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.
I stopped reading the comments after page 3. Same old, same old.
ED diversion is often dictated by local or state law. In my state, there is no diversion unless the whole hospital goes "black" - closed to admissions. The doors never close.
Right? I can't think of ONE time we went on divert and it was when there were (quite literally) more dead bodies than beds/live bodies. We don't divert for anything.
Write an incident report and keep a copy for your personal record and don''t let anyone know you kept a copy. Name names and point fingers. I would give a copy to the appropriate person and I would also send a copy to legal, registered mail, return receipt so I could prove it was received by the hospital. The ER nurse's negligence may have exposed you to meningitis and that is NOT ok to do. I have a friend right now, gravely ill who contracted it at his workplace, it is unknown if he will survive at this point. Protect yourself in this because you can only count on the hospital to protect their own interests.
Sounds like the real problem is not enough staff. I do feel bad for placing blame when there is only so much a nurse can do. We're all frustrated because there are tons of things needing to be done and not getting done. We just can't do it all. I'm not saying that I don't stand by what I've witnessed where I work, but I'm sure there are reasons for the things not getting done.
I wasn't trying to compete with ER nurses. Clearly they have an endless cycle of the same crap I deal with, but that's not what I signed up for. I was a new grad and wanted experience. I feel like I can't even retain things sometimes because I'm just doing so many things at once and in a state of panic at all times. One person said maybe I'm not made for the hospital. Well that wasn't very nice. I actually love it most of the time and have been told by my boss that i do great and she's had enough confidence in me to make me in charge of the hell floor I chose to work on. Maybe that's because we're so short staffed and have such high turnover, but damnit I did it and **** didn't fall apart.
One day i will go to the ER and I guess at that time I'll get to be the blame for things like this. ER nurses have it rough because of that, but that doesn't mean it's easy for any other nurse. As long as it's understood that every one of us deals with serious issues and have a different set of problems then i can try to be more understanding too.
I feel like a big problem is that we know the person we're giving the patient to will be critical of us if certain things aren't done or if we don't know all the answers, so we get snappy. I've done it. So then you decide to be more honest about why things didn't get done, but it starts sounding like excuses. Sometimes it seems like you just can't win.
Sounds like the real problem is not enough staff. I do feel bad for placing blame when there is only so much a nurse can do. We're all frustrated because there are tons of things needing to be done and not getting done. We just can't do it all. I'm not saying that I don't stand by what I've witnessed where I work, but I'm sure there are reasons for the things not getting done.
I wasn't trying to compete with ER nurses. Clearly they have an endless cycle of the same crap I deal with, but that's not what I signed up for. I was a new grad and wanted experience. I feel like I can't even retain things sometimes because I'm just doing so many things at once and in a state of panic at all times. One person said maybe I'm not made for the hospital. Well that wasn't very nice. I actually love it most of the time and have been told by my boss that i do great and she's had enough confidence in me to make me in charge of the hell floor I chose to work on. Maybe that's because we're so short staffed and have such high turnover, but damnit I did it and **** didn't fall apart.
One day i will go to the ER and I guess at that time I'll get to be the blame for things like this. ER nurses have it rough because of that, but that doesn't mean it's easy for any other nurse. As long as it's understood that every one of us deals with serious issues and have a different set of problems then i can try to be more understanding too.
I feel like a big problem is that we know the person we're giving the patient to will be critical of us if certain things aren't done or if we don't know all the answers, so we get snappy. I've done it. So then you decide to be more honest about why things didn't get done, but it starts sounding like excuses. Sometimes it seems like you just can't win.
You work on med Surg- your pts are mostly STABLE pts who just have tasks that need done- you seriously can't tell me you are doing the same thing as ED or ICU nurses. You don't routinely and daily, take care of multiple DYING patients. I'm sorry to be snippy but you just don't get it. Sorry it's "annoying" that the ED sends you pts- who was taking care of those pts trying to climb out of bed prior to them coming to you? US! I also can be on hold for 5 minutes bc we have ascom phones, so while I'm hanging meds, titrating gtts, that phone is with me- hell, I've been doing CPR while on the phone- now that's multitasking! I do those things bc it is what you have to do! What's "annoying" is nurses who complain constantly no matter what- I could answer every question explicitly and it's still not good enough- this is why our hospital no longer requires ED to give report for stable floor patients- the complaining and arguing from the floors became too much. We give report to ICU- which is why I take the time to go outside my ED bubble and get to know my fellow nurses- so they KNOW ME and understand I've done the best I can.
It is 100% ok to vent- it is not ok to TRASH your fellow nurses, especially when you have ZERO concept of the responsibility of the nurse within the ED. You are a brand new nurse in charge and that says a lot about your hospital- start placing the blame towards a more appropriate entity. It sounds like your hospital has a high turn over rate with nursing staff.
Write an incident report and keep a copy for your personal record and don''t let anyone know you kept a copy. Name names and point fingers. I would give a copy to the appropriate person and I would also send a copy to legal, registered mail, return receipt so I could prove it was received by the hospital. The ER nurse's negligence may have exposed you to meningitis and that is NOT ok to do. I have a friend right now, gravely ill who contracted it at his workplace, it is unknown if he will survive at this point. Protect yourself in this because you can only count on the hospital to protect their own interests.
So, it's the ER nurse's responsibility to diagnose a pt with meningitis? Why aren't you advocating for the Ed Dr or the admitting dr to be written up? Both have the capability to diagnose, not the nurse, but that's the one you throw under the bus.... Nice
So, it's the ER nurse's responsibility to diagnose a pt with meningitis? Why aren't you advocating for the Ed Dr or the admitting dr to be written up? Both have the capability to diagnose, not the nurse, but that's the one
you throw under the bus.... Nice
The need for droplet precautions was not
conveyed in report. The need for a tele bed or a private room is apparently of little concern for some ER staff. Awesome teamwork.
The first time I worked fast track dealing with the light 3s and 4s, I said to myself - "this feels like med-surg on steroids." Some days it is much more chill. I think working with those patients may be equitable to M/S as far as acuity and level of patient care.
Multiply that by 5 when working in the main ED. The main ED is some heavier M/S patients, lots of tele and stepdown, and ICUs thrown in the mix.
In some ways med-surg and ER are similar. We are both practicing nursing. Depending on your unit, the work is constant and never ending.
However, in the ER the interruptions are 10fold. My phone (ascom) must ring 50 times a day. Sometimes when I go into see a new patient I am interrupted 5 times. The patients notice it too. The patients in med-surg don't comment on how many times my phone rings. (When my patient wants to borrow my phone (we have poor reception because we are the ground floor) I jump for joy because I have a break from those calls. Most are mindless.)
Imagine your busiest craziest day in med-surg x2 and always. That is the pace of the ER.
I think that if you have never worked critical care it is hard to understand the amount of effort and work it takes to deal with a critically ill patient. I don't think I ever spent 4 straight hours with a single patient until I worked in the ER. ICU nurses can understand the aspect of critical care, but they don't know what it's like (unless they've worked in the ER) to have a crashing ICU patient plus 3 other patients (one or two of which can be a step-down patient, a sicker tele patient, or another ICU patient who is hopefully more stable now).
Med-surg has codes like 2-3x a year. ER has codes much more often. They come in waves. Sometimes we'll have 3 codes a week and then we'll have a couple weeks without a code.
Can we find some similarities between med-surg and ER? Yes
I guess we each would have to work with each other to fully understand. The med-surg floor I work on has just as many codes as the ER called every week. I'm not exaggerating.
Mostly because we're taking patients that belong in ICU. Not blaming that on any nurse for goodness sake. I'm just saying the patients aren't as stable anymore.
I guess we each would have to work with each other to fully understand. The med-surg floor I work on has just as many codes as the ER called every week. I'm not exaggerating.
Mostly because we're taking patients that belong in ICU. Not blaming that on any nurse for goodness sake. I'm just saying the patients aren't as stable anymore.
Well your hospital must not be the norm. It is not normal for med-surg and ER to have the same amount of codes. We don't broadcast our codes. Many ERs do not. The last hospital I worked at did broadcast their ER codes and every other day we heard "code blue - emergency room." I understand that med-surg patients aren't as stable anymore. They can be unstable.
If your hospital has staffing problems and does not send patients to the appropriate level of care it is hardly an ED only problem, it is an institutional problem.
You can't put all your frustrations on the ED nurse who sent you a patient too sick for med-surg. Your problem is your hospital. Survive for now and get out when you can.
But you didn't change the field-started PIV??? Some nerve. /sarcfont/
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 agree with the posters who talk about the importance of teamwork and each department understanding that we all have different areas of practice and different roles in caring for patients.
I have worked in the Med/Surg setting before and now I work in the ED, I have transported patients with Chest Pain R/O ACS on telemetry to the Med/Surg floors and got them settled into a bed only to have the Med/Surg receiving nurse say "This patient has been here since 1 PM and it's 5:30 PM now and you haven't fed them dinner!". I will remain calm and realize that in their role this is a very important task that must be done as a part of the daily routine. My response is calmly and respectfully, "I apologize but the ED is busy and we weren't able to do that for this patient. He has had IV access established, fluids replenished, EKG completed/labs were drawn and I have gotten his chest pain, dyspnea, and GI upset under control. I know that he will continue to receive good care."
I have also transported patients up to the Med/Surg floor and had the admitting nurse ask why I didn't administer the patient's home medications from the admitting orders sheet. Again, I know this is an important task in this setting but not the priority in the ED. I take a breath and calmly explain that I have only just received the admitting orders prior to transport and most of the patient's home medications are not stocked on formulary in the ED as they are on the floors. I also explain that when I speak with the admitting physician/hospitalist I ask if there are any medications/treatments that need to be administered STAT in the ED and will do so prior to admitting to the floor which means that the other medications/treatments can wait until the patient has been admitted.
With that being said, I understand that each setting is different and it takes a special kind of nurse to work in that environment. We need to respect each other and remain focused on the task at hand which is the delivery of high-quality patient care and the safe transition of patients from one practice area/level of care to another.
Sun0408, ASN, RN
1,761 Posts
Post hijack!!! Sorry but I can't start a new post on my phone.
Anyone heard from Esme12, she hasn't been on in a month ??!!