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.
What was challenging about ICU and or other floors?
Has your hospital did the float challenge?
I have worked med-surg ICU, med-surg neuro ICU, and ER (level 2 trauma centre). I worked briefly on a general surgery floor.
Emerge (sorry, I say emerge, some ppl hate that) is very intense. ICU has its intense moments, but once your patient is stabilized, to the OR or expired, you're pretty much done. In trauma, you can just get that person tubed, sedated & starting your list of orders when another CTAS 1 is arriving, whom you know nothing about because your team leader hadn't had time to relay the paramedic report yet. & you have to act, knowing nothing but what the medics are telling you & what you can glean from your assessment that you're completing while simultaneously setting up to do a line, hooking them up to the monitor, paging RT & ECG, drawing blood work, paging for extra help if you have it (our trauma room is set up so you can page for a nurse from the clinic area to come assist staffing permitting), getting oxygen/nebs, calling a code, etc etc. Emerge is just plain intense, while ICU is sometimes intense.
ICU, you are never alone. My coworkers would all swoop in when an admit landed so I could get report & start my charting prior to heading in the room. Emerge... You might not be physically alone, but if your partner has someone just as sick, or someone with a lot of orders, it's all you baby!
Both are challenging areas, but it was a huge reality check for me when I finally saw what goes on in emerge... So if you've never worked in ED, I can 100% see where these types of threads come from ... They just have no idea.
Keep in mind, please, that I'm not excusing poor patient care or passing the buck. It would just be nice if we could support each other instead of eating each other alive, & realize that we are mostly all trying to do our best: ED, floor, ICU...
Honestly, the only thing that really gets me that the ED does is not take people for stat scans. In the middle of the night, the only open CT scanners are in the ED.
My ICU is all the way on the other side of the hospital. Once the ED brings me the patient, and I get the patient on the ICU bed which is way bigger, heavier, and harder to steer than the ED stretchers, I have to take the patient right back down to the ED for a head CT that takes less than five minutes. I wish they would just tell me up front they weren't willing to do that - I'd have someone watch my other patient and I would go down, roll the stretcher into CT myself, bring the patient to ICU, and I'd even return their stretcher to them when I was done. It would be so much easier than rolling our old dinosaur beds, half of which have broken/malfunctioning steering mechanisms and take at least two of us to manhandle the bed in the right direction.
ED people - what do you think about this? Coming from the ED, the CT scanners are right before you get into the rest of the hospital. Am I being unreasonable when I ask the ED nurses calling me report why they can't do the stat head CT that's literally on the route between where they are and where I am? I don't mind when the patient is filthy and covered in poop. I don't mind starting new lines. I don't mind intubating a patient. I don't even care if you don't know what the patient's name is. I just mind having to take the patient back down to the ED myself when the patient was already in the ED to begin with.
I haven't taken the time to read the 150+ responses so I do apologize if I have say what has already been stated above somewhere.
I work on a busy tele/trauma floor. We are lucky to even get notice of an admit before the phone is ringing to give report. All I want is the basic information and then get the patient up to me. They are safer on the floor than in the ER due to how busy the Rns are down there. The least I can to do help their day move along is to take report and ask pertinent questions relating to the patient at that time.
I don't care about a chole from ten years ago. Coming in with chest pain? What meds were given and what are their trops. Who is consulted for cardiology so I can call if need be when they get to the unit. Working iv? Awesome! Thanks! VSS? Works for me. Are they possibly septic? Lactic
Yes there have been one or two times I have been screwed by the er, but I don't think they were intentional. It just was how things worked out by the time the patient got to me and lab results.
I am much better focusing my energy on my patient than the rn in the er.
I think all floor and ICU nurses should have to spend a couple shifts in the Emergency Department as well as all Emergency Department nurses spending a couple shifts on the floor and ICU.
That said... It is a totally different world in the ER. Often or even all of the time we do not have time to get the entire story. We have multiple patients and they NEVER stop coming in. On the inpatient side you can anticipate your arrival and you're capped when you reach your nurse to patient ratio... we do not have either of these luxuries. They keep coming and we have to constantly juggle the ones trying to die while completing tasks on our not going to die right now patients.
Do do nurses miss things? Yes. Do families always gives us all the important information up front? No.
One the of the comments I read stated the ER is like a rapid response or code. Now imagine each of your rooms going through this process - sometimes at the same time. There is no team to call, the ER nurse IS the team. Sometimes the ER nurse is the only one available because someone more critical is taking the other team members attention for several minutes. Now consider your patient, who isn't coding.... who was seen by doctors and nurses and deemed stable for transfer to your unit and you are upset that report wasn't more thorough.
I get it, you want the whole picture. You DESERVE the whole picture. But, this is when you investigate and use your license and your expertise and your resources.
I've been on both sides. It's a completely different environment, a completely different way of treating the whole patient. Before pointing fingers maybe you can be happy you were able to use your assessment skills to get this patient the care he needed.... after all that's what we are all in the trenches for anyway.
I haven't read through all the responses, but a recurring theme seems to be that there are system failures and issues specific to certain facilities that don't apply to all, and that could be coloring some of the situations you're experiencing. For example, someone mentioned earlier that in their hospital "the ED nurses don't give potassium (even with a pt. with a K of 2.1), they don't start insulin on DKA patients, and they don't place OGT on intubated patients" [i'm paraphrasing here.] None of these are an issue in my facility.. I work ED, and if my patient were severely hypo or hyperkalemic, it would be treated; insulin drip would be started and protocol would be initiated and followed (on the same form the ICU uses) on a patient in DKA, and I try to always place the necessary tubes on my intubated patients (OGT/NGT, foley, get a doc to obtain central line access if pressors are needed, etc.) ED nurses in my hospital are also expected to take patient for stat scans (particularly CTs on r/o stroke patients) and monitor them during the scans. Our policy for report on med-surg or observation patients that don't require telemetry monitoring is to wait 15 minutes after bed assignment, then call and try to give report, and if the nurse can't take report we are to fill out a standardized report form and let them know we're faxing/tubing the form and also send a copy up with the patient and transporter. If they are telemetry monitored or ICU patients, we call 15 minutes after bed assignment to give report, and if they can't take report we let them know we're bringing the patient up (we must travel with the patient and a monitor in these situations) and will present a bedside report - which is the STANDARD OF CARE on the units ANYWAY. We don't change medic sticks in the ED if the line is patent and intact, but then, we don't have a specific policy that says we're supposed to. Again, I don't think all of these issues have to do with ED nurses in general having unethical and dangerous standards of practice, which is what some of you seem to be asserting - these sound more like hospital policy issues that need to be addressed much higher up.
You obviously have not worked a fresh trauma- the algorithm is the SAME for EVERY trauma- you SECURE the airway regardless of mechanism. If a pt needs to be intubated it is done immediately- we do not do a full neurological assessment while the pt is a fresh trauma- that is done later in the ICU during a sedation vacation. I have been the nurse in THOUSANDS of trauma resuscitations and they all RUN the same. Being angry at the ED trauma nurse for not having a neuro assessment on an intubated fresh trauma is ridiculous. If you have TNCC or ATLS you would know that.
People need to stop speaking to situations they have no experience in- this is where the problems begin- you speak without having first hand knowledge of a situation.
Must be nice to be able to look things up before a pt arrives to you- I wish the ED had the ability to look up a pts history prior to arrival- then maybe I could know it all like every other department seems to think they do.
I find it comical that not a single ED nurse has called another nurse a name here or flat out said another department "sucks," yet people who are not ED have openly attacked those of us who are ED- says a lot.
This is where these ED/inpatient arguments get ridiculous. The specific assessment you're saying is never done was if the patient was "following commands or withdrawing from pain", in other words a GCS. As a trauma nurse it's a bit embarrassing to hear another nurse claiming to represent trauma nursing to claim it's ridiculous for us to know a GCS on a patient, it's something you are aware of if you're within 5 feet of the patient at any time if you're a competent trauma nurse. So to try and support the argument that the "other side" is ignorant of what you do, you're willing to support that by admitting you're an incompetent trauma nurse, which I doubt is actually true.
This thread is actually making me very glad I don't work ER. These nurses work under tremendous pressure and some pretty challenging conditions. And they are often the "bad guy" much of the time, apparently.
Kudos to you guys. I don't think I have the temperament to handle what you guys do on a daily basis!
Finally, a smart nurse, who actually assesses his/her pt by physically assessing the pt & looking up his pt's H&P, VS, & lab results. Why should I sit there & read what you can read off the computer just as well. Like it says here, ask me what you can't find in the computer, I am willing to answer everything except about a BM....LOL!
Specializes in Medsurg/ICU, Mental Health, Home Health.
Emerge (sorry, I say emerge, some ppl hate that) is very intense. ICU has its intense moments, but once your patient is stabilized, to the OR or expired, you're pretty much done.
I have never heard the ED called "emerge" but now that I have I can say that I hate the term. Haha.
As for being okay once the ICU patient is stabilized, I have to disagree somewhat...because a lot of times these patients are NOT stabilized...ever. Gram negative sepsis and ARDS come to mind.
Still, I don't wanna be an ED nurse. Y'all can keep it.
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€
Again, I ask why?
Calling someone out for giving inaccurate information is not being a troll or unprofessional. The issue is speaking about nursing priorities in other departments when you have first hand knowledge. I, at no time in this post or any other, have presented information, or ideals, about a unit I have not worked in-- correcting someone again, is not unprofessional.
The original premise of this post is that OP has no firsthand knowledge about the primary responsibilities of the ED nurse and therefore, placed blame and anger where it did not belong. Understanding the primary responsibility of nurses in differing units is key to cut down on "turf wars." A nurse(s), sharing inaccuracies based on opinions, is not professional and further leads to division of nursing departments. Just bc YOU think ED nurse should do A,B, and C does not mean that A,B, and C are ACTUALLY what is expected of that nurse or part of their primary duties.
BellionRN
117 Posts
I have worked med-surg ICU, med-surg neuro ICU, and ER (level 2 trauma centre). I worked briefly on a general surgery floor.
Emerge (sorry, I say emerge, some ppl hate that) is very intense. ICU has its intense moments, but once your patient is stabilized, to the OR or expired, you're pretty much done. In trauma, you can just get that person tubed, sedated & starting your list of orders when another CTAS 1 is arriving, whom you know nothing about because your team leader hadn't had time to relay the paramedic report yet. & you have to act, knowing nothing but what the medics are telling you & what you can glean from your assessment that you're completing while simultaneously setting up to do a line, hooking them up to the monitor, paging RT & ECG, drawing blood work, paging for extra help if you have it (our trauma room is set up so you can page for a nurse from the clinic area to come assist staffing permitting), getting oxygen/nebs, calling a code, etc etc. Emerge is just plain intense, while ICU is sometimes intense.
ICU, you are never alone. My coworkers would all swoop in when an admit landed so I could get report & start my charting prior to heading in the room. Emerge... You might not be physically alone, but if your partner has someone just as sick, or someone with a lot of orders, it's all you baby!
Both are challenging areas, but it was a huge reality check for me when I finally saw what goes on in emerge... So if you've never worked in ED, I can 100% see where these types of threads come from ... They just have no idea.
Keep in mind, please, that I'm not excusing poor patient care or passing the buck. It would just be nice if we could support each other instead of eating each other alive, & realize that we are mostly all trying to do our best: ED, floor, ICU...