Been working in the ER for a while but I don't feel like I've improved

[Catch22Personified]

I work in a Level 1 Trauma Center in a growing urban area. Our nurses can be separated into two groups: Newer nurses (Less than 3 years of ER/Nursing Experience) and Experienced Nurses. Our manager has this belief that that newer nurses should be exposed to the harder assignments like Charge, Triage, and Psych. I fall into the newer nurse category, I've worked in that department for 2 years and before that I worked on Tele/Long Term Care for 2 years. None of my experience prepared me for this. However, management keeps assigning me to Charge or Triage and my peers/management keep saying I'm doing a good job.

I don't feel like that at all, every day I come back mentally exhausted looking back at every choice I made thinking I could have done it better. Every time I have to assign one of my nurses their 5th or 6th Patient it kills me inside because I know it's unsafe but we simply have no nurses. I've at times taken an assignment only for upper management to tell me I can't take an assignment as ER charge (bizzare as hell). I try rounding on all my nurses to make sure they aren't drowning but sometimes I can't leave the high acuity section because the staff need me there to make sure things don't fall apart.

Two questions for the folks that managed to get through my little rant there:

1. How do you improve as being a charge nurse?

2. This is a scenario I dealt with as a triage nurse. I had a 37 y/o Male no prior medical history come in with a complaint of left arm numbess/chest pain with an onset of 1 hour prior to arrival with no causative event. On examination he totally had paresthesias on the left arm along with a decreased grip/shrug. But his chest pain wasn't chest pain, but a left shoulder pain with no real aggravating factor. I ask one of the ER attendings to screen the patient to rule out calling the stroke team, my gut instinct was leaning towards a shoulder impingement due to the pain with a lingering possibility being a stroke. The attending flat up told me, up to you to call the stroke alert, because of the lingering doubt I called it. The stroke team after their workup wrote it off as a radiculopathy. If you were in my shoes, would you have called the stroke team at that time?

[JKL33]

I don't feel like that at all, every day I come back mentally exhausted looking back at every choice I made thinking I could have done it better.

I think you are likely being too critical of yourself. We are all in trouble if we expect to come home from work thinking "well, I'm pretty proud of myself, I think I did everything perfectly today!" I mean that seriously. We are to do our very best, but that is rarely going to mean that we couldn't have done anything just a little better at the end of the day. Also, avoid taking responsibility (accepting fault/blame) for things that are not in your control. For example, if staffing sucks and you are doing your best to help, allocate resources, and make assignments as fair as you possibly can, then you can not personally take responsibility for how people react to getting yet another patient. That is for the manager/director to answer for.

The stroke team after their workup wrote it off as a radiculopathy. If you were in my shoes, would you have called the stroke team at that time?

You made a safe decision in the heat of the moment after asking for help and having it turned back to you by the physician. Sometimes that's what we have to do. But, it's not fair of you to say to yourself that the stroke team "wrote it off as...." - - rather, what they did was rule out stroke.

Continue to do your best and allow yourself to think positively about the good decisions you are making. Will you be better in 2 more years? Yes, I would certainly hope so - I hope I'm a better ED nurse 2 years from now too! But you can truly wear yourself down with overwhelming feelings of not being/doing "good enough". Don't do that to yourself! :)

[~Mi Vida Loca~RN, ASN, RN]

Always looking at ways we can improve, or thinking "is there a better way", reflecting on things is a sign of growth and maturity and learning. Becoming complacent or never questioning things is when things can become dangerous and things get missed.

However, don't obsess on it. On your drive home or when you get home if you want to spend 10 mins reflecting on the choices you made and deciding if there is something you could have done better or if you know you did the best you could with what you were given. Have at it, but then let it go and enjoy the rest of your time off leaving work at work. If not you're going to burn out quick.

The second scenario, you asked the doc to evaluate. The doc put it back on you, had you NOT called it and it came back as a CVA there would have been a massive fall out that would have come back on you. "What do you mean you didn't call this, he had obvious one sided weakness blah blah blah" Really the doc should have went immediately evaluated and made a decision. Better to be wrong and have it be nothing and maybe a minor embarrassment (I wouldn't even go that far) then to have been right and doubted yourself into not calling it and had a poor patient outcome.

[bgxyrnf, MSN, RN]

2. This is a scenario I dealt with as a triage nurse. I had a 37 y/o Male no prior medical history come in with a complaint of left arm numbess/chest pain with an onset of 1 hour prior to arrival with no causative event. On examination he totally had paresthesias on the left arm along with a decreased grip/shrug. But his chest pain wasn't chest pain, but a left shoulder pain with no real aggravating factor.

I would not have called a stroke alert. The patient presumably had no risk factors, a negative Cincinnati PHSS score, and a 0 on the mNHISS.

[Kuriin, BSN, RN]

I would not have called a stroke alert. The patient presumably had no risk factors, a negative Cincinnati PHSS score, and a 0 on the mNHISS.

Humm...would you not think the patient had some sensory impairment due to the paresthesia?

[bgxyrnf, MSN, RN]

Humm...would you not think the patient had some sensory impairment due to the paresthesia?

Yep, that's the definition of paresthesia, right? That doesn't make it suspicious for a stroke, though.

Given that both the CPSS and mNIHSS were negative and that the patient had no risk factors, a stroke alert would not be warranted.

Not everybody with some numbness or tingling is a stroke alert.

[Lunah, MSN, RN]

I would not have called a stroke alert. The patient presumably had no risk factors, a negative Cincinnati PHSS score, and a 0 on the mNHISS.

I would be more concerned for a STEMI. I had a patient who had similar symptoms who was having an MI, but he attributed his discomfort (shoulder more than chest) to having used a chainsaw to cut wood for several hours the previous day. My spider sense kicked in (he didn't look right) and I put him on the monitor after I took him straight to a room, and sure enough — STEMI.

But if he really had loss of sensation, wouldn't his mNHISS be a 1? Not quite a zero, not really concerning for stroke, but not a 0.

[amzyRN]

It sounds more cardiac to me than possible stroke as being the primary concern without risk factors such as diabetes smoking, etc. At our facility, stroke alerts are called by a physician or charge nurse if the physician isn't around. The patient you describe coming into my facility would have had an ekg done, evaluation by a physician rather quickly with the numbness in the left arm, and if they (the MD) deemed it necessary would have activated a stroke alert, which would bump him up to the front of the line for a CT scan.

I feel like everything is a learning opportunity and no one is going to make the correct call all the time. You erred on the side of caution, what is wrong with that? Was anyone harmed in the process? Maybe it revealed that you don't have the same intuition as a nurse with 10 years experience or even 5 years. But so what. They moved you to a charge nurse role, that's pretty impressive.

I have come to the conclusition that I must humble myself to my learning process. I have missed a few things that I wished I would not have because they revealed that I am still somewhat of a beginner. I only have 1 year now, so I have to accept that there are things I won't know and things I get wrong and will have to learn by mistakes. As long as I keep my mistae to something that doesn't endanger anyone than it's all good. I think erring on the side of cauiton is always the best route when you are not totally sure of something.

[bgxyrnf, MSN, RN]

I would be more concerned for a STEMI. I had a patient who had similar symptoms who was having an MI, but he attributed his discomfort (shoulder more than chest) to having used a chainsaw to cut wood for several hours the previous day. My spider sense kicked in (he didn't look right) and I put him on the monitor after I took him straight to a room, and sure enough — STEMI.

But if he really had loss of sensation, wouldn't his mNHISS be a 1? Not quite a zero, not really concerning for stroke, but not a 0.

You're right... abnormal sensation makes mNIHSS = 1... still not a stroke alert.

And I agree, much more likely to be cardiac in nature than brain related.

[bgxyrnf, MSN, RN]

You erred on the side of caution, what is wrong with that?

Nothing wrong at all with that.

When in doubt, up-triage.

[~Mi Vida Loca~RN, ASN, RN]

I would be more concerned for a STEMI. I had a patient who had similar symptoms who was having an MI, but he attributed his discomfort (shoulder more than chest) to having used a chainsaw to cut wood for several hours the previous day. My spider sense kicked in (he didn't look right) and I put him on the monitor after I took him straight to a room, and sure enough — STEMI.

But if he really had loss of sensation, wouldn't his mNHISS be a 1? Not quite a zero, not really concerning for stroke, but not a 0.

I was thinking it would be a 1 for the sensory and we don't really have the info for the arm if there was a drift and what that score was, just decreased grip. But the sensory would be a 1 on the scale.

We had a similar patient once, almost to every detail except he also had neck pain and trouble with deep breaths from the chest pain. 43 yrs old with no prior hx. I was working with one of my favorite residents and he was like Mi Vida, I almost wonder if he has a tamponade. He was like I wouldn't normally jump to that but take into consideration this is also your patient and you're a black cloud for nursing, and I am a black cloud for residents and well wouldn't you know the patient had a cardiac tamponade. Patient had been for the most part stable, I say most part because that condition isn't stable in itself as it can change quickly obviously. Resident grabbed the U/S and checked and called cardio and they thought he was absurd and said they will be down after CT results. By the time the patient got back from CT there was no longer time to wait for Cardio and I got to assist in the trauma bay with a pericardiocentesis. Not sure what caused it because patient denied any of the common things that would cause it. Plus he went to cath lab after the initial draining anyway and I am sure I had a stemi or O/D or DKA or all three come in right after per my normal shift and never had a chance to check.

[~Mi Vida Loca~RN, ASN, RN]

You're right... abnormal sensation makes mNIHSS = 1... still not a stroke alert.

And I agree, much more likely to be cardiac in nature than brain related.

Absolutely, I feel it annoying the doc couldn't come peek real quick. But with a newer nurse still getting his feet wet and learning I definitely would rather error on the side of caution then not and have it be missed because without fail it would be, the patient had numbness and decreased strength why didn't you call it. Got to love hospital politics sometimes. For the record. I loathe stroke patients. Well not the actual patient themselves obviously. But stroke cases.