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.
Anyone with a fever and confusion "might" have meningitis, (or they might just have a uti or low sodium or with the chest pain, reduced cardiac output or reduced oxygen to the brain, hell, maybe he wasn't wearing enough oxygen at home) just like anyone with diarrhea "might" have c-diff, but we don't put on precautions unless proven (pt's don't like it and God forbid our press gainey scores go down, but that's another rant) the pt had no diagnosis of meningitis and it sounds like he had a bunch of chronic things going on. His vitals were stable. He was stable. Afebrile while in the ER for 12 hours. He doesn't even sound like an ICU pt. He had no drips, no respiratory failure, no abnormal labs according to op except an elevated wbc. Tele yes, but icu no
conveyed in report. The need for a tele bed or a private room is apparently of little concern for some ER staff. Awesome teamwork.
That's the thing, the pt had no DIAGNOSIS of meningitis, nor does he even sound like he has it. The pt's I've seen with meningitis were extremely sick/about to die. This guy doesn't sound like that. It's always a possibility (see my above post) and if the DRS who have a lot more schooling and experience than I do with this kind of stuff don't believe it enough to put it on the diagnosis or place the pt on isolation, how is it the NURSE'S fault and she deserves to be written up but no one else.
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 last few times that I had a patient who needed any sort of precautions, I didn't find that out until I was on the floor or calling report and I saw what the doctors were using for an admit diagnosis. The couple times that I did find out about all that before calling report, I'd already been in and out of their room, for several hours. At some level, all ED nurses are waiting to get sick with something really nasty - minor things like influenza are part of the job. And yes, I do call influenza minor. TB, meningitis...not so minor.
I have advocated time and time again that this patient needs an ICU bed, this one needs telemetry...do the doctors listen? Nope. I've sent up patients who have needed telemetry but their rooms weren't wired for it. How is that my fault? Am I supposed to keep a patient in the ED because I disagree with what unit they've been admitted to?
And on that same note, I've sent patients to the ICU who only needed a med/surg bed. Usually that's because of staffing issues, but there have been other times that the doctor has seen something that I didn't and they didn't tell me about it.
Look, it's obvious that you are upset. But automatically blaming the nurses for the decisions of physicians doesn't get anybody anything. I can talk at my docs until I pass out and they won't change their minds. Teamwork? We have it coming out of our ears, but when the doctor is in the middle of telling you something about your patient and a crashing patient comes in, you're suddenly the last thing on their mind. Your patients are considered stable, they've got a nurse to keep an eye on things and have been admitted.
Incompetent or lazy nurses work in all different areas of the hospital. Everyone is overworked and understaffed. We're all busting our butts to provide the best care while having more and more expectations/requirements added to our workload. I agree we all work better as a team when a little forgiveness for small errors/mistakes is given, and we actually acknowledge that each department is doing their best. Every area has their own skill set and goals, along with their unique struggles.
I would say I've seen a nurse from just about every department "drop the ball" before. Heck, I've dropped the ball myself. ED gets the bad rep because they are the initial triage point, and most patients who are admitted come from the ED. Unless it's truly critical or particularly offensive (it rarely is) then I don't make a fuss.
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.
!Chris
I have not read each post in this thread, but wanted to quote you because I really like what you've said. I am a med-surg nurse, and I cringed at your examples of the petty things you have been called about. Thank you for being calm and patient in how you responded. You have a great attitude.
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.
Don't dare compare ICU to ED because you will NEVER get a cardiac arrest admission whereas rescue will bring us a cardiac arrest in the middle of giving report and the nurses upstairs are so concerned if the MRSA screening was done. Then when we transport the pt upstairs, the receiving nurse is sitting at the station drinking their coffee and watching videos on their cellphone.
I'm starting to feel as though the report from the ED is useless bc they always give completely incorrect information as if they don't even know the pt at all. It's dangerous for the pt and the staff. I've heard all the excuses about being short staffed. I get it, we're all short staffed, but when pt/staff safety is at stake, something needs to change...period.
ER one night sent me a DEAD patient because they didn't want it on their record as "died in ER" (bad for statistics.) (The transporter told me the patient was dead before leaving ER.) So TRY to do an admission assessment/H&P on a DECEASED patient! But has to be done for the record. Talk about a WASTE OF MY TIME!!!!!
As a very busy floor nurse I understand it can be insane in the ER but although you are multitasking there is absolutely no excuse for not having vital signs in a patient ; hook them up to a monitor. VS are a very important tool needed to continue evaluating the patients status. Sending them to the floor without giving fluid boluses or having labs done in 12 hours is unacceptable and furthermore not giving a complete report to the accepting unit is setting the patient and floor up for a medical/life threatening disaster . On Med-Surg I am held accountable for completing orders, administering stat meds and fluids and reporting off correctly at the end of my shift even though some days I have admitted and discharged 15 or more patients. The lack of appropriate care is unacceptable! If tasks are not completed then report it to the receiving nurse so it can be done , that's team work. Not doing it and not reporting it is negligence.
ER one night sent me a DEAD patient because they didn't want it on their record as "died in ER" (bad for statistics.) (The transporter told me the patient was dead before leaving ER.) So TRY to do an admission assessment/H&P on a DECEASED patient! But has to be done for the record. Talk about a WASTE OF MY TIME!!!!!
Really? They purposefully sent you a dead patient? I call shenanigans.
It's funny that (with the exception of THAT guy, because he's "that guy") not one ER nurse has returned fire and called the floor nurses names, but the floor nurses have called us just about every name in the book.
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.
It is never my intention to "trash other departments." What it boils down to is that there needs to be more adequate staffing. Every department in the hospital where I work is short staffed due to inadequate hiring. Until that changes, things will only get worse bc it's impossible to keep up with everything without proper help.
kimmie4476, ASN, RN
107 Posts
Anyone with a fever and confusion "might" have meningitis, (or they might just have a uti or low sodium or with the chest pain, reduced cardiac output or reduced oxygen to the brain, hell, maybe he wasn't wearing enough oxygen at home) just like anyone with diarrhea "might" have c-diff, but we don't put on precautions unless proven (pt's don't like it and God forbid our press gainey scores go down, but that's another rant) the pt had no diagnosis of meningitis and it sounds like he had a bunch of chronic things going on. His vitals were stable. He was stable. Afebrile while in the ER for 12 hours. He doesn't even sound like an ICU pt. He had no drips, no respiratory failure, no abnormal labs according to op except an elevated wbc. Tele yes, but icu no