Emergency Nursing

Mary3010 · Apr 12, 2018

Peak RN:

It sounds like you have to have more experience in emergency than other wards. Wow you must have a massive hospital campus!!! It sounds like a great hospital. I suppose the Peds ED nurses and ED doctors are distinct from the adult ED because it is quaternary care. Tough love in ED...in what way? At your hospital if the Peds nurses were good enough in the ED, could they be used in the ED if they were needed to perform a speciality? I guess they are probably not needed though.

It sounds great specialising in different areas. I like the sound of the ED, maternity, paediatric and neonatal. Probably more the first 3 because in maternity you can also see healthy babies and Paediatrics covers birth-teens. I feel like working in ED broadens the scope of practice to people of all ages though which sounds good.

Also, I feel like it combines the knowledge from other wards e.g maternity (dealing with pregnant women), geriatrics and paediatrics and it does't specialise e.g just dealing with cardiology for instance. Also there is a bit of psych when patients go into the ER before being changed to the psych ward. Hopefully that all made sense...this is all just my understanding.

I'm not very familiar with a EMS pre-hospital nurse...as in you work with paramedics? Disease-oriented mindset...do you mean because adults are more afraid of germs/diseases etc. than kids? I would never have thought that it isn't much harder to do a physical exam on kids in contrast to adults.

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I don't think where I come from paramedics can work in the ER (unless I am unaware of it). It sounds like it is better to be a nurse over a paramedic then because you must have to know more about medicine.

Wow that sounds awesome that you can perform x-rays, CT's, EFAST ultrasound etc.!!!!! That's basically what a radiologist/sonographer does. So you can read/understand those results and basically form your own treatment plan for the patient. I always thought that it was the doctor that does that. That sounds so great!!!

That would be frustrating to see doctors being portrayed as doing nurse's tasks. That makes sense that doctors rarely perform bedside care in contrast to nurses (excluding ED and anaesthesia) because I have seen this but not realised. Thank you so much for your comment!!!!!

Mary3010 · Apr 13, 2018

Thank you so much everyone for your comments...I really appreciate it!!! I don't know of any Emergency nurses so it is so great to hear from people like you who actually work in emergency. Also, I enjoy hearing your comments/stories etc.

I just had a question. Do people tend to find death/suffering in the ED easier to cope with as time has gone by or is it just as difficult to cope with? Maybe it's easier than other wards because you have the patient for a shorter term and may not necessarily see them suffer for as long. I've been in ICU and I found that ward more depressing than the ED. I could be biased though because I had someone close to me die in there.

I heard from someone who was in the war say that death was at first a shock to them, but soon it seemed normal seeing dead bodies. Also, I heard from a paramedic that there's not a time limit for when things start to feel ok when dealing with death. I just wanted to hear your thoughts.

Do you have to clean patients when they die? I know someone who is a nursing student and had to clean a dead body. I didn't know that nurses would have to do that. I once saw someone wheeling out what I thought was a dead body with a white sheet over them (it probably was). Maybe nurses do that too. I thought it was the people in the morgue who did that. Unless they were giving her the bad task.

I've just never seen a dead human body in person before and I don't know what to expect. I can only think of having seen it on TV, images, I think in a museum they showed mummies. I saw on tv a dead body being embalmed and they were draining the fluids out of the thigh. Their chest had sunken in as well. They wanted their body donated to science. It was kind of confronting...though I had never seen it before. I've seen dead animals including my dog die after getting run over though I didn't know he had died straight away. That's basically all I can think of. So basically no human contact.

That's excluding when I was in ICU with my closely related family member because when I saw her I truly didn't know if she was dead or alive. She was on life support after having a stroke (she had had one before) and she had blood coming out of her mouth through a tube. They had to drain it out of her mouth as well. It was a real shock to be honest esp. because it was so sudden. It happened within 30 min and her last words where that she couldn't see. I didn't see her having a stroke thankfully because it would have been worse. When I last said goodbye to her to me her leg had felt hardened and so had her hand. I felt as though she was slightly discoloured and she had sweat on her forehead like she had just worked out. Thinking about it maybe they were signs of death. Maybe the fluids were draining from her body...I have no idea. Though when you're saying goodbye forever to someone, maybe I was out of it and it wasn't signs of death. I'm half curious and half not sure if I'm ready to know yet because it has been a few days over a year ago that this happened. Unless I read it wrong her systolic reading was 70 or so which is so bad!! Though like I said I might have read it wrong being 'out of it'. It didn't hit me that she had died until about half a year later. I feel now maybe she was dead but I think her heart was still going so half dead I guess. You probably are reading this and and know exactly what was wrong with her.

I just want to know, is it depressing in EM? Like do people fall into a depression from seeing people the way they are? I just want to know what to expect. Maybe you try to avoid closeness to patients. I mean do you have to go through the 'stages of grief' so to speak every time a patient dies? Maybe not so much because you don't know them...unless they make you think of someone you know. Maybe it's hard at first and then I guess you get used to it over time.

PeakRN · Apr 18, 2018

Peak RN:
It sounds like you have to have more experience in emergency than other wards. Wow you must have a massive hospital campus!!! It sounds like a great hospital. I suppose the Peds ED nurses and ED doctors are distinct from the adult ED because it is quaternary care. Tough love in ED...in what way? At your hospital if the Peds nurses were good enough in the ED, could they be used in the ED if they were needed to perform a speciality? I guess they are probably not needed though.
It sounds great specialising in different areas. I like the sound of the ED, maternity, paediatric and neonatal. Probably more the first 3 because in maternity you can also see healthy babies and Paediatrics covers birth-teens. I feel like working in ED broadens the scope of practice to people of all ages though which sounds good.
Also, I feel like it combines the knowledge from other wards e.g maternity (dealing with pregnant women), geriatrics and paediatrics and it does't specialise e.g just dealing with cardiology for instance. Also there is a bit of psych when patients go into the ER before being changed to the psych ward. Hopefully that all made sense...this is all just my understanding.
I'm not very familiar with a EMS pre-hospital nurse...as in you work with paramedics? Disease-oriented mindset...do you mean because adults are more afraid of germs/diseases etc. than kids? I would never have thought that it isn't much harder to do a physical exam on kids in contrast to adults.
-----------------------------
I don't think where I come from paramedics can work in the ER (unless I am unaware of it). It sounds like it is better to be a nurse over a paramedic then because you must have to know more about medicine.
Wow that sounds awesome that you can perform x-rays, CT's, EFAST ultrasound etc.!!!!! That's basically what a radiologist/sonographer does. So you can read/understand those results and basically form your own treatment plan for the patient. I always thought that it was the doctor that does that. That sounds so great!!!
That would be frustrating to see doctors being portrayed as doing nurse's tasks. That makes sense that doctors rarely perform bedside care in contrast to nurses (excluding ED and anaesthesia) because I have seen this but not realised. Thank you so much for your comment!!!!!

My only real experience is in the prehospital and ED environment; I can tolerate the ICU, PICU, and Peds for a couple of days but that is about it.

Critical care specialties in general have more of a get it done attitude, the ED especially so. For example no kid ever wants to get an IV and most will start to cry, complain, fight, try to escape, et cetera to avoid it. We still use local anesthetics but the reality is the thought itself if frightening. On the floors the nurses can sometimes spend several hours explaining the procedure, doing play with the kids to reduce anxiety, et cetera however in the ED I might have 5 minutes. The same goes with splinting or placing NG tubes, after they are done the kid will feel much better, however it is an unpleasant experience. I know that I am causing them some pain or discomfort during those procedures but I also know that they need it in order to have a good outcome and to feel better 30 minutes later.

How much peds nurses help in the ED just depends on the campus. Ours don't really come down at all because we have pediatric ED nurses, but in general EDs where there is no distinct separation they may come down to help with the ED clinicians are not as skilled in certain pediatric procedures. The PICU nurses will come down when we have codes but they are more an extra set of hands than anything else (for which I am always very grateful for).

The ED is certainly a great environment for seeing a variety of patients, but we also tend to only see the initial steps in their treatment. In many ways the ED is like nothing else, we have a different plan for the day, different goals for our patients, and often a different personality from most of the other clinicians in the hospital. We certainly have our psych patients, and if they have a medical condition then they may end up admitted to a medical unit.

I'm part of a group that provides care for kids diagnosed with cancer out in the wilderness (and everyone that goes with them). We staff at least two medical staff members and one must be an experienced ED nurse. Most often our second provider will be paramedic, sometimes we will have pediatric nurses or less experienced ED nurses as the second provider. We have the same equipment that would be in a paramedic level ambulance (and have an expanded version of the county EMS protocols), plus any specialized equipment for their medical problems. For example our nurses may give chemo and other infusions, access ports, or treat new concerns without needing to transport to the hospital. If we do need to transport we keep the patient under our care and have a local ambulance provide transport to an appropriate ED.

There are other groups where nurses staff critical care ground or air transport that may respond to 911 calls, but typically these groups mostly run transfers. These are the majority of prehospital nurses, but they typically have more of an ICU background since their patients are mostly ICU to ICU or ED to ICU transports. I've never worked in this area so I can't expand much more on it, but they do have a very different approach to field care.

Adults tend to become their disease states. Their lives revolve around their chronic pain, appointments, and daily decisions. They tend to not want to participate in sports, limit their daily activities, et cetera because they don't want to or don't believe that they can participate.

Kids tend to try to live their lives as normally as possible and then do what they have to (or sometimes ignore) to manage their diagnosis. I have had kids getting TPA who are jumping on their hospital bed, multiple toddlers singing with a TV show while being given racemic epi for croup, a kid who played hockey with a prosthetic leg after having an amputation due to osteosarcoma, kids and teens with congenital heart defects who are climbing 14ers, and multiple teens who are playing sports while getting their chemo induction.

When I'm interpreting images it is to determine interventions rather than for diagnosis per se. For example if a patient is hemodynamically unstable and has barcode sign on their EFAST then they are going to get a chest tube, if they have a large pericardial effusion then we may perform a US guided pericardiocentesis (this was a push from one of our medical directors and still makes me nervous). Our images are still read by a radiologist.

Thank you so much everyone for your comments...I really appreciate it!!! I don't know of any Emergency nurses so it is so great to hear from people like you who actually work in emergency. Also, I enjoy hearing your comments/stories etc.
I just had a question. Do people tend to find death/suffering in the ED easier to cope with as time has gone by or is it just as difficult to cope with? Maybe it's easier than other wards because you have the patient for a shorter term and may not necessarily see them suffer for as long. I've been in ICU and I found that ward more depressing than the ED. I could be biased though because I had someone close to me die in there.
I heard from someone who was in the war say that death was at first a shock to them, but soon it seemed normal seeing dead bodies. Also, I heard from a paramedic that there's not a time limit for when things start to feel ok when dealing with death. I just wanted to hear your thoughts.
Do you have to clean patients when they die? I know someone who is a nursing student and had to clean a dead body. I didn't know that nurses would have to do that. I once saw someone wheeling out what I thought was a dead body with a white sheet over them (it probably was). Maybe nurses do that too. I thought it was the people in the morgue who did that. Unless they were giving her the bad task.
I've just never seen a dead human body in person before and I don't know what to expect. I can only think of having seen it on TV, images, I think in a museum they showed mummies. I saw on tv a dead body being embalmed and they were draining the fluids out of the thigh. Their chest had sunken in as well. They wanted their body donated to science. It was kind of confronting...though I had never seen it before. I've seen dead animals including my dog die after getting run over though I didn't know he had died straight away. That's basically all I can think of. So basically no human contact.
That's excluding when I was in ICU with my closely related family member because when I saw her I truly didn't know if she was dead or alive. She was on life support after having a stroke (she had had one before) and she had blood coming out of her mouth through a tube. They had to drain it out of her mouth as well. It was a real shock to be honest esp. because it was so sudden. It happened within 30 min and her last words where that she couldn't see. I didn't see her having a stroke thankfully because it would have been worse. When I last said goodbye to her to me her leg had felt hardened and so had her hand. I felt as though she was slightly discoloured and she had sweat on her forehead like she had just worked out. Thinking about it maybe they were signs of death. Maybe the fluids were draining from her body...I have no idea. Though when you're saying goodbye forever to someone, maybe I was out of it and it wasn't signs of death. I'm half curious and half not sure if I'm ready to know yet because it has been a few days over a year ago that this happened. Unless I read it wrong her systolic reading was 70 or so which is so bad!! Though like I said I might have read it wrong being 'out of it'. It didn't hit me that she had died until about half a year later. I feel now maybe she was dead but I think her heart was still going so half dead I guess. You probably are reading this and and know exactly what was wrong with her.
I just want to know, is it depressing in EM? Like do people fall into a depression from seeing people the way they are? I just want to know what to expect. Maybe you try to avoid closeness to patients. I mean do you have to go through the 'stages of grief' so to speak every time a patient dies? Maybe not so much because you don't know them...unless they make you think of someone you know. Maybe it's hard at first and then I guess you get used to it over time.

One of the great things about nursing is that you can change specialties. Some people find the ED to be a very hard place to cope, we often have very little time to pause and may not be able to debrief a case for hours if not until well after the shift. We also don't often get to see our sickest patients recover, most ED nurses don't get a lot of closure. ED nurses also have a tendency to be 'adrenaline junkies' and have a reputation for wanting to be 'tough' and I think that some clinicians develop poor coping habits because of this.

Death is never easy, though I have become better at coping with adult deaths over time. I have never gotten better at coping with pediatric deaths, and to be honest my coping mechanisms for it are definitely not healthy. For me the rewards of every kid I help heavily outweigh the difficulty of the deaths, but that doesn't make the poor outcomes any better. Seventy percent of pediatric cancer diagnoses are made in the ED, telling families that their kid has cancer is one of the hardest things we do. We have been the bad guys who call PD and send parents to jail, and while it is for the child's benefit seeing parents cuffed infront of them is devastating (our PD will ask parent to step out of the room before cuffing them, but some refuse to do that).

We do postmortem care, although if they are a medical examiner's or elective autopsy case then we do far less to preserve their exam, typically this means we do less than the inpatient units do. Since this is the same body that we were resuscitating minutes before it's less weird than you would think. It's not like we walked in and found them when they already died, and we rarely have any established relationship with the patient (typically we don't know them and they are either already dead or rapidly decompensating).

I don't think the ED is depressing, but I think some people would disagree. I would actually encourage you to form relationships with your patients, we should never lose our humanity. Everyone grieves differently, for me adults are pretty quick and I usually don't think much about it after shift, although there are definitely exceptions. Peds deaths are much harder, they typically involve an hour on the rower or stairmaster followed by a bit too much scotch and a couple of nights of poor sleep.

I have a bit of a unique position in that I get to see some of our patients outside of the hospital, and seeing them without illness and living their lives normally is huge for me. A lot of the other nurses that work in Peds EDs tend to have other ways of coping outside of their regular work, some work few hours and spend a lot of time with their families, some spend time with advocacy groups.

Mary3010 · Apr 21, 2018

Peak RN:

Why do you not like ICU, PICU and the Paediatrics wards as much? Thinking about it, I feel like I would be the same as far as working in intensive care for adults and paediatrics. As in, I would only do it for a couple of days and would prefer somewhere else. I guess it sounds pretty depressing in ICU.

I suppose that makes sense that in the emergency department it is a more of a 'get it done quickly' attitude. You would have all these orders from the doctor that you have to finish and unlike the Peds ward, you are limited with time due to there being emergency cases. I would have thought that the Peds ward is too busy to be going through a procedure for an hour or so (I didn't realise). I feel like an NG tube would be hard to place down the throat of a child because they might move whilst you are doing that. First starting out, I'd be so concerned that I would make a mistake and possibly cause harm to the patient!! I guess it comes with experience though in becoming comfortable with it. I mean if you know what you are doing then it should be ok. I suppose the clinicians in the ED generally have more of a 'tough love' approach too, in comparison to elsewhere in the hospital.

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If it is anything like the wilderness in Alaska and Wyoming, then you are so lucky. The scenery is just amazing!!! It would be great to have the two different sceneries from the hospital to out in the wilderness. It sounds like you work part-time in the hospital and part-time as a pre-hospital nurse. Do you help people in locations where there wouldn't normally be that many nurses/doctors around to do home visits? I have heard from a GP who has travelled to a remote area to treat people, saying that the clinics there even have midwives. Apparently, there just aren't that many healthcare professionals around there. This is what we have here:

*Nurses:How to become a Nurse - Registered | The Good Universities Guide (we have RN's and Enrolled nurses but I think RN's are higher because they go to Uni whereas the Enrolled nurses go to TAFE).

*Doctors: How to become a Medical Practitioner | The Good Universities Guide We also have the 'flying doctors' who visit remote areas.

*Paramedics: How to become a Paramedic | The Good Universities Guide

I suppose in a way, adults would probably encourage their children to be doing things that other children do so that they don't miss out on their childhood fun. Maybe it's also to take away the thought of being sick. Exactly...to live their lives as normally as possible. Maybe for adults, it's a fear of hurting themselves or maybe they physically don't have the energy like younger children do. I'm not sure...I could be wrong here. I suppose some young kids may not be fully aware of their conditions like adults are. For instance, a two-year-old.

That's pretty cute the toddlers singing with a TV show. The poor kid who had their leg amputated...that would be so hard for them. Even the children with croup, I feel like that would be hard to sing with. Wow that is such an achievement to climb a mountain if they have heart problems and kids playing sports whilst undertaking chemo. From hearing your response, it would seem that you prefer the optimism that the children have.

So basically, the doctor diagnoses what is wrong and you choose the best treatment plan in consultation with the doctor. That sounds great! It sounds like you have a lot of years of experience in nursing. I can see why it would make you nervous to perform the Ultrasound guided pericardiocentesis because you're dealing with the heart and I guess you could accidentally pierce it. Even though the images are still read by a radiologist, it is still great that you can read it and understand it for yourself!! It'd be great to be able to read them.

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I guess all types of nursing would involve seeing death. I'm not sure if that is a good or bad thing that you can't debrief a case for hours after it has happened. I suppose in a way, maybe not being able to take the time to think about the patient who had just died straight away may be better because you are being distracted by the amount of work you have. I suppose sometimes you don't often get to see your sickest patients recover because they may have to be taken to ICU. I wonder why doctors would develop poor coping habits because of nurses wanting to act tough as you say.

It's good that you are becoming better at coping with adult deaths. Wow, 70% of paediatric diagnoses are made in the ED...I would never have thought. So, you as a nurse have to tell them that they have cancer? I didn't realise...I thought it was the doctor who did that. That would be sad for the children to see their parents cuffed...you would think that they would step out just for their child not to see that. I guess if the child was abused by their parent then yes it might be for the child's benefit.

That's good to know that it is not as confronting to see patients who had died (you said that it's less weird than you would think). Post-mortem care...that's basically cleaning the patient, right? I guess it makes sense because if they have died just after attempting resuscitation for instance, then they will not really show signs of death straight away (I would assume). Apparently, people who have died just look like they are sleeping. I guess in situations like that, it might not be as big of a shock to you, rather than walking into their room and finding them dead. Maybe it is easier to cope with death when you don't know the patient. Just out of curiosity did you know from what I explained, what happened to my close relative who had died in the ICU? (Maybe don't tell me what happened but if you know what happened).

That's really good to know that you don't think the ED is depressing. I agree...I would find it hard not to form relationships with the patients I reckon. Do you find some deaths harder than others because you can relate to them somehow? I feel like if I can relate to the patient it might be harder for me (as in if they are similar to a family member or a friend etc.). Maybe you have kids and that is harder for you for instance. Peds deaths would be really hard esp. because sometimes they have barely even lived. Like a two-year-old, for instance, has barely even seen and experienced the world.

Wow, an hour on the rower or an hour on the Stairmaster!!!! That would be so hard to do esp. after a 12-hour shift. I think it would be hard to do in general actually. I would say that that's probably a really good coping mechanism because you are exercising and it apparently releases endorphins making you feel happier. I feel like I would do something similar. So basically, nursing makes people drink. I guess that's like other professions too...apparently, teaching makes you drink. Try listening to music it could help. Whatever you do, don't blame yourself if a patient passes away though. I don't have any patients to compare it to but when my dog had been run over by a driver who didn't stop, somehow, I seemed to think that it was my fault because I had stupidly left the gate open. It would only make you feel worse if you did think like that. That must be a really good feeling seeing patients well outside of the hospital!! It would be a nice thing to see and would make you feel like you have actually made a difference in people's lives!!

Mary3010 · May 6, 2018

Thank you everyone once again...I really appreciate it!! I guess that's why you're all nurses because you're all really nice!!

I just had a question. I feel like it'd be awesome to have an all-rounder based knowledge in treating patients rather than specialising in one area like just neurology for instance. That way I could cover everything. If I was interested in the following, then would that be the work undertaken within emergency?:

*Either prescribing medications or at least knowing what medications a patient would need through your knowledge of medicine.

*Performing first aid/other procedures e.g IV's, blood transfusions, treating physical injuries like broken bones etc. Basically knowing by looking at a patient what is wrong and what treatment to perform. Obviously sometimes scans will be needed to determine different things but having ideas of what it could be. It would be great to apply that outside of work in public/with friends/family etc. As in if someone needs help then I would know what to do!!

*Being able to read and interpret scans/results/monitors (e.g ultrasound, x-rays etc.) or just understanding them. Even performing scans like EKG's etc.

*Checking vital signs

It doesn't have to include all of those esp. because I basically like anything medical related. I just feel like emergency would be good to experience all sorts of patients and you could choose (from my understanding) if you prefer all age groups or pediatrics. Like you could have psych patients, pregnant women, babies etc. So I guess on occasion in an emergency you could even be delivering babies. I guess you would also be triaging the patients. This is just my understanding so I'm sorry if I am wrong.

From my understanding, I know that there are different areas of emergency like resus, the fast track etc. Maybe it is the work within one of the areas within emergency. Also, would this be advanced practice?

Thanks heaps once again!!!