Am I ill-suited to the ED?

Emergent, RN · Nov 15, 2016

If you can let go of your desire to address everything, you can adapt.

There's nothing stopping you from quickly redressing a wound, in the ED we nurses don't wait for a Dr order to place a dressing, we just use common sense.

Pts will come in saying they have a headache, then they want a pimple looked at, their sore knee x-rayed, and a whole bunch of other complaints they'll pile one. But, sometimes a pt comes in for a more minor problem and when you get their vitals their HR is 140, you put them on the monitor and find out they have new onset a-fib. Then, that becomes your focus.

As far as psyche patients, ER can only do so much, we can't fix a broken system. Most ER nurses are on the cynical side and many psych pts are manipulative. They certainly aren't my favorite pts. If you can put up with the attitudes of coworkers and not expect miracles, you can do ok.

Boomer MS, RN · Nov 15, 2016

***Please do not move to student nurse forum. I want advice from nurses*****
I chose to have my leadership (capstone, senior practicum) clinical in the emergency room. I have a strong interest in psychiatry, and I was aware that many psych patients wind up in the emergency room. This is where I would like to make a difference.
I felt the ED was a good place for me because I enjoy a fast pace, I like to see many different people, I am okay with trauma and emotionally charged situations, I keep a cool head under pressure.
For the most part, I enjoyed it. I handled two codes and one death very well. I also really admired the charge nurse and I think the hospital is a good one.
However, I became very frustrated with a few things. I would like your opinion on whether these things happened because I was sometimes paired with a bad nurse (and I think I was) or whether my difficulty means I am not right for the ED, or whether it is something else. Your insight, whatever it may be.
In short, these are the things that happened that I struggle with:
1. A general and open disdain for psych patients.
2. A nurse told me to discharge a patient AMA even though the patient told me she had changed her mind and would like to stay. I refused to discharge her, by the way. That did not go well, but I survived. (this I attribute to the bad nurse). In addition to this, there was a general rush to clear the beds, especially during busy times.
3. I was told that we do not address problems that weren't "what the patient came in for." I also attribute this to the bad nurse, because the charts suggest that we do in fact do that, or we are supposed to.
4. A disregard for all things not immediately life threatening. For example, a physician removed an unconscious patient's leg dressings, then just threw the bandages back on without tape saying, "Ok, that's done." When I addressed this problem with the nurse and asked if I could redress the wounds she said "No, we don't do that. The ICU will take care of it." But the ICU did not have a bed for the patient for the rest of the 12 hour shift.
***On a side note, I am noticing most of my issues have to do with one nurse whom I feel gave poor care. ***
5. In general, I heard a lot of "we don't do that." in response to my questions about interventions.
One thing that I feel may make me ill suited to the ED in general is that I prefer to address all the issues with the patient., rather than just the emergent ones.
I would like to think about the future for the patient and not just their present needs. If a psych patient keeps bouncing to the ED, for example, I would like to help address this problem rather than send him out without referrals knowing he'll be back tomorrow. Is there any ED that works this way? Does this mean I should go to psych inpatient instead?
The social worker in charge of admitting or releasing crisis patients had so much disdain for the psych patients too. It was disheartening. The other social worker, the one not in charge of that, was wonderful.
Your comments are appreciated in advance.

Congratulations on how far you've come. If you have been able to get your senior practicum in an ED, you are very fortunate. At least I feel that way because I loved the ED.

I'm sorry you're feeling disheartened. You are there to learn, and you may also learn what you don't like and how you won't practice after you graduate. But the reality is that nursing and healthcare are difficult. Any specialty is difficult. Don't ever lose your compassion and empathy for others, but nurses are human and get worn down. Depending on the kind of ED, there are different cultures and policies. Some have the attitude of "Treat em and street em." With the department overwhelmed with incoming ambulances and the waiting room full, patients have to be moved. And some issues can wait. The ED is not for everyone because of its very nature, such as not addressing all the issues that patients have. Sometimes a nurse can spoil an experience for you, but you are there to absorb knowledge. It's OK to form opinions about what you see, and that will continue on throughout your career. You sound idealistic, and that is admirable. But you cannot save the world; you can only do your best and advocate for your patients. Perhaps sharing your thoughts and observations with your instructor(s) and classmates during conferences may offer some insight.

Experienced ED staff get frustrated because of the problems that plague healthcare today. The ED is the safety net for many who come back again and again through the revolving door. It may be that these issues would not suit you professionally, and that's fine. I think, however, that you need to give it more time. I found it helped to work with a good group, which included social workers. What I hear you saying is that there are all types of people in the work place. That is true anywhere. Keep an open mind and keep learning.

Best wishes.

TheCommuter, BSN, RN · Nov 16, 2016

***Please do not move to student nurse forum. I want advice from nurses*****

Okay...moved to the Emergency Nursing forum to elicit responses from ER nurses.

Lev, MSN, RN, NP · Nov 16, 2016

In short, these are the things that happened that I struggle with:
1. A general and open disdain for psych patients.

Some depends on the culture of the particular ER. However, psych patients (especially those in crisis) are often not very nice people to be around and interact with.

2. A nurse told me to discharge a patient AMA even though the patient told me she had changed her mind and would like to stay. I refused to discharge her, by the way. That did not go well, but I survived. (this I attribute to the bad nurse). In addition to this, there was a general rush to clear the beds, especially during busy times.

The proper thing to do in this situation would be to check and see if there was a discharge AMA order in the computer instead of arguing with the patient's nurse.

3. I was told that we do not address problems that weren't "what the patient came in for." I also attribute this to the bad nurse, because the charts suggest that we do in fact do that, or we are supposed to.

The emergency department addresses the patient's chief complaint and/or any emergent needs of the patient. If they want to see a dentist or a podiatrist - they need outpatient referral. Busy EDs don't have time to address every single need of every patient.

4. A disregard for all things not immediately life threatening. For example, a physician removed an unconscious patient's leg dressings, then just threw the bandages back on without tape saying, "Ok, that's done." When I addressed this problem with the nurse and asked if I could redress the wounds she said "No, we don't do that. The ICU will take care of it." But the ICU did not have a bed for the patient for the rest of the 12 hour shift.

I have seen the ED doctors I work with do the same thing. The ED is not focused on wound care. The focus of the ED is stabilizing patients. Once you stabilize your patients and have a moment to breathe, then you can take a couple minutes to do some wound care.

***On a side note, I am noticing most of my issues have to do with one nurse whom I feel gave poor care. ***

Maybe because you don't like her you are nitpicking, perhaps too harshly?

5. In general, I heard a lot of "we don't do that." in response to my questions about interventions.
One thing that I feel may make me ill suited to the ED in general is that I prefer to address all the issues with the patient., rather than just the emergent ones.

This can be overcome.

I would like to think about the future for the patient and not just their present needs. If a psych patient keeps bouncing to the ED, for example, I would like to help address this problem rather than send him out without referrals knowing he'll be back tomorrow. Is there any ED that works this way? Does this mean I should go to psych inpatient instead?

We have counselors in our ED for people who have used drugs or overdosed. Not all people want help despite our best efforts. Especially the homeless population. You will discover this with time. There are people who deal with this problem, but they are not ED nurses.

FolksBtrippin, BSN, RN · Nov 16, 2016

If you can let go of your desire to address everything, you can adapt.
There's nothing stopping you from quickly redressing a wound, in the ED we nurses don't wait for a Dr order to place a dressing, we just use common sense.
Pts will come in saying they have a headache, then they want a pimple looked at, their sore knee x-rayed, and a whole bunch of other complaints they'll pile one. But, sometimes a pt comes in for a more minor problem and when you get their vitals their HR is 140, you put them on the monitor and find out they have new onset a-fib. Then, that becomes your focus.
As far as psyche patients, ER can only do so much, we can't fix a broken system. Most ER nurses are on the cynical side and many psych pts are manipulative. They certainly aren't my favorite pts. If you can put up with the attitudes of coworkers and not expect miracles, you can do ok.

Thanks Emergent, I was hoping that you would respond. I think I may come back to the ER. It may not be a "not for me" but a "not for me right now". I am going to apply for med surg and psych. ER is not permanently off the table.

FolksBtrippin, BSN, RN · Nov 16, 2016

Boomer, thank you so much for your thoughtful reply.

I loved my clinical for the most part and even when I didn't, I learned so much. It really was a great privilege to be in the ER and especially at that particular hospital.

You are correct that I am idealistic. I am also quite ambitious about my ideals, so that leads to some disappointment here and there.

I did discuss many issues in post conference, my instructor was very helpful.

It was very good to hear your opinion. Thank you very much for your well wishes.

Congratulations on how far you've come. If you have been able to get your senior practicum in an ED, you are very fortunate. At least I feel that way because I loved the ED.
I'm sorry you're feeling disheartened. You are there to learn, and you may also learn what you don't like and how you won't practice after you graduate. But the reality is that nursing and healthcare are difficult. Any specialty is difficult. Don't ever lose your compassion and empathy for others, but nurses are human and get worn down. Depending on the kind of ED, there are different cultures and policies. Some have the attitude of "Treat em and street em." With the department overwhelmed with incoming ambulances and the waiting room full, patients have to be moved. And some issues can wait. The ED is not for everyone because of its very nature, such as not addressing all the issues that patients have. Sometimes a nurse can spoil an experience for you, but you are there to absorb knowledge. It's OK to form opinions about what you see, and that will continue on throughout your career. You sound idealistic, and that is admirable. But you cannot save the world; you can only do your best and advocate for your patients. Perhaps sharing your thoughts and observations with your instructor(s) and classmates during conferences may offer some insight.
Experienced ED staff get frustrated because of the problems that plague healthcare today. The ED is the safety net for many who come back again and again through the revolving door. It may be that these issues would not suit you professionally, and that's fine. I think, however, that you need to give it more time. I found it helped to work with a good group, which included social workers. What I hear you saying is that there are all types of people in the work place. That is true anywhere. Keep an open mind and keep learning.
Best wishes.

GCom24, ASN, RN · Nov 16, 2016

1. A general and open disdain for psych patients.

So, psych patients can be very testing. A general ED course involves, presentation, needs medical clearance, needs 1-2 liters of fluid to lower a CPK, then patient holds a bed for 10 or more hours (I have heard cases of 24-48 hours) before placement can be found in a psychiatric facility. This is frustrating because you have a patient who literally does not need any medical attention at this point, but is holding a bed, reducing throughput, all the while, they need to be fed, blanketed, toileted, etc. etc., also reducing your tech availability because they are on 1:1 observation. You add to all of this, the patient may be acutely psychotic, delusional, manic, suffering hallucinations, combative, wandering in the halls, calling out loudly (disturbing other patients), etc. This is just a frustrating situation that, right or wrong, leads to a stigma associated with psych patients in the ED. Of course, they deserve proper, compassionate, evidence-based care, but you will inevitably hear venting from staff.

2. A nurse told me to discharge a patient AMA even though the patient told me she had changed her mind and would like to stay. I refused to discharge her, by the way. That did not go well, but I survived. (this I attribute to the bad nurse). In addition to this, there was a general rush to clear the beds, especially during busy times.

To this, that RN in question does not have the scope to disposition patients. Consult the physician. It'd be useless to D/C her though, she can walk right back to triage and check right back in if she so pleases. So, why not let her stay.

3. I was told that we do not address problems that weren't "what the patient came in for." I also attribute this to the bad nurse, because the charts suggest that we do in fact do that, or we are supposed to.

This is a complicated, entirely subjective discussion in and of itself. As someone else stated, if someone comes in for toothache, but oh, it turns out you're in SVT, we might need to take care of that. Then of course, we do not just give ibuprofen/antibiotics and discharge. In the same vein though, if you come in for "toothache," but your back is hurting (as it has 15+ years) and you just lost your script for pain meds, oh and I think my toenail is ingrown, do you guys cut those? And can I get sandwich and ginger ale too? This (to me) is the case of "Mm, no, you came here for a toothache. This is not your primary care provider, we cannot manage chronic pain here, our provider is not a podiatrist, and food is for admitted patients." This just taps on over-reliance on the ED, lack of access to primary care, access to insurance, etc. But we just can't treat all of the things all of the time, it's not what we're here for. Sometimes you just have to tell us what hurts the most and we'll go with that.

4. A disregard for all things not immediately life threatening. For example, a physician removed an unconscious patient's leg dressings, then just threw the bandages back on without tape saying, "Ok, that's done." When I addressed this problem with the nurse and asked if I could redress the wounds she said "No, we don't do that. The ICU will take care of it." But the ICU did not have a bed for the patient for the rest of the 12 hour shift.

There's a couple comments, I would make on this. First and foremost, hospital geography does not have to define care. Now, I can't imagine having the time or supplies to do any full on debridement, wet-to-dry, hypo-silver-aquagel-P90X wound dressing in the ED, but come on, there is nothing wrong with letting a student nurse (or doing it yourself) throw some kerlix and gauze on a leg. In this case, that nurse needs to get over him or herself. That legs going to take 30 seconds or a minute to do some basic first-aid on. What next, we don't put patients on the bed pan, ICU can take care of that. Good luck explaining why you transported a patient to the ICU in pile of stool. It's a matter of time and resource management. No, we don't always have time to get cups of water, find extra pillows, but I have seen on more than one occassion the "THIS IS THE ER, AIN'T NOBODY GOT TIME FOR THAT" mentality used to cop out of providing some basic care when it would have been perfectly possible to do.

***On a side note, I am noticing most of my issues have to do with one nurse whom I feel gave poor care. ***

5. In general, I heard a lot of "we don't do that." in response to my questions about interventions

See number 4, I think lol.

In summary, I think all of your internal frustration and confusion is most definitely temporary and "fixable," not to say that you are broken. Emergency nursing is most definitely 100% different from any other area. It takes a certain mindset, a certain focus, a really different model of care than the traditional "nursing model" that you might find in other areas. I think school puts you in a very med-surg, very Nightingale-esque mindset of nursing. You want to fix the whole person, body, mind and soul. Emergency medicine/nursing flips the entire healthcare dynamic upside down. When you go to a PCP with cough, congestion. They're going to say, "Okay this is most likely acute sinusitis, doesn't really need antibiotics, but I'm going to get a crap review on Yelp if I don't prescribe anything so, here's a script for penicillin, get well soon." So emergency medicine flips this, and says, "Okay SOB, cough, congestion. I need to rule out pneumonia, acute bronchitis, CHF exacerbation, etc." So run some basic labs, get a CXR, order a DuoNeb in the meantime. When that all comes back negative, okay you're not dying, here's a script for abx, discharge.

Anyway, all of that is to say, emergency nursing requires you to take everything you learned in school and adapt it, refine it, flip it upside down to look for acute signs and symptoms, changes, recognize and response to them. It will a good year there to do this, and then you'll continue doing that, learning and changing it, growing for the rest of your career.

I do not think an ill experience with one not-so-super preceptor defines you as a poor candidate for ER. If it's in your blood, go for it.

FolksBtrippin, BSN, RN · Nov 16, 2016

1. A general and open disdain for psych patients.
So, psych patients can be very testing. A general ED course involves, presentation, needs medical clearance, needs 1-2 liters of fluid to lower a CPK, then patient holds a bed for 10 or more hours (I have heard cases of 24-48 hours) before placement can be found in a psychiatric facility. This is frustrating because you have a patient who literally does not need any medical attention at this point, but is holding a bed, reducing throughput, all the while, they need to be fed, blanketed, toileted, etc. etc., also reducing your tech availability because they are on 1:1 observation. You add to all of this, the patient may be acutely psychotic, delusional, manic, suffering hallucinations, combative, wandering in the halls, calling out loudly (disturbing other patients), etc. This is just a frustrating situation that, right or wrong, leads to a stigma associated with psych patients in the ED. Of course, they deserve proper, compassionate, evidence-based care, but you will inevitably hear venting from staff.
2. A nurse told me to discharge a patient AMA even though the patient told me she had changed her mind and would like to stay. I refused to discharge her, by the way. That did not go well, but I survived. (this I attribute to the bad nurse). In addition to this, there was a general rush to clear the beds, especially during busy times.

To this, that RN in question does not have the scope to disposition patients. Consult the physician. It'd be useless to D/C her though, she can walk right back to triage and check right back in if she so pleases. So, why not let her stay.
3. I was told that we do not address problems that weren't "what the patient came in for." I also attribute this to the bad nurse, because the charts suggest that we do in fact do that, or we are supposed to.

This is a complicated, entirely subjective discussion in and of itself. As someone else stated, if someone comes in for toothache, but oh, it turns out you're in SVT, we might need to take care of that. Then of course, we do not just give ibuprofen/antibiotics and discharge. In the same vein though, if you come in for "toothache," but your back is hurting (as it has 15+ years) and you just lost your script for pain meds, oh and I think my toenail is ingrown, do you guys cut those? And can I get sandwich and ginger ale too? This (to me) is the case of "Mm, no, you came here for a toothache. This is not your primary care provider, we cannot manage chronic pain here, our provider is not a podiatrist, and food is for admitted patients." This just taps on over-reliance on the ED, lack of access to primary care, access to insurance, etc. But we just can't treat all of the things all of the time, it's not what we're here for. Sometimes you just have to tell us what hurts the most and we'll go with that.
4. A disregard for all things not immediately life threatening. For example, a physician removed an unconscious patient's leg dressings, then just threw the bandages back on without tape saying, "Ok, that's done." When I addressed this problem with the nurse and asked if I could redress the wounds she said "No, we don't do that. The ICU will take care of it." But the ICU did not have a bed for the patient for the rest of the 12 hour shift.
There's a couple comments, I would make on this. First and foremost, hospital geography does not have to define care. Now, I can't imagine having the time or supplies to do any full on debridement, wet-to-dry, hypo-silver-aquagel-P90X wound dressing in the ED, but come on, there is nothing wrong with letting a student nurse (or doing it yourself) throw some kerlix and gauze on a leg. In this case, that nurse needs to get over him or herself. That legs going to take 30 seconds or a minute to do some basic first-aid on. What next, we don't put patients on the bed pan, ICU can take care of that. Good luck explaining why you transported a patient to the ICU in pile of stool. It's a matter of time and resource management. No, we don't always have time to get cups of water, find extra pillows, but I have seen on more than one occassion the "THIS IS THE ER, AIN'T NOBODY GOT TIME FOR THAT" mentality used to cop out of providing some basic care when it would have been perfectly possible to do.
***On a side note, I am noticing most of my issues have to do with one nurse whom I feel gave poor care. ***
5. In general, I heard a lot of "we don't do that." in response to my questions about interventions
See number 4, I think lol.
In summary, I think all of your internal frustration and confusion is most definitely temporary and "fixable," not to say that you are broken. Emergency nursing is most definitely 100% different from any other area. It takes a certain mindset, a certain focus, a really different model of care than the traditional "nursing model" that you might find in other areas. I think school puts you in a very med-surg, very Nightingale-esque mindset of nursing. You want to fix the whole person, body, mind and soul. Emergency medicine/nursing flips the entire healthcare dynamic upside down. When you go to a PCP with cough, congestion. They're going to say, "Okay this is most likely acute sinusitis, doesn't really need antibiotics, but I'm going to get a crap review on Yelp if I don't prescribe anything so, here's a script for penicillin, get well soon." So emergency medicine flips this, and says, "Okay SOB, cough, congestion. I need to rule out pneumonia, acute bronchitis, CHF exacerbation, etc." So run some basic labs, get a CXR, order a DuoNeb in the meantime. When that all comes back negative, okay you're not dying, here's a script for abx, discharge.
Anyway, all of that is to say, emergency nursing requires you to take everything you learned in school and adapt it, refine it, flip it upside down to look for acute signs and symptoms, changes, recognize and response to them. It will a good year there to do this, and then you'll continue doing that, learning and changing it, growing for the rest of your career.
I do not think an ill experience with one not-so-super preceptor defines you as a poor candidate for ER. If it's in your blood, go for it.

Thank you so much. This really helps. Some of the difficulty I have had is in determining which of the differences I noticed from what I was taught in school are necessary adaptations for the ED and which are just non-ideal practice.

FolksBtrippin, BSN, RN · Nov 16, 2016

I want to explain what happened with the whole AMA discharge problem better. I was vague because I would like to stay anonymous, but I don't think I was clear enough in explaining.

The nurse wasn't asking me to discharge the patient as in make the decision that the patient should leave, but instead to go over the discharge instructions, and get the discharge paperwork signed by the patient. In this ED this nursing task is called "discharging the patient" although it is a different thing altogether than what the physician does. The nurse handed me the discharge paperwork and told me to take it to the patient to be signed.

In nursing school it was strongly impressed upon us that a discharge needs to include education on each diagnosis and treatment with the "teach back" method of ensuring that the patient understood the directions. The importance of this has been stressed again and again.

The paperwork stated that the patient was leaving against medical advice. I went over that with the patient, and she said that she did not want to leave against medical advice. She was shocked and scared that the papers said she had been advised to stay for observation. She was leaving because she "thought everything was ok." I told her that I would tell the nurse.

So I returned to the nurse and explained that the patient did not seem to understand that she was leaving against medical advice. She didn't want to do that. The nurse said, "She's crazy. Just tell her to sign it anyway." I told the nurse that I would not do that. The nurse was miffed, and took the papers and did it herself.

I don't regret how I handled this situation.

As far as not liking the nurse, I actually liked her personality. I didn't dislike her, but she wasn't a great teacher for me. She was new to the ED, and she was flustered a lot of the time and she continually asked me to do things that were contrary to what I was taught without explaining why it was important to break the rule this time.

caddywompus · Nov 16, 2016

In a perfect world...

Where to start? As others have said, ED is very different from other areas of nursing, and each ED has its own culture and flow. For many nurses, coming to the ED can be a little shocking or eye-opening. All of the "fluff and puff" goes to the wayside. There just isn't time. Even if there is time now, in ten minutes that can all change. I'm not saying we are uncaring. You just have to prioritize your care. Then re-prioritize. Then start over again.

A few things- the disdain for psych patients. It's not disdain, really. You'll find if you work ED, psych isn't always psych. Sometimes it's "I don't want to go to jail, so I'm going to say I'm suicidal." Or "I got evicted and need a place to crash. Better go to the ER." With that said, many are truly psych patients and there's no doubt the system could be better. Psych patients, like all patients are as varied as they come. Some are manipulative. Some are just plain dangerous. And some are just sad. You said, "I would like to think about the future for the patient and not just their present needs." You have to remember, the ED is focused on present needs. ED is meant to stabilize. Stabilize and Move.

A disregard for all things not life-threatening- that is why it's called EMERGENCY DEPARTMENT. Sorry, not at all trying to sound harsh. Assessments are quick and focused. They have to be to ensure there is a room and staff available for the patient brought in not breathing or post-trauma. I don't mean that it is only important if it's life threatening, just that again, it's priorities first. Example, a chief complaint of "Elbow pain x 3 months" is lower priority than "Elbow pain and limited ROM post-fall at 0300." It's not that the 3 month elbow pain doesn't matter. It's just obviously not acute. If often makes us wonder "why now" is it an ED visit? The second CC gives us something to work with, something to rule out.

We don't do that- Not sure about this one. No doubt it can and has been used to avoid work. Human nature being what it is. I can't think of any examples. I think we do what we can in the limited time we have with our patients.

ED is awesome if you can let go of the little things, prioritize, and adapt. You'll find you have to be quite direct to get things done. I don't mean rude. Just direct. Direct with co-workers, patients, and patient's families. Some will test you. Confidence shows. Speed with empathy. We have to move the patients or the gears come to a grinding halt.

Remember this, the ED (and maybe L&D?) is the only department that can't say no to another patient. The doors are always open, regardless of staffing, icy weather, and full-moons.

I wouldn't want it any other way!

GCom24, ASN, RN · Nov 16, 2016

I want to explain what happened with the whole AMA discharge problem better. I was vague because I would like to stay anonymous, but I don't think I was clear enough in explaining. . .

So, in this specific situation. I will guarantee that the doctor. "Hey, you have xyz, I'd like to keep you at least over night to make sure your xyz lab stays stable, your BP is stable, etc. But everything looks fairly normal right now, but you had chest pain, and it's just in the best interest to hang out with us." You get the idea.

Patient doesn't want to stay, obviously, financial reason, other commitments in life, etc. whatever the reason, just who really wants to stay, amirite?

Doc says "All right, well if you want to go, you can go." /leavesroom

You go in, "All right so the doctor has recommended to stay, to make sure your troponin doesn't rise, you don't have another episode, just to make sure everything is chill. If you leave, you're accepting responsibility that if you go outside and go into cardiac arrest and hit a light pole, we are not liable."

Patient says the doctor said I was fine, no nevermind, I want to stay! Oh my!

Moral of the story, that patient has the right to accept, decline, refuse treatment, and the right to change her mind. It's her dang-blasted life, sheesh.

You by every stretch were in the right. Don't sweat it. You advocated for your patient's decision. Period. Game. Touchdown. Super bowl. Home run. Checkmate. So on that one, that nurse can squash all the noise.

Some of the difficulty I have had is in determining which of the differences I noticed from what I was taught in school are necessary adaptations for the ED and which are just non-ideal practice.

This. Hm, first let me premise this with, if you have any questions, are confused, unsure, worried, whatever, feel free to PM me, or post it here, whichever.

So let me share my back ground story that I think might help. My last year of school, I worked as an ED Tech. I struggled with a lot of conflicting attitudes and ways of doing things, etc. that contradicted everything I learned in school. I wanted to wait until I had an order before I did anything because "YOU DONT DO ANYTHING WITHOUT AN ORDER MR STUDENT, YOU WILL BE SUED, IT WILL KILL YOU, AND YOU'LL GET EBOLA >:OOO" (nursing instructor rage)

Okay well, I slowly (only working on weekends, got a better feel of how this machine that is ED works. If someone's O2 is 86%, you do not go looking for the doctor, ask him for an order, then wait til it's in, and then go back to your patient that is now 78% and cyanotic, and now apply some supplemental oxygen. You will learn what's what, when to do it, and how. That's purely time and experience. Chest pain? Oh okay I'm going to get the tech to grab the EKG machine, I'm put some cardiac leads on em, I'ma throw some O2 on em, I'm gonna drop a line in em, and go ahead and get a rainbow of labs, draw an extra so the tech can go run a istat and get us a Chem8 and trops. Then I'm going to go ahead and get the aspirin and nitro, and throw those in. Then, since we've managed to knock all of this out before the doc has even gotten to the room, he or she already has a EKG, a line, appropriate treatments started per protocol, and he/she is already ahead in the game. Makes things more efficient for everyone, and sure he'll drop orders in later, and I'll chart em off. Success!

When I graduated, I worked for a year in Med-Surg, but the itch for the ER forever burned inside me. Med-Surg taught me a lot of great traditional nursing skills, some specialized things from that floor. (I.E. I'm the only ED nurse in our dept that knows how to set up a peritoneal dialysis cycle, I'm the go-to for CBI, and some other nephrology/dialysis skills. So I loved the floor, but I yearned for that thrill, that flavor that the ED offered, I finally got a call that they wanted to get me down there. I went, I love it, haven't regretted it for a second. I've been a nurse 2 years now, and not that I found what I love, I literally love to go to work, I look forward to it.

It will definitely take time to get that point. How do you differentiate between "This needs to be done, we don't have time to do it that way." versus "I'm lazy, and we just do this instead or the right evidence based way you have been taught.

Well, again time, but something more tangible and helpful: I know it's basic, but literally, think ABCs.. Airway Breathing Circulation. You just have to address, life-threatening/most serious things first. Then it is up to you to manage your time and resources, and you are free to address other issues as needed and best fits you as an individual. There is no law or rule that says you cannot take care of little/non acute issues in the ED if it is possible and time allows. You just have to balance and not let another more pressing issue suffer while you, idk, call 12 different family members for someone trying to find them a ride home.