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

  1. 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!!! *****!

    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.




    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...
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  2. 38 Comments

  3. by   canoehead
    Initially I thought you worked in the ER, but on the floor all you can do is assess carefully and create a paper trail. By the way, social admits happen all the time at our hospital too, especially from LTC on a Fri night when they get tired of dealing with someone they just refuse to take them back. Apparently the hospital is the only place that can't say no, legally.
  4. by   fab4fan
    The guy with abd. pain/N/V/D could have been admitted to observe for things that may have shown up hours later. And if the pt. was feeling really sick, would have had problems caring for himself, and had no one willing to help him at home, then you have an unsafe discharge situation. It does seem ridiculous, but what if he went home, was alone, tried to get up, was dizzy, fell, hit his head, had a bleed...do you see where I am going with this? It does seem dumb, I agree.

    The other pt., what can you say. Things do get overlooked, and if she came in saying she just hit her head, things in the ED were busy...I can see how that might have happened (not that it makes it right). Also, I can't tell you how many times an alert/oriented pt. will tell us one thing, then tell the doc another, then the doc comes back and says, "Why didn't you tell me about XYZ?"

    Every department misses things; we're human. It's hard to believe that everyone there is a goofball, but, I don't work there, so I don't know your situation. Did you fill out an incident report on the elderly woman? Have you discussed your concerns with your NM?

    Also, the ED does not decide admissions; that's up to the attending.

    Sorry if I sound a little testy, but I do get tired of the ED being blamed for everyone's woes. Most of us are trying to do the best we can, and we don't have the luxury of telling an ambulance to wait to bring a pt. in because we're busy; often we are also holding pts that should have been admitted, so we're trying to do floor nursing and ED nursing at the same time. As far as assessment, if a pt comes in c/o a sore throat, I don't do a head to toe assessment...I don't know any ED nurse who does. You do what is pertinent; if we did head to toe assessments on everyone who came in, we'd still be working on pts. from 4y ago.

    Sorry you've had such bad experiences.
    Last edit by fab4fan on Jan 7, '03
  5. by   Dr. Kate
    Sometimes it just seems that everyone takes stupid pills and works hard at being dumber than dirt.
    Out here we can always blame the santa ana winds. But the phase of the moon, tilt of the earth, sunspots, they all work.

    Poor assessment in the ER brings home why it is essential for every patient to be assessed by an RN on admission. People are human and things get missed. And there is always the whole raft of things the patient just happens not to share with anyone.
  6. by   l.rae
    Originally posted by fab4fan


    Also, the ED does not decide admissions; that's up to the attending.

    Sorry if I sound a little testy, but I do get tired of the ED being blamed for everyone's woes. Most of us are trying to do the best we can, and we don't have the luxury of telling an ambulance to wait to bring a pt. in because we're busy; often we are also holding pts that should have been admitted, so we're trying to do floor nursing and ED nursing at the same time. As far as assessment, if a pt comes in c/o a sore throat, I don't do a head to toe assessment...I don't know any ED nurse who does. You do what is pertinent; if we did head to toe assessments on everyone who came in, we'd still be working on pts. from 4y ago.

    Sorry you've had such bad experiences.



    a big AMEN from me fab4!....l will conceed that we get some real screwball admits in our ER too.....stupid residents, not the nurses fault. Floor nurses have a hard time understanding that ER assessments are focused assessments....if a A&Ox3 pt says l have no other pain/injuries, l generally take their word for it..... got a broken toe?....if pt is pink and eupnic...l don't get a sat and listen to breath sounds...get the picture?....when squads are coming in left and right with critical pts, head to toes are not apprropriate for every ER pt
  7. by   Scavenger'sWife
    A Huge Thank You to you guys


    I had a bad day and I needed to vent..........

    You guys were correct. I will now accept my twenty lashes with a tourniquet...

    This is why I love this BB.....You screwed my head back on straight, but did NOT yell at me personally.

    I will now revert to my former sweet, loving self...:chuckle
  8. by   DIPLOMATICRN4HIRE
    Honey we would never be so generous to beat you with the IV tourniquet lol Its the IV tubing lol
    It was a bad day and yes there are times where you must inhale and exhale and wonder what kind of day the person that just sent you that patient had. Its hard when I worked ER , there were times you prayed that if it would just slow down one minute you could do all that could be done, but it never does.
    Vent away it allows you to let go of that days crap and you will have a brighter tomorrow. Vent Girl Vent.
    Hugs to ya for being a great nurse
    Zoe
  9. by   Sally_ICURN
    My daughter, who's an asthmatic, walks into a Kaiser ED. I parked the car while her boyfriend went in with her. She's audibly gasping for air and in panic mode because she can't breathe. Her inhaler isn't doing crap. When I walked in, to my utter and complete shock, there she and her boyfriend was sitting in the waiting area, both with looks of complete fear in their faces! When I asked what the hell was going on, the boyfriend told me that the triage area took her vitals and then they were told to go and have a seat and to let them know if it got any worse!?!?!?!?!?!

    WTFFittyFF? And that's EXACTLY what I said to the triage person. Of course after that, they immediately took her back.

    Don't get me wrong, I'm a nurse, I totally feel for my overworked, stressed out, unappreciated, underpaid, disrespected, etc., etc., colleagues out there, but this was just plain negligence and unbelievable stupidity on the part of the triage person!!!!!!!!!!
    Last edit by Sally_ICURN on Jan 10, '03
  10. by   traumaRUs
    I'm an ER charge nurse in level one trauma center who is sometimes so overwhelmed that yes (unfortunately) people have to wait. Not people with resp distress of course. Whatever happened to across the room assessment???

    In our large hospital - we hold pts out the wazzoo sometimes - last night we had five ICU admits I had to keep for up to five hours before bed could be cleared.

    And...I hate to say it but its gonna get worse.
  11. by   Flo1216
    I am doing my ER rotation right now and yesterday I was in triage. A 45 year old woman came in and was complaining of sudden, severe headache, right- sided weakness and numbness and tingling in the right side. Her vitals were all normal but I put her as emergent based on what she told me. She was also crying. The RN who I was assigned to disagreed with my putting her as emergent, because her vitals were normal. But she(the pt) also has a hx of HTN and had taken her BP med that morning. The nurse has about 20 years experience on me, so of course I am now second-guessing myself. If she had just complained of the headache and her vitals were normal, I may have thought migraine and downgraded her from emergent but based on her other symptoms I thought STROKE or ANEURYSM and put her as emergent. I figure she could always be downgraded from emergent later but if I had put her in fast track and she threw a clot or something, I don't think I would be able to live with myself. The nurse felt this was a woman trying to get out of work. I thought if that were the case, she was going to extremes, you know? I think if I had to do it again, I probably would have made the same decision. I would rather be accused of overreacting rather than be accused of being negligent. What would YOU have done?
    Last edit by Flo1216 on Jan 10, '03
  12. by   emily_mom
    Flo,
    You neglected to tell us the outcome.

    Kristy
  13. by   Flo1216
    Last summer I stumbled into the ER with SEVERE abdominal pain. I was greeted by the registrar who rolled her eyes and me and told the security guard he shouldn't have opened the door, as if I were bothering her. She then took my insurance info and sent me into the waiting room for an hour where I ran back and forth to the bathroom evacuating from both ends. I almost passed out. I never saw a nurse or anything or even had my vitals taken. Also I was the only one in the waiting room.I could have collapsed and no one would have known. I don't know where the securty guard went. Once the nurse came in and got me(an hour later), everything was fine and I was treated appropriately. My question is, why is the registrar my initial encounter? In the ER where I work, pts sign in and then the nurse calls them , does vitals , etc. Is this common practice? What if I had a ruptured appendix or something and based on the registrar's asessment I am sent to the waiting room to die? It was weird.
  14. by   Flo1216
    Emily, I don't know the outcome because I was in triage and it was insane. I asked about her as soon as I got the chance and I think they had taken her up to catscan. I don't know what happened after that. I know when I left she wasn't there, so I don't know if she was admitted or what. I mean, for her sake I hope it was nothing but I just feel more comfortable erring on the side of caution. My best friend's father went to the ER 3X complaining of chest pain and 3 times they sent him home. I don't know what kind of tests he had(I wish I did) but they kept telling him he had heartburn and gave me an antacid. Well, after the 3rd time, he went home and had a massive MI. Luckily he survived and now has an implantable defibrillator.

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