with an emergency and doing the best I can. Just forgive me if I defend myself sometimes when attacked. I am proud of what I do and what my co-workers do.

Actually, proud of nursing and being an RN. Even if we eat our young.

Last post. Promise

Randy

[2001Flushes]

Hi. I'll introduce myself more in the general discussion forum but thought I'd share personal ER horror story here...

A few years ago I had a rather significant MOI including about a 30 ft fall onto some ice according to witnesses. I had been knocked out at least for a few seconds. Came to, unable to breath at first (talk about wind being knocked outta ya- twas frightening not being able to catch my own breath). Instead of call an ambulance (had insurance but was afraid of bill, etc. etc.) my roommate helped me into the car and drove me to a local L2 trauma center in a moderate size city we lived in at the time.

Well, the triage nurse thought nothing of it. We didn't have to wait too terribly long as it was a slow night there. a slow ER one night.. imagine that!. They took a couple x-ray's at the ER revealing at least one very obvious vertebral wedge fracture. The incompetant ER f### doc on duty gave 1 mg of Morphine and sent me home with roommate with instructions for "BACK STRAIN" Uhhhhhhhhhhhhhh okay! My roommate helped me home, me barely walking mind you, and assisted me into to be where I layed in agonizing excruciating pain from missed injuries, etc.

Two days later I was literally paining me to even breathe. My roommate came in to check on me and I just felt I was in trouble with that whole impending doom feeling. He took me back. The dumb triage nurse (i'm being too polite here) triaged me to the fast track room where I waited in excess of 6 hours. In fact, I do remember seeing a kid triaged as priority for conjunctivitis!!!!

To make a really long story short, it turns out the triage nurse wrote me down as "fell out of bed"... hmmm what ever happened to LISTENING to the patient.. I told her what happened and that I could get out of bed well. Well, fortunately a very competant doc was on duty that night, did a CT... then eventually an MRI revealing 5 fractured vertebrea, not including the wedged one, several broke ribs, cracked sternum. Woke up on a vent a few days later due to resp. distress. Some of it after going in is a blur, but after that, even now my view on ER's is very dim.

[LilgirlRN, ADN, RN]

It's all about attitude, that's whats wrong with the ER (update, we're not just a room anymore, we're a department now.) I just started working in a different ED, one where the NM has the same thought process as I do and it has made a huge difference to me. I was taught in nursing school to treat each patient as if they were my family member, and I try to do that. Could we also try to think of all of our coworkers as family members? We all have family members who are not quite right, who are addicted to something, who think they hung the moon etc. Our hospital families are the same way, they are human beings. Part of the human condition is making mistakes, unfortunately some of th e people who make mistakes are in the postion where mistakes can hurt other people, perhaps even take their life. This is a quite unfortunate situation, what do we do about it? Does criticizing ER nurses change anything at your hospital? Probably just makes people mad or their feelings get hurt. How about meeting in the middle to solve the problem, it's a shared problem, should have a shared answer. I think we can all agree that we are ALL overworked, not just the ED nurse, or the floor nurse, ALL nurses have more paperwork than ever and less time to spend giving patient care. Kudos to you guys on the floors and in the ICU's, IMO you have it much harder than I do. For the most part we treat 'em and street 'em, whoever said that 80 percent of our census in the ED could be seen in their MD's office (if they had one) was right. If I have a patient who is being admitted and I can't seem to do anything to please them, usually it's the family who I can't please, they're coming to see you, they don't stay with me for hours and hours (usually). I don't know how you guys do it, deal with them for days and days. I am thankful that I love the ED, cause I could NOT do your job. If I had to do your job I would have stopped being a nurse long ago. I think I have the easiest job in the house. You probably think mine is harder because it's mostly chaos. I hear "how do you stand working in the emergency room?" from nurses all the time, easy... I'm lazy. Now before you other ED nurses have a fit, don't think I don't think you work hard cause I'm right there in the trenches with you, I know you do. Time to stop the feuding between departments and do what we were taught to do,take care of our patients, and try to care for ourselves at the same time. Here's one for you.... triaged a 6 year old last night, mom found him having a seizure with no hx of same, dad says he feels really hot to me. Temp ORALLY is 106.3, ONE HUNDRED and SIX point THREE!!! I stopped triaging him and took him into the ED immediately. The nurse that had the room where I put him got mad cause I didn't finish triaging him. They did a CBC, gave him some Motrin and sent him home?!!! Yeah some things are dumb in the ED.

[bluesky, BSN, RN]

In my life, I have been to ERs for many, many different complaints including, 2nd degree full thickness burns, dog attack, seizures (from epilepsy) and others. I have always had great and competent care from the nurses. Period. I love 'em so much I went and married one and hope to become one myself soon! So y'all keep on doing a great job, I am so proud of you.