ER dropping the ball?

Nurses General Nursing

Published

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.

Specializes in SICU, trauma, neuro.
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?

Nobody told her it wasn't critical in her dept, and if it's critical then she can check that. Checking gag on an intubated pt is super easy--watch their face/mouth during subglottic suctioning...which we do in the ICU, q 2 hrs for VAP prevention.

What was being objected to is the "excuses, excuses, excuses" accusation, when the ED nurses told what is and is not a priority in their unit. I imagine any of us would get defensive when being accused of making excuses, when we are simply giving reasons for why things are the way they are.

Another example: I've heard LTACH and floor nurses express dismay about pressure ulcers on ICU pts. "Do they never turn their pts??" or "how can they let that happen??? Nursing school 101!" My answer would be, sometimes it is not possible to turn pts. I've had very unstable spines who can't be fused for days...because the spine is the least of their problems. I've had a pt who had such severe ARDS that she was prone for 26+ hours (flipping her supine caused an immediate desat into the 60s--and that was on 100% FiO2 and 20 of PEEP. I've had pts who were on multiple pressors, and any movement made them tank--that combo of pressors and not being able to turn is a disaster for the skin.

I imagine I would get defensive if I explained why ICU pts get HAPUs, and was told to "stop making excuses." Just like in this thread, ED nurses are getting raked over the coals in some posts...and then accused of making excuses when they are simply telling those who don't work ED the reasons why some things can't be prioritized.

Specializes in PCCN.

I'm curious- since it is so crappy to be an ER nurse,is there a high turnover, higher than ,say on other floors?

Sounds like across the board, the ratios for er nurses are inappropriate. It makes me fear being a patient or bringing a family member being brought to the er.

Specializes in SICU, trauma, neuro.
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..

Hmm, in my hospital, they always get their stat scans before coming to the ICU. I agree that it makes most sense; taking them to the ICU (in my case, up 7 floors) first delays the scan, which can delay treatment.

Specializes in Critical Care.
The discussion was about a neuro assessment, to include gag reflex, pupils, etc., nothing about GCS. Of course the GCS is the first thing assessed- it's called out by the MD at the head of the bed while assessing the airway. I, as the trauma nurse, do not assess the GCS- why would I when it is the responsibility of the MD at the head of bed?! I have numerous other responsibilities as the primary RN. Be embarrassed all you want, but I can assure you I'm way more competent at trauma resuscitations than you- I have 20,000+ traumas in Afghanistan to thank for that, with a 99% survival rate at the only level 1 in country. Put the claws away and calm down.

This is the post you were replying to in saying that you don't do that type of assessment in a trauma, it was pretty clear in specifying what it was referring to by neuro assessment;

.... 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 ������ ....

That's pretty basic GCS.

..."excuses, excuses, excuses” ...

This is what happen in the entire healthcare system. Medical errors kill almost 100000 Americans a year! (Source: PubMed)

Some errors in medicine are stunningly bad. One study, published in the journal Surgery, found that surgeons operated on the wrong part of the body 2,413 times between 1990 and 2010. They left foreign objects behind in the body (typically sponges) 4,857 times. In 27 cases, they operated on the wrong patient altogether. (Source PubMed, Surgical never events in the United States.”)

By 2006, more than 3,000 American hospitals, representing 78% of the acute care beds in the country, had enrolled in a systems-based program called the 100,000 Lives Campaign. A Harvard-Stanford group examined patient harms in hospitals in North Carolina, the state with the highest rate of enrollment in that campaign, at 96%. As the authors of the 2010 study put it: "We chose North Carolina as a site that was likely to have improvement, since it had shown a high level of engagement in efforts to improve patient safety." But the authors found no reduction in preventable patient injuries between 2002 and 2007, the period when the systems method was being rolled out. At the same time, a report from Medicare found that the preventable death rate among hospitalized seniors was at least as high as it had been prior to "To Err Is Human.” (Source: NEJM, "Temporal Trends in Rates of Patient Harm Resulting from Medical Care”)

Again, "excuses, excuses, excuses!”

Specializes in Emergency Medicine.
This is the post you were replying to in saying that you don't do that type of assessment in a trauma, it was pretty clear in specifying what it was referring to by neuro assessment;

That's pretty basic GCS.

A freshly intubated pt does not follow commands nor have a response due to being just intubated!

I mean, that's pretty basic knowledge.

I agree with everything you said and have great respect for the ER nurses, it's nuts all the time! The only thing I wanted to mention is that I don't know many floor nurses anywhere that has 2-6 patients a day, I'm admitting and discharging all day and receiving post-op as well so I usually have had a dozen or more pts in a day. I wish everyone just had a mutual respect. We all work hard and have different challenges on our perspective floors. Thank you for all you do, I'm so thankful for everyone in every dept, I have met and learned from so many wonderful nurses.

Specializes in Critical Care.
A freshly intubated pt does not follow commands nor have a response due to being just intubated!

I mean, that's pretty basic knowledge.

If they don't follow commands then they don't score a 6 on the motor section of GCS, but they would fall between 1 and 5. If they have absolutely no response, for instance if they still under paralytics, then they still get a score of 1. There is no patient that can't be given a GCS score.

Specializes in Emergency Medicine.
If they don't follow commands then they don't score a 6 on the motor section of GCS, but they would fall between 1 and 5. If they have absolutely no response, for instance if they still under paralytics, then they still get a score of 1. There is no patient that can't be given a GCS score.

I never said there was no GCS score, thank you. A nurse who is experienced and actually understands the concept of a newly intubated pt, does not care what the current GCS is- perhaps a pre-intubation. The argument was that the PP stated she thought it was a joke that the trauma nurse didn't even know a GCS on an intubated pt- when it's pretty darn obvious what the GCS would be on a freshly intubated pt in the trauma bay. In all the years and traumas I've done, I've NEVER been asked what the GCS is on a fresh, intubated trauma- you put them down and keep them down while in the bay. An EXPERIENCED ICU nurse doesn't need to ask such a pointless question to the trauma nurse in the trauma bay. The point of the PP was again trying to make ED/trauma nurses look dumb and like we are neglectful- when in actuality our priorities differ, which further proves the points I've outline diligently in this post- that nurses in different departments have differing priorities and responsibilities and that you should not speak about areas or make generalizations with no first hand knowledge.

Specializes in Emergency/Trauma/LDRP/Ortho ASC.
I'm curious- since it is so crappy to be an ER nurse,is there a high turnover, higher than ,say on other floors?

Sounds like across the board, the ratios for er nurses are inappropriate. It makes me fear being a patient or bringing a family member being brought to the er.

Have you ever started your shift by unsuccessfully coding an infant after his mother's meth crazed boyfriend tossed him against a wall(given 0 time on shift to debrief after) been physically assaulted by a patient, cussed out in the hallway because your level 4 chronic back pain hasn't been seen "fast enough" despite only being in the department for 30 minutes...top that off with several ICU patients and your other three rooms turning like a carousel...and oh guess what? Here's two ambulance patients that can't go out to triage...now you have two in a hallway bed!

Surgeons fussing because their Zosyn hasn't been hung on their appy while you're trying titrate Levophed and run a Code Cool your post arrest because there's no unit bed for him. Where the hell is my psych pt? Security left him alone!

Come back the next day and the manager wants to know why you aren't clocking your breaks because someone complained to the DOL and she doesn't want trouble. She's also mad that you didn't do service recovery for the chronic back pain guy because he called an administrator this morning.

This is a recap of an actual shift of mine last year, and other than the physical assault it's quite a typical day for me in ED.

Does that shine some light on ED turnover rates?

Specializes in Critical Care.
I never said there was no GCS score, thank you. A nurse who is experienced and actually understands the concept of a newly intubated pt, does not care what the current GCS is- perhaps a pre-intubation. The argument was that the PP stated she thought it was a joke that the trauma nurse didn't even know a GCS on an intubated pt- when it's pretty darn obvious what the GCS would be on a freshly intubated pt in the trauma bay. In all the years and traumas I've done, I've NEVER been asked what the GCS is on a fresh, intubated trauma- you put them down and keep them down while in the bay. An EXPERIENCED ICU nurse doesn't need to ask such a pointless question to the trauma nurse in the trauma bay. The point of the PP was again trying to make ED/trauma nurses look dumb and like we are neglectful- when in actuality our priorities differ, which further proves the points I've outline diligently in this post- that nurses in different departments have differing priorities and responsibilities and that you should not speak about areas or make generalizations with no first hand knowledge.

I've worked on trauma teams at multiple level 1 trauma centers and ICU for 9 years, there are few bits of information that are as standard as a GCS. You're of course free to clarify that their GCS is a 3 post paralytics or with heavy sedation on board, but they still have a GCS score and it's still useful going forward. I've never worked with anyone at any facility on an ED trauma team or ICU that just felt GCS status was "pointless", so please don't generalize this to all of us.

Specializes in Emergency Medicine.
I've worked on trauma teams at multiple level 1 trauma centers and ICU for 9 years, there are few bits of information that are as standard as a GCS. You're of course free to clarify that their GCS is a 3 post paralytics or with heavy sedation on board, but they still have a GCS score and it's still useful going forward. I've never worked with anyone at any facility on an ED trauma team or ICU that just felt GCS status was "pointless", so please don't generalize this to all of us.

You seem to know it all, good for you.

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