ER dropping the ball?

[Birdy2]

Well, once again I've been sent a patient that is just a complete mess and I have no idea what is going on with him. This seems to happen more than a lot lately.

This patient came in because his wife found him on the floor and when he came to he was confused and weak. He had chest pain in the ambulance that was relieved by nitro.

When he got to the ER they did a lumbar puncture, EKG, CT of chest, abd, and head that were all negative except the LP. They were unable to get that because of bone spurs apparently. His vitals were stable, but white count was 23.9 and he had some respiratory acidosis. The man wears oxygen at home due to copd and smoking 3 ppd. He has sleep apnea but will not wear a cpap, so they sent him up on 2L. I ended up having to get him a mask due to him breathing through his mouth and being knocked out cold from morphine he got in the ER.

So anyways, I talk to the wife and she says he has been throwing up every morning and sometimes through out the day for 9 months, also having malaise, fevers, urinary retention, and just not feeling well. Apparently he had been confused more over the last three days. Turns out he had a pretty significant cardiac history with stents and was a recovered alcoholic. There was no mention of this by the ER nurse.

I soike to the MD and she said he was over sedated from meds he takes at home and possibly had gastroenteritis. She said she was going to order a repeat LP for the am.

First of all, I was only told that he came in confused for 3 days and had an elevated white count and unsuccessful LP. The nurse said he had no other tests done, did not mention any of his history other than HTN and COPD, and didn't say anything about fevers or vomiting. Second, he had been in the ED for 12 hours and didn't even have his EMS stick replaced, had no temperatures recorded except right before coming to the floor, and hadn't been given any fluids, just 1 dose of vanc and ceftin.

Im very confused as to how they can get away with not recording vitals. I figured she had only given me his last set because he just got there. She could've given me a range if he'd been there an entire shift already!

I had to call that nurse back when I got the patient to ask why there were orders for fluid boluses and to get the results of tests that she said he had never had. She denied he ever had a fever or that there were orders for a bolus when she had him. She was very rude and acted as if I was overreacting, but the Dr told me the patient needed to be in ICU. There were just no beds. Then the nurse finally said she thought he had meningitis and to just wear a mask. Ugh!

Also, in the doctors h/p it said nothing about any of his symptoms except for chest pain and elevated white count. I'm so confused and probably too exhausted to be thinking about this right now. All I know is this patient is sick and would be better off going somewhere else if the ER doesn't even have a clue what's wrong with him after he's been there for that long.

[ProgressiveActivist, BSN, RN]

It is incumbent upon the trauma nurse to continually reassess as per TNCC and ATLS.

[ED Nurse, RN]

It is incumbent upon the trauma nurse to continually reassess as per TNCC and ATLS.

You have obviously never been a trauma nurse- a real trauma is in the bay no longer than 15-20 minutes- from there, dependent upon injury, goes to the OR, scanner, or to the ICU. You cannot continually reassess neuro when a pt has just been intubated- how do you do that when they have a paralytic on board? Checking pupils, reflexes, etc on a fresh trauma continuously is a futile effort. I assess VS every 3-5 minutes, sometimes longer, depending on injury, mechanism, and interventions so I can anticipate the meds needed or how much fluid/blood I'll need to give. Full assessments, including neuro exams, are done in the ICU- there is no place for that in the trauma bay bc there isn't time. Again, placing blame on the nurse for not doing something that is NOT part of their primary responsibility. Please see my previous statement of making judgements with no firsthand knowledge or experience.

[Farawyn]

Level I Trauma centers get em in, stabilize, and get 'em out.'

[ProgressiveActivist, BSN, RN]

Paralytics for RSI wear off in ten minutes.Sedated you should be assessing pupils corneals gag and cough as part of your continuous assessment which absolutely is your responsibility. You cant treat it if you never look.

[Farawyn]

Yes, ED Nurse. Stop massaging the patient's heart and check for gag.

[BrnEyedGirl, BSN, MSN, RN, APRN]

Nope still not buying it. No guilt here for for exposing the dangerous and unethical practice of some ER nurses. Excuses excuses and more excuses.

Go on divert. Send them elsewhere if youre full. Stop enabling your incompetent

staff and blaming the rest of the hospital for calling out their negligence. Are you suggesting that we act like some of your staff and just not care? The we're always right mentality is dangerous.

Go work Med Surg then you can lecture the rest of the hospital

about how the ERs bed situation takes priority over patient safety.

Wow,...I spent the first 8 years of my nursing career on a cardiac unit, the last 11 in the same hospital's Level I ED.

I have no control what so ever to put the ED on divert (It has happened maybe 5 times in my time there)

I have no control over who gets transferred to where or when, that is the doctors call.

The answer to an over crowded ED is to move patients as quickly as possible. I also have no control over where they go, the admitting doc makes that decision.

The goals of the ED are way different than those of the rest of the hospital. We don't get report on our patients, they just show up, we can't say we are full or don't have the room or the staff to care for the next patients.

I am obviously not familiar with your ED, but in my ED we follow the orders from the ED doc, the admit orders are in a completely different system and carried out by the admitting floor.

It is not an exaggeration to say that sometimes I am running to CT with a class I stroke when an acute MI shows up in one of my rooms and there are 30 people in the waiting room who have yet to see a doc!

The ED is the entry to the hospital for a large majority of the patients. The longer a patient stays in the ED the longer patients stay in the waiting room. Our hospital actually has a policy in place to assist when the ED is overloaded. The floors and units move patients and come to the ED to pick up patients. The safest place for our patients is NOT in the waiting room. We keep them alive until they can get to where they need to be for care. It is a totally different environment with different priorities, different policies with a focus on moving people through!

[ED Nurse, RN]

Paralytics for RSI wear off in ten minutes.Sedated you should be assessing pupils corneals gag and cough as part of your continuous assessment which absolutely is your responsibility. You cant treat it if you never look.

Roc, on average, lasts 30 minutes but can last up to 90 minutes.

Vec, again, on average 30 mins but can last up to 90 mins.

Succs, most commonly used for RSI, can sometimes only keep pts paralyzed for ten minutes, but again, can last longer.

Additionally when using RSI, multiple drugs are used which have Linder durations and would further hinder the ability to do a full neuro assessment. Once the trauma pt is intubated, they need to stay that way until we identify the life threatening issues- you don't back off sedation in the trauma bay, you keep them down.

You have made it quite obvious that your knowledge of situations is limited and not first hand. Stop arguing just for the sake or arguing when you have no first hand experience in the ED or trauma bay. When you have as many ED and trauma pts under your belt as I do, then we can have a concise and educated conversation, however, if you did have as much first hand knowledge on these subjects as me, there would be no reason for such an argumentative tone from you bc you would realize what I'm saying and advocating is truth.

On a more personal note Libby, your posts for the most part, and not just on this post, are dripping of disdain and hatred towards others- hardly qualities of a well respected nurse. I suggest you look inward, instead of judging others, and question if this is a profession you feel passionate about and enjoy doing.

For now, I would appreciate it if you did not speak on issues you have no real experience in, such as the ED/trauma bay, bc your lack of knowledge in such is painting an inaccurate picture of the primary responsibilities of those nurses- although you may think you know what you speak of, your previous postings prove otherwise. Furthermore, it gives other nurses inaccurate ideals, without such experience, a basis for further misrepresentation bc you present yourself as experienced. This leads to the further separation and cooperation of units when the more experienced nurses tout such a hostile and hate-filled attitude around the younger generation of nurses, therefore making them think this type of behavior is acceptable.

[ED Nurse, RN]

Yes, ED Nurse. Stop massaging the patient's heart and check for gag.

Haha farawyn, you just became my BFF!

[Farawyn]

Haha farawyn, you just became my BFF!

Just massage my heart when I code and don't worry about my gag.

[ED Nurse, RN]

Just massage my heart when I code and don't worry about my gag.

Whoa, let's keep your personal life out of it! :***: Hahaha

[Lev, MSN, RN, NP]

Paralytics for RSI wear off in ten minutes.Sedated you should be assessing pupils corneals gag and cough as part of your continuous assessment which absolutely is your responsibility. You cant treat it if you never look.

Not rocuronium.

[ED Nurse, RN]

Not rocuronium.

I don't like inaccurate information passed on about my speciality that I am passionate about and work daily in, doing the best I can for my fellow staff and patients.