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.

[mvm00]

The patient was dehydrated when I tried twice, then had to just use the EMS one, because I had other patients who needed care immediately and this one to go talk to the doctor about and figure out what I needed to do. I'm not s bad stick either. I usually have no trouble, the hectic and stressful night I had could've had something to do with it though.

Hmm maybe this is why the ER nurse didn't change it.. Hopefully the nurse following you was more understanding than you were about not changing the site either..

[guest744967]

But he's still alive though right.....stabilize...send for better care...Welcome to the ER! Sometimes balls are dropped because of the chaos in an ER and some things are unacceptable..but we are all humans who have errors...Sorry this was this case..

[Lev, MSN, RN, NP]

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.

Do you know hard it is to go on divert? We are on yellow alert most shifts and that still doesnt stop EMS!

Red alert takes an act of God because it requires supervisor permission.

[Lev, MSN, RN, NP]

I actually still work medsurg. Working ER has given me a whole new level of tolerance for those ER admits.

[SmilingBluEyes]

THIS. THIS. THIS.

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.

[BellionRN]

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.

As a nurse, I can't order a head CT on a patient or admit them to the ICU. I also can't write my own orders for things I feel my patient might need in order to be stabilized.

I can advocate, I can let my team leader know that they are too sick for the floor or tell the MD their clinical assessment shows they need XYZ test, I can push hard, but in the end, the final decision is not mine.

Additionally, saying our department is full to the brim plus more isn't an excuse. It's a reality some nurses will never know because they haven't worked in the ED.

I had the very same opinions seen in this thread when I worked ICU until I went down to the ED and got a huge reality check. Now I realize that most ED nurses are doing their very best in less than desirable situations... Just like many floor nurses.

[NurseOnAMotorcycle, ASN, RN]

So picture this happening...

https://allnurses.com/emergency-nursing/real-life-and-1029107.html

...and then being called from the floor about a field site IV.

[ProgressiveActivist, BSN, RN]

As a nurse, I can't order a head CT on a patient or admit them to the ICU. I also can't write my own orders for things I feel my patient might need n order to be stabilized.

I can advocate, I can let my team leader know that they are too sick for the floor or tell the MD their clinical assessment shows they need XYZ test, I can push hard, but in the end, the final decision is

not mine." (Quote)

Yeah I have been in an RCA because the ED did

not scan a patient who came to me with blown pupils. The ED staff let it be known "that all

happened in ICU" and never documented a thing

which was shady AF. None of those cowards showed up for the RCA either.

[ED Nurse, RN]

The day that the floors start housing patients in the hallway bc there are no more beds, is the day everyone will understand what ER nurses go through daily. Our hallway beds in the ED are full almost 24/7- with the exception of those magical hours from 3a-7a, SOMETIMES. So 50 beds plus unlimited hallway beds- bc we can put a bed ANY WHERE, creates the disaster that is the ED. Seriously, if you've never shadowed in the ED, do it- you will gain a whole new perspective, even if just for an hour. Hell, if anyone lived near me, come hang with me, I'd be happy to open your eyes. The blame needs to be placed on administration, not the poor nurses who are doing the best they can with what they have.

[Lev, MSN, RN, NP]

Where I work I have been told by my manager that it is the ER nurses job to go over home meds and present them to the doctor. It may be different where u work and I wish it were where I work. That would make sense. The doctor should be doing that.

We as nurses do take med histories. At the very least I try to get a copy of their med list and put it on the chart. However this is often at the bottom of my priority list.

[Dranger]

1. I have worked both the ED and ICU

2. ED nurses while resourceful fall into the trap of being too tasky. I have had ED nurses with 20 years experience asking me what neosynephrine does or why do we use it. Really? Why would you hang it if you have no idea what it does.

3. ED is a place to ship in and ship out and I get the stressors. However, that isn't an excuse for blatantly poor care.

4. ED nurses have the luxury of having a doc there, many ICUs don't so we need to call for everything and thus need to know those small details. It's our job to figure a lot out but you can at least do the basics.

5. A triage 5 vs 1 is a big difference, obviously you can spare a bit more time prepping the crashing ICU patient than the d/c stub toe in room 6.

Let the hate flow, but at the end of the day I have perspective from both areas.

[ED Nurse, RN]

1. I have worked both the ED and ICU

2. ED nurses while resourceful fall into the trap of being too tasky. I have had ED nurses with 20 years experience asking me what neosynephrine does or why do we use it. Really? Why would you hang it if you have no idea what it does.

3. ED is a place to ship in and ship out and I get the stressors. However, that isn't an excuse for blatantly poor care.

4. ED nurses have the luxury of having a doc there, many ICUs don't so we need to call for everything and thus need to know those small details. It's our job to figure a lot out but you can at least do the basics.

5. A triage 5 vs 1 is a big difference, obviously you can spare a bit more time prepping the crashing ICU patient than the d/c stub toe in room 6.

Let the hate flow, but at the end of the day I have perspective from both areas.

You are making generalizations- I could make numerous generalizations about other departments, but I won't. And I've had 3 crashing patients at the same time- the "stubbed toes" get treated in triage or fast track, so those aren't taking up monitored beds. I understand you've done both, but making general assumptions is not helpful. You can't call out an entire group of nurses for things a small group of nurses have done- that can be done about any group of nurses from any department. No one department is better than the other- we all have different skill sets and priorities. Learn to appreciate your counterparts.