ER nurses (or any RN), what would you have your tech do?

Unfortunately, even water can be an order and these guys with God complexes will undercut your common sense just to assert their dominance.

You did right. The nurse who followed orders - well, maybe she's had run-ins with this doc before. I don't know.

that's a tricky situation since the doctor's order opposed the ER P&P.

for a patient with a partial thickness burn with closed blistering, it's ok to first emerse the hand in cool, sterile water to decrease pain and stop the burning process.... usually about 30 minutes or so is good enough.

now, if the patient came in with blisters that were wide open and seeping, i would say that the running water is not a good idea--can increase the risk of hypovolemia.

did the patient have open or closed blisters? this may have made the difference in the doctors judgement.

if the patient's blisters were closed, he may have ordered the dry, sterile dressing to try to protect them and let them open on their own and prevent any infection. also, petroleum and adaptic dressings CAN hold heat and increase swelling and pain if used on a raw, fresh burn.

the dressing 24 hrs after the initial dry, sterile dressing should include a layer of adaptic, tho. this layer over the skin would help prevent any maceration or further tissue damage from when the blisters open and the dry gauze sticks.

he also should have ordered at the least an NSAID for this patient to help with the swelling and the pain. some doctors order PO abx too.

anyway, if the nurse really felt like the doctor was violating hospital policy and had put the patient at risk, she should have involved the charge nurse or the house supervisor.

The blisters were closed. Although now i'm a bit more confused because with the grease fire burn a few months ago (third degree to the hand) during my training, the tech had Dr. oders to run the sterile water. It was then that I learned her fancy poke the holes trick. Different Dr, different approaches?

/sigh

So much to learn.

tx of burns is varied, depending on thickness and severity, health of the patient, and the cause of the burn (ie scalding, electrical, chemical, etc).

for a grease burn, it's a little different, bc those usually are a little ugly. grease burns usually blister and pop quickly and the substance on the skin can hold in the heat and increase risk for infection. lots of times with grease burns, you'll see the wound being cleaned with sterile water and somewhat "debrided" to clean out the foreign material, gunk and dead tissue and covered with an abx ointment like silvadene. these pts will sometimes get a tetorifice shot too.

if that pt had a third degree burn, those do not heal on their own without intervention. usually, second degree burns do.

Ah, thank you flight nurse. It makes more sense now.

I'm still bothered that he would not let us relieve her pain until the meds kicked in. But I suppose this is a small thing and not worth it to my nurse to take up with the Dr as pain relief is on the way anyway via medication. It was stressful to the patient and her husband, but she isn't going to die. She will be ok.

I appreciate the feedback. Understanding why helps very much.

I don't like that Dr. though. If it were my child, or my husband, I would be very upset. I wish he was more...kind I guess. Ah well, I need to toughen up anyway.

Ah, thank you flight nurse. It makes more sense now.

I'm still bothered that he would not let us relieve her pain until the meds kicked in. But I suppose this is a small thing and not worth it to my nurse to take up with the Dr as pain relief is on the way anyway via medication. It was stressful to the patient and her husband, but she isn't going to die. She will be ok.

I appreciate the feedback. Understanding why helps very much.

I don't like that Dr. though. If it were my child, or my husband, I would be very upset. I wish he was more...kind I guess. Ah well, I need to toughen up anyway.

you are welcome!

the ER is a stressful place to work. i worked in the ED for about 6 years, first thru EMS and then got hired on full time as a medic, and it takes a while to get comfortable. you will see allll kinds of things!

good luck to you. i admire your quest for learning :)

Very interesting thread and step by step of the thought process for this situation.

Sorry I have no knowledge of my own to add, just enjoyed reading it.

Just clarification flightnurse2be,

The poster said the woman had a 2nd degree burn to the back of her hand. You had stated in your post that after a half hour of water to wound the patient could become hypovolemic. Really? Just from a burn to the back of the hand? I am suprized that someone can become hypovolemic when treating a small surface area. I don't know a lot about burns, so I am just curious. Can you give more information?

Thanks,

alwayslearnin

Just clarification flightnurse2be,

The poster said the woman had a 2nd degree burn to the back of her hand. You had stated in your post that after a half hour of water to wound the patient could become hypovolemic. Really? Just from a burn to the back of the hand? I am suprized that someone can become hypovolemic when treating a small surface area. I don't know a lot about burns, so I am just curious. Can you give more information?

Thanks,

alwayslearnin

i just meant as a general rule of thumb, for a burn thats partial to full thickness and seeping, that running water over it for that long could cause hypovolemia.... but for the burn to the hand that was closed (which is like, 1.5-2% BSA, it wouldn't happen unless that thing was really oozing) it was OK to do... the burn usually has to cover around 10% or so of BSA for fluid volume depletion to occur.

ETA: i double checked in my paramedic textbook just to make sure :)

Thanks for the information. Good learning thread!

alwayslearnin

What would I have my tech do? I would have the tech be the primary on ALL of the tasks within their scope. Unfortunately, many ER RN's have become task oriented. The techs see the RN ONLY doing tasks, plus meds and hopefully an assessment. Therefore you have the statement by a few techs that "I can do everything a nurse can do accept give meds". The RN's should be assessing, reassessing, educating, collaborating, anticipating and driving the plan. The RN should be secondary on the tasks. Unfortunately, this has not happened and thus you have the role confusion (or resentment depending upon whom you speak to) of the difference between a tech and a nurse.

Wow, that is a very good and insightful post Mcvaragon. Especially in this case as I was left very confused. I would still be very confused if not for these boards, quite honestly.

I know my role. I am merely the helper. I am that third set of hands that can help things run more smoothly. That's it. I get this.

But still...

Your post is so spot on with some vague feeling in the back of my mind that I catch myself rereading it. I have to sleep on it and consider it more in the morning, I think.

Before I leave I have to ask myself, WHY do I feel I should've "done something different?" This is incorrect and illogical. This is not my role. I am a tech, not the nurse, and I did my tech job like I should've. And yet I feel there was something wrong with this picture.

It may be because the RN did not give me any direct instructions, actually. I was the one that approached her about the water. I was the one that decided to have the husband to continually apply the water. I was, well, being the nurse. The nurse wasn't there but to give meds (it was slammed and she was very busy) nor did she say anything about/for the patient to the Dr. She didn't even look at the wound except to wrap it in dry gauze when all was said and done. I felt her role was unfulfilled in this case?

...

Well, if that's it then I need to get over it. First of all, a second degree burn is not a huge deal for heaven's sake. Second, my nurses will be slammed more often than not and I am not here to demand they hold my hand through the trivial. I want to help, which means I need to apply some critical thinking skills and pull my weight.

Having said all that, I think I would've appreciated my nurse to assume her role there very much. Just anything, really. "Bring me another set of vitals in 30." Or "Make sure that's kept sterile." I suppose that's just rookie nerves talking?

Wow I over-analyze.