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.
It is incumbent upon the trauma nurse to continually reassess as per TNCC and ATLS.
Libby, I'm not sure how long it has been since you took TNCC or ATLS, or how long it has been since you cared for a critically ill trauma patient in the ED, but let me share a very common scenario in my world.
EMS call: "50ish F, multiple trauma to head, initially called by LE as dead at scene, found pt unresponsive with agonal respers, LMA in place, I/O to LL leg, 70/47, 165, bagging with ETCO2 12, ETA 3 min"
This pt arrives, she has a metal tool stuck in her head, we start 3 14G IV's, draw labs, intubate, quickly staple 22 staples to open skull fx, cut off all clothing, order mass transfusion protocol, place OG, place foley, hang 3 units PRC's, rush to CT, then directly to OR. Total time in ED et CT 37 minutes! I have no name on this pt, no hx, I never checked her pupils, if she exhibited a gag reflex I pushed drugs until it stopped! Her GCS was 3, she was not protecting her airway, she was bleeding to death. We kept her alive to get to the OR where someone could help her, then on to NTICU where they helped her heal.
FYI this pt left the hospital alive 16 days later.
That's what we do, why we are there and what our goal is!
Libby, I'm not sure how long it has been since you took TNCC or ATLS, or how long it has been since you cared for a critically ill trauma patient in the ED, but let me share a very common scenario in my world.
EMS call: "50ish F, multiple trauma to head, initially called by LE as dead at scene, found pt unresponsive with agonal respers, LMA in place, I/O to LL leg, 70/47, 165, bagging with ETCO2 12, ETA 3 min"
This pt arrives, she has a metal tool stuck in her head, we start 3 14G IV's, draw labs, intubate, quickly staple 22 staples to open skull fx, cut off all clothing, order mass transfusion protocol, place OG, place foley, hang 3 units PRC's, rush to CT, then directly to OR. Total time in ED et CT 37 minutes! I have no name on this pt, no hx, I never checked her pupils, if she exhibited a gag reflex I pushed drugs until it stopped! Her GCS was 3, she was not protecting her airway, she was bleeding to death. We kept her alive to get to the OR where someone could help her, then on to NTICU where they helped her heal.
FYI this pt left the hospital alive 16 days later.
That's what we do, why we are there and what our goal is!
Great example and illustration of how things are ACTUALLY done- there is no room for theoretical ideals in the ED or trauma bay.
People who preach theoretically have no real world experience or practicality where it counts.
Just throwing this out there: for our trauma residents Succ sucks and Roc rocks. Our pts stay paralyzed for much longer than 10 min, but like PP said, they're out of the trauma bay within 15-20 min of arrival unless we're performing CPR.
I'll try to remember to squeeze in some neuro checks to pass the time next time we are cracking a chest in the bay.
Just throwing this out there: for our trauma residents Succ sucks and Roc rocks. Our pts stay paralyzed for much longer than 10 min, but like PP said, they're out of the trauma bay within 15-20 min of arrival unless we're performing CPR.
I'll try to remember to squeeze in some neuro checks to pass the time next time we are cracking a chest in the bay.
Ummm excuse me trauma surgeon, you're gonna have to get that rib spreader yourself, I have to check the gag reflux of your intubated, unresponsive pt.
What was challenging about ICU and or other floors?
Has your hospital did the float challenge?
I worked med surg for 1.5 yrs- there were times I had 10 pts and was in charge. Always had an assignment as charge. Med surg for me was all about planning, implementation, and time management. I learned a lot and it created a great foundation for me to build upon. My worse day in med surg is my best day in the ED. Although I'm in charge, I don't have to take an assignment; however, I run my butt off helping, putting out fires, and keeping everyone else from drowning. I don't eat or use the restroom regularly most days. For me, med surg was easier. I typically knew how my day would go, and after awhile, could anticipate the unexpected, or at least work in a buffer to deal with the unexpected; in contrast though, in the ED there is no planning or buffering for the unexpected. It's all about priority and knowing had to deal with the intense situations. You tread water and sometimes you drown- I leave somedays feeling defeated- I never felt that way in med surg. In med surg, you deal with what you know typically. In the ED, I see new things everyday. I'm put in situations I could never in my sickest imagination, could ever dream happening. I love the ED though, it's my passion, and it's what I excel in.
I've floated to the ICU, but not enough to comment on the differences or parallels.
Great example and illustration of how things are ACTUALLY done- there is no room for theoretical ideals in the ED or trauma bay.
People who preach theoretically have no real world experience or practicality where it counts.
That's nursing school for you. they teach theoretical and student nurses become nurses who take that with them. Some people are very regimented so they follow things they've learned to a T even if the real world scenario is completely the opposite. First thing about being a graduate nurse is unlearning almost everything in nursing school. We were taught the 2-step blood pressure method...even before I went into nursing school I've never seen anybody anywhere do that, so I knew that was BS.
One of our ICU nurses came down to work with us in the ED Saturday night. She told me at the end of the shift how much she appreciated all we did. She saw the Code-STEMI who was in and out in 28 minutes, the new onset of Afib-RVR who never had a heart issue before, the drunks who came in by law enforcement in handcuffs, after driving drunk, the one who "tucked and rolled" out of the car at 55mph and called us all every name in the book. She told me we had the patients all wrapped up in a bow before sending them up. she had no idea what our nights were like. I thanked her....
This kind of dropping the ball happens A LOT at my hospital too in ED. I am an SICU nurse and I know there are plenty of competent ED nurses working at my hospital but there are also a number of new grads that are brand new out of school with no other experience so they don't have that foundation you get being up on the floor and they overlook serious things sometimes. It's annoying. It dangerous and it's aggravating as an ICU nurse to constantly get a ****** report from them 95% of the time. I've even talked to my manager about it and she basically said its been this way since the beginning of time and there's nothing we can do.
Don't get me wrong there are good ED nurses out there but the majority of the ones I work with just suck. I usually just look up everything I can before they call report and I ask the things I need to know. I gave up when I was getting a trauma patient with a bleed and when I asked about neuro status I asked if the patient was following commands or withdrawing to pain and the nurse told me "Well he's intubated" Like thats the reason he's not doing anything neurologically ������ It sucks for us bc we have no baseline to go off of with traumas and it makes my job harder. And I'll never forget when I asked if at patient was PERRLA and I got "um the right is a 3 and its sluggish and and L is a 3 and its reactive...the patient came up and the left eye that was supposedly reactive was a glass eye lol. So you are not the only one that is frustrated with the way ED does things!
1- I usually just look up everything I can before they call report and I ask the things I need to know.
Excellent practice. Keep up the good work on this one. Reading is much faster than speaking, and, in reality, the ER nurse would have to look the stuff up anyway, then essentially read it to you. Please pass the word to your peers about how this practice speeds up report, and increases accuracy. It's really different than giving report of 1 of 2 patients after a 12 hour shift.
2-It sucks for us bc we have no baseline to go off of with traumas
Yes, it does suck. But that is kind of the nature of traumas if you think about it. Nobody gets to see them at their baseline.
3-I asked if at patient was PERRLA
My answer would have been- "I did not check". I would not have explained why, or justified my actions.
It seems unlikely that the majority of the ER nurses where you work suck. It's possible that you don't have a firm understanding of the job. As far as having a bunch of new grads, that is often a reflection on management. But, since you knew they are new grads, you probably shouldn't expect a high level of expertise.
FWIW, I do get where you are coming from. I am no critical care expert, but I do have 2 years in the ICU and my CCRN. Maybe you will be lucky enough to float down to the ER for a bit someday. Most people who work both units don't have the nasty hostile attitude you displayed in your post.
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.
ED Nurse, BSN RN,
Calling a person a troll†is NOT professional, does not add to the conversation, AND will NOT help improve care (even if you are correct or not). It is the the as using certain slang terms for patients. Although they MAY be descriptively correct, the tone that they imply dehumanizes them, nullifies them as a person, and perpetuate stereotypes.
Each facility has their own SOPs (standard operating procedures) both official and unofficial.†Yes trauma/ED deals with life and death and one needs to prioritize, but once a patient is stabilized does being busy incomplete information. In trauma, just because a gag reflex is not considered critical, that does NOT mean that it is not a critical vital in other departments. Just as you criticize Libby for not understanding your department, how can you turn around and tell her what is priority in her department?
Part of the consensus of what constitutes good care in the profession is the passing along of notes.†To justify shortcuts because a department is critical or busy does not constitute good care. If there is a staffing shortage, then every member of that department should be flooding the administration with letters of concern over the situation.
I am not getting in to a p****** match over what information is important to which department, but I will say that it is situations like this that allowed insurance companies to convince government that EHRs were necessary. I can also tell everyone here that this continued strife will be used as justification by big corporations and insurance companies to convince government to implement the next PIA to make the job more grueling.
This strife is also what administration uses to keep doctors and nurses employed as indentured servants. The ED is not forwarding completed info, no raises this year. ICU is not doing complete assessments, no raises this year.
It is also a shame that patients view healthcare just as they view cable TV and cell phones, it is NOT who is the best, it is who sucks the least. Patients enter the system with the expectation of incompetence and mistakes occurring. It seems that everyone accepts that it does not have to be good, only good enough.â€
Really, I feel bad when I sometimes have to send a patient up to the unit with a dirty gown and sheets. I wish I knew all his/her history. I wish I could give you an ICU level report. But I just didn't have the time.
I was busy putting in every line and tube that you document intake and output from.
I was titrating up his sedation so you can have a sleeping patient instead of a bucking one.
I was busy stabilizing the patient's vitals signs
Dealing with truly sick patients in the ER (people that belong to be hospitalized) is like having a rapid response again and again and again. That is the amount of work and interventions and meds and IVs and labs and tests. Imagine having to put in multiple lines on your patients each shift, everyone has labs ordered, give meds every hour, do vitals every two hours (or more often and sometimes less) and discharge half of your group of patients and get 4 new ones each shift, sometimes two new patients at a time. Not to mention having an unstable patient thrown in here and there. And these people are all hungry, tired, and thirsty and you can't get them food and half of your patients are in severe pain. In addition to all that hands down one of your patient is either psych, drunk, critical, or demented and trying to to climb out of bed. Then your tech is pulled to sit on the psych, drunk, or demented patient and you have to do all the valuables sheets and take all your patients to the bathroom (and there are no bathrooms in the room).
Perspective.
Very well stated, and represented! You didn't miss anything here. I came from floor nursing to ED and see both sides in a different light. In ED we basically are left to "pick our battles," stabilize and get placement. Due to staffing etc etc we have all we can handle. We ED Nurses want it "fixed" and voice our concerns, and then are ignored etc etc...
And, it doesn't feel good when we have to hand off a patient that we know will be more of a challenge than the receiving Nurse has perceived...it really doesn't.
Each facility has their own SOPs (standard operating procedures) both official and unofficial.†Yes trauma/ED deals with life and death and one needs to prioritize, but once a patient is stabilized does being busy incomplete information. In trauma, just because a gag reflex is not considered critical, that does NOT mean that it is not a critical vital in other departments. Just as you criticize Libby for not understanding your department, how can you turn around and tell her what is priority in her department?
Yes, there are things that are more important in other units than in the ED, but are we supposed to delay care so that we can tell the receiving nurse every little detail? Frankly, I'd rather give the basics over the phone - this happened, patient is intubated, on drips X, Y, Z, is a full code, this is the admitting physician. Once I get that patient upstairs, more of a report can be given at bedside.
Yes, it's frustrating for the floor to not be given what they feel is a full report. But on the same note, it's frustrating for the ED to feel interrogated. (For example: family is on their way in. When they get here I'll send them to your unit. I don't have contact information, I don't know when they'll get here, I don't know names. EMS said that PD spoke with the family. No, I don't know which family members are coming.)
Part of the consensus of what constitutes good care in the profession is the passing along of notes.†To justify shortcuts because a department is critical or busy does not constitute good care. If there is a staffing shortage, then every member of that department should be flooding the administration with letters of concern over the situation.
Administration will point out budget constraints. Administration will also start to make things uncomfortable for the people who are complaining until they leave. Not everybody has administration that actually cares about the working environment.
BrnEyedGirl, BSN, MSN, RN, APRN
1,236 Posts
Libby, I'm not sure how long it has been since you took TNCC or ATLS, or how long it has been since you cared for a critically ill trauma patient in the ED, but let me share a very common scenario in my world.
EMS call: "50ish F, multiple trauma to head, initially called by LE as dead at scene, found pt unresponsive with agonal respers, LMA in place, I/O to LL leg, 70/47, 165, bagging with ETCO2 12, ETA 3 min"
This pt arrives, she has a metal tool stuck in her head, we start 3 14G IV's, draw labs, intubate, quickly staple 22 staples to open skull fx, cut off all clothing, order mass transfusion protocol, place OG, place foley, hang 3 units PRC's, rush to CT, then directly to OR. Total time in ED et CT 37 minutes! I have no name on this pt, no hx, I never checked her pupils, if she exhibited a gag reflex I pushed drugs until it stopped! Her GCS was 3, she was not protecting her airway, she was bleeding to death. We kept her alive to get to the OR where someone could help her, then on to NTICU where they helped her heal.
FYI this pt left the hospital alive 16 days later.
That's what we do, why we are there and what our goal is!