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

[Washoften]

I am a new ER tech in a small town hospital. I have recently finished orientation and am still far from comfortable, as it's clear I have a great deal to learn. I would never, ~ever~, second guess one of my nurses (I adore them) let alone a Dr. Though I'm new, I can already see we have a solid crew and I trust my nurses and Dr's.

But I think we did wrong by a patient on my last shift. It bothers me very much. I talked to my boss about it today in fact to get some feedback on how I could've handled this better. I'm posting to get some feedback from more nurses in the hopes of learning how in the world I should react to situations like last shift.

At 2200 a couple arrives. They had tried to relight their water heater pilot and the wife burned the back of her hand pretty badly. As I am new, I have only seen one comparable burn (kitchen fire grease burn). This particular case was a pretty good second degree burn that spread between her fingers. She is crying (of course) and the husband is terribly anxious as he can do nothing for her.

I get her vitals to triage, settle her in a room and immediately ask her nurse if I can apply sterile water via the fancy poke holes in the top and turn the bottle over trick. "Of course. I have the basin there already" she says, so I set to it.

It's crazy in the ER. It's a full house, another nurse is calling for my assistance in another bed, a baby is still screaming in triage, we've run out of IV start kits, you know how it can get. I need to get out of this particular room and help. So I instruct the husband to glove up. I tell him to be certain not to touch her hand, but keep the water running on it. She jokes that I ~must've~ put some sort of meds in the water, it took so much pain away. I prop her elbow up with a pillow. I set two more prepped bottles by the husband in case we (Dr, nurse or myself) can't get back to them soon. I leave the room feeling proud. The couple came in stressed and in pain. Now she is not in pain and the husband is not anxious as he is helping his wife. They are even joking with eachother, saying that he looks so handsome in gloves he should've been a nurse. All is well, and I move on to assist elsewhere.

It is 20 minutes before I can get back, roughly 10 minutes before I am off shift. I don't want to leave without making sure they are ok, so I stop in while the nurse is giving some pain meds. Husband is still applying water. All is still well. I am feeling good.

Dr. comes in. I have never worked with this Dr. before. He is a traveler (I don't think that means anything, just something I noted) and we haven't even introduced ourselves. He quickly assesses the room and says, "I don't know what's going on here. I didn't order this."

The oh-#*$# feeling comes on.

He stands there looking at the hand. He looks at me. "I want this wrapped in dry guaze. Medication will take her pain away more than water." Then he looks to the patient. "So tell me, how did you do this? ...." and so forth. He leaves shortly thereafter.

I'm left standing in the room thinking...? Dry gauze. No silvadene? Not even adaptic? I look at the nurse and she's already at work. She took the bottle from the husband and started drying the hand. The wife starts to cry again. It's 3 min before I'm off shift. I stand there a while, tell them they'll be ok, then turn to leave.

As I'm walking out of the ER a few minutes later I turn to look in their room. The last thing I saw before I left was the woman crying in the bed, her hand in a dry dressing, holding it over her head to stop the throbbing, the husband shifting back and forth back and forth in nervousness STILL GLOVED! Everything they need to take away the pain RIGHT IN FRONT OF THEM. Bottles of water, a basin, even a pillow for her elbow!

I haven't seen that much in my little ER. I'm new, like I said. I've seen a shooting, some stabbings, a couple of good MVA's. Lots of sick people, a miscarriage. Nothing has ever really ~bothered~ me about it. It's actually been a wonderful experience. But this...this felt like torture to me. Why did he stop us from helping her? Why? Why didn't the nurse stand up for her? Let the water take the pain until the meds kick in at least. I mean, helping her was at verrry little cost to the hospital. We don't pay her husband and water is cheap, you know?

I think just knowing why will help me with this. Why did he order that? Is he worried about contamination? Why didn't the nurse say anything? Are they not supposed to? What am I supposed to do? Nothing I suppose. I know my place.

It just bothers me. I went to my boss this morning to get some feedback. My boss is very maternal and protective of her staff, yet very authoritative. Just being in her office recounting the story of that poor woman I started to cry like an idiot. Now I'm embarrassed and don't want to talk about it anymore. She said that I shouldn't worry about what that Dr. said, that I did the right thing. Policy is to apply water and I asked my nurse before hand. She was surprised he didn't order silvadene and floored he stopped the water. She said she should talk to him. God I hope not. This isn't worth any drama. It was just a second degree burn. Nothing truly serious.

But it bothered me. I don't think we did the right thing. She says I will see lots of this kind of thing in the ER. Man, I hope not. So I'm left here just...confused....and waiting the day when I have more education and my RN to stand up for patients like that woman.

I don't know. Am I being too silly?

[SuesquatchRN, BSN, RN]

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.

[flightnurse2b, LPN]

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.

[Washoften]

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.

[flightnurse2b, LPN]

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.

[Washoften]

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.

[flightnurse2b, LPN]

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 :)

[John20]

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.

[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

[flightnurse2b, LPN]

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 :)

[alwayslearnin]

Thanks for the information. Good learning thread!

alwayslearnin

[mcvaragon]

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.