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.
Our ed doesn't give report because too many things were getting missed and nurses were complaining such as this case. They give us half hour or so notice of admission and we r required to get our report from h&p and ed documentation. I work a busy progressive care unit but this seems to work
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.
I'm definitely not buying this, you lost credibility. Either 1) You are either stretching the truth to what actually did happen or 2) You work in a rinky-dink hospital. Theres absolutely no way a pt with a potassium of 2.1 wouldn't receive IV replacement, a pt presenting with stroke like symptoms with no C/T done (even if the onset first witnessed was greater than 4hrs), a DKA pt with no insulin drip, or OGT's not being place in intubated pt's. It just sounds too made up. Like i said, you're either stretching the truth for whatever reason, or the hospital where you work may not be up to standards. But I HIGHLY doubt the ER can get away with the core, life saving interventions from the examples you've mentioned.
OP, most of your complaints are issues with the MD. It is not the RN's fault that there is no diagnosis, this patient got a full work-up and was stable for several hours. The MD admitted this patient, this means that they spoke with a hospitalist who ACCEPTED this patient for the floor. Not the RN's problem. The med reconciliation is not the RN's problem either, if I have time I will do this, otherwise it can wait. Changing a perfectly patent field IV is ludicrous. It is also not the RN's problem when the patient and family are inconsistent with history of present illness and poor historians. I can't tell you how many times patients leave out information or tell inconsistent or ever-changing stories about their symptoms. As far as past medical history, you have every ability to dig through the chart as I do. (It doesn't even sound like the patient was septic, he had symptoms for months? Lactate was 2? Normotensive? Afebrile?)
well, then they should have transferred this patient out to another hospital that has ICU beds available. Our ICU is currently closed due to a roof leak. We have 3 ICU make-shift beds in PCU right now. We ship out the critical ones. That's the Dr's bad... ER shouldn't be punished for that one.
Code strokes go directly to CT upon admit to the ER at our hospital. Insulin drips get hung, Potassium runs are given. That's just how it is. There are protocols that ER's have to follow. Your hospital has some serious issues....
The night before last, I walked into the Ed for work and took report from the of going nurse "good news and bad news, I'm discharging the last pt in this pod (of 4) but you have an ambulance coming with a shortness of breath". OK, I think, I can start stocking the rooms until she gets here. Go to the stockroom and come back and the charge nurse puts a young woman in my pod with a hx of vomiting x 2days and diabetes and unable to take her meds. Is in DKA Sugar in the 700's. Has done this so many times, she has no veins left. I'm frantically trying over and over to get a line on her while she's vomiting away when the ambulance comes in with a 70 yr old with stage 3 lung cancer, O2 80% on a non-rebreather, pt is on chemo and has a fever of 103 at this time. Thankfully, EMS has started the line for me and drew labs, but she still needs blood cultures drawn. She has a port, so I go ahead and access this real quick and draw the cultures and grab some fluids and tylenol, take off the 42 blankets she has on and run back and keep attempting the iv on my DKA pt. I'm in the room and charge comes in to tell me she put a frequent flyer in one of my other rooms complaining of abdominal pain. I ask if she can try the iv on this pt as I haven't been able to and leave her to it while I go assess the new pt. I walk in the room to see this pt is white as a sheet with a trach and she tells me she has abdominal pain AND shortness of breath and she needs a breathing treatment as I assess, she has crackles and wheezes all throughout her lungs and guess what, she's diabetic too with a sugar in the 400's. Get her iv started labs drawn and radiology comes to take her for a chest x-ray. As I'm walking out of her room, the other radiology tech comes and tells me my other pt's port won't flush for the CT. OK, deaccess and reaccess port real quick and send that pt off to CT. Charge is still trying the iv on my DKA pt when the triage nurse puts a 70 something F with a fever and "shaking" in my last room. Start the iv, draw the labs tell her we need a urine sample, she sits up and starts vomiting. Grab her some zofran and fluids, come back and she's ripped out her iv. By this time, the iv is started in the DKA room and there are orders for 3 boluses, 2 k riders, an insulin drip, zofran, morphine and Ativan. I start all this, and the lab calls with more criticals. The cancer pt has a white count of 1.6 her temp has come down and her o2 has come up to 96% so I titration her down to a high flow nc at 6lpm, put her on reverse precautions. Lab is on the phone again, the 3rd pt has an h&h of 6.4 and 23 so, redraw for blood bank and there's now orders for bicarb insulin, d50 lactulose and calcium and bolus. Now, remember I still have to go back and restart the iv on the 4th pt (who has family members that are so bad no one else will go in the room, so no help delegating) wait, the DKA pt now has hourly fingersticks and q2 hour bmp so I redraw those and send them off. Charge comes and tells me we are transferring DKA and lung pt, transport is on the way will be here in 10 minutes. Hurry up and chart what I've done and try to call report, the floor nurse at the first place is busy and "will call me back" call report to the second place, transport is here for the second one and I send them off. Flight crew is now here and say they will listen while I give report. Call report and the floor nurse now can't be found. I state I will wait on hold while they find. 5 minutes later they find her and I give report, send the pt off. Go to restart iv on the 4th pt and still no urine, so I straight cath pt also. My other two rooms are now empty and 2 more pt's are on the way. Now, tell me again about getting two admits back to back on the floor or Call me to complain about an iv site or a bolus not given on a stable pt. We spend the whole shift putting out fires and stabilizing patients quickly with no information
I'm definitely not buying this, you lost credibility. Either 1) You are either stretching the truth to what actually did happen or 2) You work in a rinky-dink hospital. Theres absolutely no way a pt with a potassium of 2.1 wouldn't receive IV
replacement, a pt presenting with stroke like symptoms with no C/T done (even if the onset first witnessed was greater than 4hrs), a DKA pt with no insulin drip, or OGT's not being place in intubated
pt's. It just sounds too made up. Like i said, you're either stretching the truth for whatever reason, or the hospital where
you work may not be up to standards. But I HIGHLY doubt the ER can get away with the core, life saving interventions from
the examples you've mentioned.
More than one ER and its some of their staff who have lost all
credibility. I assure you this is not made up in fact I could describe many more examples of extreme negligence by the same nurses but I do not want to be identified by those employers.
I dont care about EMS sticks or the last time they took a crap either. If you're too busy to take care of your orders I am ok with that just be honest instead wasting MY time.
The night before last, I walked into the Ed for work and took report from the of going nurse "good news and bad news, I'm discharging the last pt in this pod (of 4) but you have an ambulance coming with a shortness of breath". OK, I think, I can start stocking the rooms until she gets here. Go to the stockroom and come back and the charge nurse puts a young woman in my pod with a hx of vomiting x 2days and diabetes and unable to take her meds. Is in DKA Sugar in the 700's. Has done this so many times, she has no veins left. I'm frantically trying over and over to get a line on her while she's vomiting away when the ambulance comes in with a 70 yr old with stage 3 lung cancer, O2 80% on a non-rebreather, pt is on chemo and has a fever of 103 at this time. Thankfully, EMS has started the line for me and drew labs, but she still needs blood cultures drawn. She has a port, so I go ahead and access this real quick and draw the cultures and grab some fluids and tylenol, take off the 42 blankets she has on and run back and keep attempting the iv on my DKA pt. I'm in the room and charge comes in to tell me she put a frequent flyer in one of my other rooms complaining of abdominal pain. I ask if she can try the iv on this pt as I haven't been able to and leave her to it while I go assess the new pt. I walk in the room to see this pt is white as a sheet with a trach and she tells me she has abdominal pain AND shortness of breath and she needs a breathing treatment as I assess, she has crackles and wheezes all throughout her lungs and guess what, she's diabetic too with a sugar in the 400's. Get her iv started labs drawn and radiology comes to take her for a chest x-ray. As I'm walking out of her room, the other radiology tech comes and tells me my other pt's port won't flush for the CT. OK, deaccess and reaccess port real quick and send that pt off to CT. Charge is still trying the iv on my DKA pt when the triage nurse puts a 70 something F with a fever and "shaking" in my last room. Start the iv, draw the labs tell her we need a urine sample, she sits up and starts vomiting. Grab her some zofran and fluids, come back and she's ripped out her iv. By this time, the iv is started in the DKA room and there are orders for 3 boluses, 2 k riders, an insulin drip, zofran, morphine and Ativan. I start all this, and the lab calls with more criticals. The cancer pt has a white count of 1.6 her temp has come down and her o2 has come up to 96% so I titration her down to a high flow nc at 6lpm, put her on reverse precautions. Lab is on the phone again, the 3rd pt has an h&h of 6.4 and 23 so, redraw for blood bank and there's now orders for bicarb insulin, d50 lactulose and calcium and bolus. Now, remember I still have to go back and restart the iv on the 4th pt (who has family members that are so bad no one else will go in the room, so no help delegating) wait, the DKA pt now has hourly fingersticks and q2 hour bmp so I redraw those and send them off. Charge comes and tells me we are transferring DKA and lung pt, transport is on the way will be here in 10 minutes. Hurry up and chart what I've done and try to call report, the floor nurse at the first place is busy and "will call me back" call report to the second place, transport is here for the second one and I send them off. Flight crew is now here and say they will listen while I give report. Call report and the floor nurse now can't be found. I state I will wait on hold while they find. 5 minutes later they find her and I give report, send the pt off. Go to restart iv on the 4th pt and still no urine, so I straight cath pt also. My other two rooms are now empty and 2 more pt's are on the way. Now, tell me again about getting two admits back to back on the floor or Call me to complain about an iv site or a bolus not given on a stable pt. We spend the whole shift putting out fires and stabilizing patients quickly with no information
And that's just the first couple of hours of the shift!!
I was a float, Level I Trauma. Never busier than the ED, never more stressed.
ICU had an abundance of nurses and docs at all times.
Both jobs have their own challenges, both have their down time, but ED is where the big girl panties come out.
Kudos, ED nurses.
Abundance? No.
Only doc we have is on call and I am charging with nurses who average 6 months or less of ICU experience. Coupled with the fact I have ED nurses transferring me patients who know about as much or less than these ICU nurses makes for a hectic situation.
Big girls panties? Being in the ED you always have a doc, at least in my ICU is where the big girl panties out. Calling a intensivist at 3am, who is half asleep and knows nothing about the patient? Fun times. Or how the rest of the floors look to the ICU for all of the answers? Or how the ED doesn't know how to set up the cardiac cooling machine?
It might be different in Level 1 trauma EDs, but for most hospitals the stress is in the ICU.
But that is just my opinion having worked in both for some years....
Only doc we have is on call and I am charging with nurses who average 6 months or less of ICU experience. Coupled with the fact I have ED nurses transferring me patients who know about as much or less than these ICU nurses makes for a hectic situation.
Big girls panties? Being in the ED you always have a doc, at least in my ICU is where the big girl panties out. Calling a doc at 3am, who is half asleep and knows nothing about the patient? Fun times. Or how the rest of the floors look to the ICU for all of the answers? Or how the ED doesn't know how to set up the cardiac cooling machine?
It might be different in Level 1 trauma EDs, but for most hospitals the stress is in the ICU.
nursetawnya07
7 Posts
Our ed doesn't give report because too many things were getting missed and nurses were complaining such as this case. They give us half hour or so notice of admission and we r required to get our report from h&p and ed documentation. I work a busy progressive care unit but this seems to work