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.

[iluvivt, BSN, RN]

Read the the MD or provider notes and the nurses notes.You are not ever going to get everything in a perfect package. They do what they can and what is urgent and then they really need to get the patient to the next level of care....which is YOU in this case...you then take over where they left off!

[jadelpn, LPN, EMT-B]

This patient may in fact be septic. All in all sounds like exacerbation of his very chronic illnesses.

Here's the thing. Chronically ill people who decline any regular medical treatment to the point of collapse, THEN, family has a laundry list of all the symptoms/stuff that has been happening in the last 6 months. And the list grows and grows...that can't be solved in an ER visit. And I am curious as to what and how much of his meds he is taking at home.

About vital signs....there are many er's who put a patient on cycle. There's many patients who choose not to have vitals on cycle. And just by the indifference and/or denial and/or non-compliance of this patient, who knows what happened?

This is a complicated dynamic and can't be solved in the ED. You will be fortunate to solve it on a unit. You can only do a good assessment, start vitals cycling now, get a head to toe detailed history, and let the provider take all of that information and create a plan.

But DO make sure that you CYA and educate thoroughly, have a detailed and solid discharge plan with home services, and get a meeting together to talk about these things in detail.

Because to go to the ED only after collapse of a billion of issues all of which are chronic in nature screams of a lot of different things--but mostly non-compliance.

[flyersfan88]

You're expecting way too much. The ED isn't going to fix the white count before they come up. It is completely unreasonable to expect a field stick to be changed if it is working. It seems like anything the ED nurse missed was nothing you didn't find out quickly, and.nothing that would have really changed the course of events. The team already knew he needed to be in the unit and didn't put him there anyway....now THAT'S dropping the ball.

I'm not sure why you didn't call the doctor for clarification of orders....that would have been entirely more appropriate.

Man, when I think the ED dropped the ball it's usually because they "forgot" about the patient being a demon seed and on a 1:1 downstairs. They can't do everything. And what am i, chopped liver completely incapable of doing anything on my own?

[Dranger]

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.

You wen't 0 to but*hu*t really fast

Yeah that sounds great, but half the time they can't even do that. Many are incompetent at handling sedation or even basic pressor titration. Insulin drip titration? What's that? This is basic stuff, I am not asking for I/Os or history, just plain old patient care. I can't even count how many patients dumps I have gotten without even the slightest due diligence being done.

Perhaps you misread my post or read what you wanted to see. I have worked the ED and know the trials and tribulations. However, I also know incompetence and half-assness when I see it regardless of how hectic it is. There are days in the ICU where 2 sick patients was worse than the 20-30 I saw during my ED shifts.

Perspective.

[ProgressiveActivist, BSN, RN]

Last night I got an patient with K+ of 2.1. I asked if any K was given and was told we dont do that. They also dont do insulin drips for DKA or place an OGT on intubated pts. I have gotten a stroke pt who never had a CT and had a head bleed. Incompetent and half assed you bet.

I dont expect perfection but sheesh at least try to

stabilize them or do something- anything- besides demanding an ICU bed. I dont buy the excuses of

we cant close our doors or we have eight ambulances outside. Even if that were true it does not give you a pass to dump

critically ill pts in non ICU beds. Just because you have

people in the lobby looking for primary care does not give you the right to dump pts and visit the hell of your world on an

already over extended med surg nurse.

The safest place for the patient in the original post was the

ICU for continuous monitoring and after that the safest place

would be to transfer him to another hospital or make him an

ER hold. He didnt even receive the boluses that were ordered and apparently no one knew anything about him other than he might have meningitis. By the way altered mentation and poor perfusion in a septic patient are signs of MODS which no nurse outside of an ED or ICU should be expected to manage.

[Ubi Quity]

Well said, Lev. I am an ER nurse as well; the word multi-tasking is an understatement when you work in the ER.

[ED Nurse, RN]

I think it is very poor form to trash other departments- especially the ED. We are one team and all have the common goal. Just as there are bad nurses in the ED, there are bad nurses in every other department. Many of the things being mentioned are ORDERS that need to be placed by a MD- as nurses, we can't place orders, correct? We can only ask and tell the MD what needs ordered, we can't make them do it.

Seriously though- if you don't agree with the practice of another, that's fine, but be professional about it. There is no reason to trash another department- you have NO CLUE what they could have been doing it who else needed a bed. To the poster who says who cares if there are 8 ambulances lined up- I CARE! Sometimes those 8 ambulances coming in go to triage, sometimes they need a bed immediately- having a STEMI, actively seizing with no airway, a drug OD where narcan isn't working- should I send those to you instead?

It is very easy to constantly blame others- it's harder to understand what another is going through and ask questions, or God forbid, lend a helping hand! Take that patient you think "nothing" was done for- tell that nurse to hang in there and do have a good rest of the shift.

Some of you need to get outside your own department and realize each of those departments have a different approach and end game to pt care. Some of you need to stop being so jaded, and having that attitude that your way is the best way. The majority of us, in any department, want the best for our patients and do the best we can to get to that goal.

Grow up, be professional, and stop trashing your fellow nurses. Meet you fellow nurses from other departments face to face, get to know them and be appreciative of everyone. That will get you much further than playing the blame game.

[ProgressiveActivist, BSN, RN]

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.

[Birdy2]

I would never expect them to fix the white count lol and EMS sticks are changed on arrival per protocol where I work. Not sure why, but maybe because they aren't compatible with our tubing, because I've had to pry some apart after they've been hooked up to fluids.

I spoke to the doctor as soon as the patient got there because the patient was transferred in the computer before he even got to the floor and had sepsis protocol fluids ordered hours ago on the emar. Usually if a patient has been in the ER that long those fluids have already been given. A lot of the time they don't scan the meds or fluids, so I have to call back and ask. This time the nurse said she had never seen the order and hadn't given those. But turns out he didn't need them anyways with bp being ok, not to say he wouldnt have for long. Who knows. I left 3 hours after getting him.

The lactate was 2. I was told he had no other tests done and the reason that matters is because results don't pop up for hours and most of the time they aren't on the chart either, so I needed her to tell me if there was anything abnormal. And If a temp wasn't recorded I wish she would have just told me that he had been having one on/off.

I understand then having to switch the patient around with several nurses and that the new nurse might not have a good idea about what's going on. I will try to be more understanding when they don't know much.

I work on a med-surg with cardiac, renal, Alzheimer's, respiratory, pretty much anything you can think of. We have had 8 patients each before. Sometimes i get 2 admits from ER back to back. It's hard to juggle all that plus your others that could be not doing so well either. And there's no doctor to just turn to and ask quickly for help. We have to wait and wait some nights for them to call back. i remember one night the supervisor transferred a patient to the ER because the doctor wouldn't respond, there were no ICU beds left, and the patient was in dts. There was no way the nurse on the floor could help him while having 6 others to tend to. He needed a sitter and we didn't have one. He was getting Ativan q1h and still HR in the 150's and going nuts. The ER was so mad at us, but it wasn't our fault. We had no choice.

Thanks for the responses. I will consider all of this when getting my next patient from ER.

[ED Nurse, RN]

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. Stop enabling

your incompetent staff and blaming the rest of the hospital for calling out their negligence.

Go work Med Surg.

Ive worked med Surg. We are a level one trauma center, we cannot go on divert. Even if we did go on divert there are serious issues- pts can still request to come to us and the ambulance must bring them to us per request. Pts can still walk in. Lastly, and the most important, if we go on divert, the smaller hospitals around us will get overwhelmed and just go on divert, reverting us back to where we started.

I don't care if you "don't buy it." This is the reality. If you think such negligence is going on then report it to the state medical board and the BON- I mean if such negligence is continuously occurring then aren't you being negligent too?

As far as I'm concerned, you too are just part of the problem. If you don't like the way things are, change them. Stop complaining, be proactive. If the ED is such a disaster like you claim, go work there, make those changes. Until then, stop trashing your fellow nurses. Gain perspective.

[Nonyvole, BSN, RN]

And in some facilities, it takes a divine act to go on divert. It's not that simple.

I can have up to two ICU boarders and 6 other patients, with no ancillary staff to help me out. And then another sick patient rolls in via EMS, and I have two options. One, curl up in a little ball and cry (or storm out), or two, deal. Once again see if anybody can be sent down to the ED, if there is any way to call in somebody. And when it's over, file a complaint about what happened.

[flyersfan88]

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.

I don't work ED, but it takes extreme extreme extreme circumstances to go on divert where I am (inner city level 1). Probably because the hospital gets fined for going on divert. Either way, that isn't the nurse's call.

I do agree with the "stop enabling incompetent staff" comment, though. But that pertains to all departments. Excuses for laziness/lack of critical thinking of everywhere. I think it is apart of responsible pt care to hold each other accountable.