Advice for new EM nurses

[MD married to RN]

I wrote this in response to a post by a nurse coming to the ED with no EM experience and thought I would share it generally:

Welcome to our crazy world.

When I have new grads or even new nurses without EM experience, I share a set of 6 rote lectures. They are about the following.

1. Intubation: Why? a. low O2 b. high CO2 c. protect airway--that's it. What do you as the RN need to have ready MSMAIDS: Monitor, Suction, Machine (BVM, RT, or vent), Airways supplies (Glidescope, Mac, Miller, tube 7.0 7.5 8.0), IV, Drugs (sedation and paralytic), stylet.

2. ACS: What causes it? (know your patho phys) What do we do? Asa, O2, NTG, TNK. Lovenox, B-blocker, Benzo, Opiate, admit, transfer.

3. DKA: What causes it? (review the patho phys) What do we do? Find/treat the cause, fluids, insulin (slowly/carefully), obsessively follow the fingersticks, labs, and most important how the patient looks.

4. PE: It's been called the great masquerader for a reason. (review the patho phys) Maintain a high level of suspicion for SOB, CP, hypoxia, anxiety. Notice EKG changes (rare S1Q3T3), RR, and sats. These patients can die fast. What do we do? O2, Lytics, Heparin, Lovenox, new fangled oral anticoags, then dispo.

5. CHF: (review the patho phys). Yes there are many different types of CHF but focus on lungs wet patient not breathe so good. Goal get fluids off lungs and into urinal/foley bag. Give O2, nitrates then Lasix. Remember loop diuretics do little good when the vessels are empty.

6. Protocols: EM is being flooded with algorithms (sadly). First, learn 'if you are wrong in the DX.' the plan fails. Have seen tachy dyspneic patient aggressively treated for sepsis only to later realize they had a PE or CHF. That said, learn what order sets are used in your ED especially for sepsis and stroke. Your docs are being pushed to use order sets, as the RN you need to know what orders you will see/do over and over again.

Final tips:

Unless the doc involved is an @&&, they will generally appreciate OMI: oxygen, monitor, IV and blood draw (for sick patients not sore throats).

After each of your first say 20 shifts, think of a patient you cared for that day and read about their dx when you get home. Takes 10 minutes but really locks in the learning.

Look at your colleagues. Who does well? Watch them, emulate them, talk to them.

Right now, COVID sucks, but this too shall pass.

“It may seem difficult at first but everything is difficult at first.” Miyamoto Musashi

[Evolving_Nurse, ADN]

This was extremely helpful!

[Raven Sierra, BSN, RN]

Very helpful, even if you aren't new to the ED craziness. ? 

Also, I have to applaud your use of "new fangled." ?

[iWish, ADN, RN]

Thank you for the advice! Steady watching for more tips and tricks as I start my new journey in the ED. 

[skylark, BSN, RN]

Old timer here, but just wanted to say that is a great "cheat sheet" for newbies who are overwhelmed by the situations they find themselves in.

Thank you for putting that all together, I think I might steal it!

[emtb2rn, BSN, RN, EMT-B]

Great post. Should be a sticky. And I can’t overemphasize the importance of using order sets to get things rolling. Get those labs processing. Also be sure to get a previous ekg for the chest pain pt (if available). New lbbb? Uh oh. 

Also pick the brains of your docs. Most love to teach and the more you understand how the physicians think, the better you will become as an er nurse. And it will all help when you take the cen exam, aka “what’s the doc gonna do?”

And most important, have fun