I don't want to judge, but I don't want to fall for ED abuse either!

[ParrotHeadRN]

Good morning! I don't know if I need to vent or ask opinions or what, but I have been feeling a need to share this for about a week or so.

I am new to the ED, have been in orientation for a few weeks now. I came from critical care, and while I don't feel I'm having a really hard time adjusting, I'm not loving it immediately like I did with critical care. I do love the people I work with, though, and that makes it easier. But that's not what I started this thread for.

I'm going to try to not write so much that it becomes a HIPAA violation.

A patient that was apparently well known to ER staff came in with gastric complaints. I wasn't really aware of the pt. for a bit because it was very busy and I was working elsewhere. I first noticed pt d/t frequent trips to the restroom, while bent over. Pt was apparently nauseated despite antiemetics and fluids. Continued to ask for antiemetics, was repeatedly going to BR, c/o emesis, but no emesis seen by staff. Pt to be discharged after all fluids in. Attending nurse had had enough when pt caught with fingers down throat in attempt to vomit. I offered to discharge pt. When I went into pt's room, I had prejudged the situation and was initially pretty sharp with pt having picked up attitude from staff and MD. When I'd first walked in, found pt with fingers down throat. Pt apologized for coming in and obviously being such a bother to us, was just at a loss of what to do. I suggested to stop trying to induce vomiting. Pt stated that vomiting relieved the nausea and if unable to vomit, would pass out; stated this had been going on for many years, uncontrolled nausea. Pt verbalized that he wished he was dead because no one could or would help him. The longer I listened to this pt, the more I realized I could be looking at myself.

My son suffered abd pain and constipation for years and we were told over and over it was emotional, take him to a psychiatrist, stop feeding into it, blah blah blah. Nothing I did helped and he was so little and so pale from not eating. I begged for help for years with no result. I truly felt at times it would just be easier if we would both die since I couldn't help him During an upper GI, spina bifida occulta was noted at S1. Now, gee, WHY would he be constipated??? He has been outgrowing it as he's gotten older, thank god, He's now a big strong healthy young man who is taller than me!

I've also had pain that was not taken seriously, that threatened my career as a nursing student because there was nothing anyone could, or would do. Finally, my doctor listened and I had an outpatient procedure that worked well and I was able to continue in school. BUT the depression and hopelessness that came with feeling that my pain would never end was awful and I remember those feelings, regarding both me and my son to this day.

SO, as I was sitting there listening to this pt, I started really identifying. I shut the door and we had a long talk about symptoms and what to do about them. Pt does have an appt at a large research facility some distance away, and we talked about taking a trusted friend or family member along for support as well as writing all questions and concerns down prior to going to appt. I told pt not to be blown off by the physicians and be adamant about receiving some type of treatment. Pt wanted one further dose of antiemetic, didn't state a particular kind, and physician turned request down although only one med had been tried. MD told pt there was nothing else to do. I'd also like to note that pt never rec'd, or asked for, narcotics.

What I really think is that pt is suffering from abdominal migraines. I'm not overly familiar with them, but I'm pretty sure it's a treat symptoms only kind of condition.

Now, this is what I've been thinking about. And I am NOT knocking the nurses or MD for their feelings. I am well aware that I am a baby ER nurse and I cannot in any way judge their reactions. I am concerned about MY reaction and how quick I was to jump on the bandwagon before seeing the pt. And I know that being an ER nurse means constantly seeing people who abuse the system. Is there a happy medium? While I don't want to turn into an uncaring person, I don't want to go to the other end of the spectrum and fall for everyone's BS. I truly feel in my gut that that pt was experiencing the symptoms stated and that because no one knew what to do, they decided pt was full of it. But what if I'm wrong?

I've been thinking a lot about this pt, and truly feeling sympathy because I know, as a mother and as a patient, what it is to be ignored because you've been labeled. I really hope the appt with the specialist provides this pt with some relief.

I don't even know what I am asking for, maybe just some clues as to what happened. Was I totally off base with this pt?

THANKS

PH

[Altra, BSN, RN]

I don't feel it's "judging" to stress to patients w/chronic conditions that they MUST obtain a PCP or see the specialist they are referred to.

While I obviously can't really say what's going on with that particular patient, what is beyond frustrating is when you see the same patients in the ER week after week w/the same complaint, who have not followed up appropriately.

[VickyRN, MSN, DNP, RN]

ParrotHeadRN, you are to be commended for your caring attitude and empathy. Your post reminds us all to not prejudge patients. I think the advice you gave him is the best that can be expected in an ER. An ER is not meant to "fix" chronic conditions. It is only a band-aid station for non-life-threatening chronic ailments, a place to be "treated and streeted." This client desperately needs to go to a specialist to find the true reasons for his unremitting nausea.

[gonzo1, ASN, RN]

Don't be too hard on yourself. I think you did a good job. It takes a long time to start to learn which patients are BS and which are legitimate. Until you start to have this skill it is okay to rely on your coworkers for some input into questionable patients. And if you trust the doctors you work with, follow their lead. Working in the ER can be an emotional tightrope and I'm sure sometimes we do make the wrong calls. Give pain meds to a pure drug seeker or not take a serious patient seriously. The important thing is that you are aware that this can happen and realize that it is something you will have to deal with on a regular basis. Try to go to some pain seminars and see what you can pick up on there as far as information in recognizing and treating the chronic pain patient.

You are right that we must try to be slow to label any patient, or better yet learn to not label them at all. This will always be a challenge.

Keep learning, learning, learning.

[southern_rn_brat]

My first husband was treated shamefully by our local ERs for years.

Just picture this....he had long hair, rode Harleys, had tattoos. About once a month he would wake up screaming in abdominal pain, vomiting and nausea. I was young (19) and we were dating. It would scare me to death. I would take him to the ER they would take one look at him and label him a drug seeker, give him fluids and send him home. Then he started having the added complication of having difficulty urinating. he was 24. The docs would tell him, your prostate is enlarged...go home.

A 24 year old with an enlarged prostate and no infection?

He would actually cry sometimes because of the way they treated him at the ER but I had no choice but take him because I didnt know what to do when this happened. He would be screaming at the top of his lungs.

I had taken him to doctor after doctor too and all said nothing was wrong.

Finally 3 years later, I took him to a different ER. They actually called in a urologist for the first time. This was the first time that ANYONE had ever taken a thorough history of him.

Had anyone ever done that they would have known quickly that his mother had Acute Intermittent Porphyria.

As soon as the doc heard that he called in an internist. It took a few weeks to get all the results back and we finally found out what was wrong and that it was porphyria.

Three years guy...three years of going to the ER, going to the docs, being labeled a drug seeker...three years before someone finally just sat down and took a history.

[ParrotHeadRN]

Wow, thank you all so much for your wisdom and experience! I do admit that I'm having trouble with the treat and street thing. Anyone with a critical care background knows that we treat and attempt to fix everything. This focusing on one thing only is taking a little time to get used to. I think pain control issues may arise for me because I am a VERY big advocate for pain control and accepting pain for what the patient says it is. I also suffer from migraines and there was a time about 2 years ago that they started going out of control and I landed in the ED of the hospital where I worked several times. The migraines would wake me up in the middle of the night and I could get no relief. Sometimes it took narcotics and sometimes I only needed imitrex or some kind of reglan/solumedrol/something else combination. On my last visit to that ER (in the hospital where I WORKED) the combination worked right away, thank god. But the nurse treating me said "boy I'm glad we didn't have to give you the big drugs this time." I knew right then that I'd been labelled, and was humiliated. Totally not the point of my post, but that is why I am not at all inclined to judge what another persons pain is. I wonder, though, how I will behave when the same person comes in again and again for pain meds. I don't know. Like I said, it's a whole new world for me, and I am muddling through the best I can. Kind of like life.

Thanks again to each and every one of you that shared.:kiss

PH

[TazziRN, RN]

I think the biggest and best thing you learned is to make your own decision about pts. You did good, Parrot.

[RunnerRN, BSN, RN]

I think the biggest and best thing you learned is to make your own decision about pts. You did good, Parrot.

I think not only to make your own decision in situations like this, but also to make your own assessment decisions. Story time....

When I was brand new, I was orienting in our peds area (about 2 weeks before being off orientation). Experienced triage nurse brings a 10 day neonate back, cc of "sleepiness" and "not acting right." Triage RN says "The kid looks great; I think they're just first time parents and need a little reassurance and education." So of course, I went in there with the idea that the big smart experienced nurse says the babe is okay and the parents are over-reacting. At the time, I didn't have a lot of experience with neonates, and assumed the decreased activity was normal for this kid. Come to find out the babe had been an NICU babe for hypoglycemia and failure to maintain body weight, and had only been home for 2 days. Blood sugar was in the 40s. Looking back, the kid was LETHARGIC (and that is not a word I use on kiddos unless they really are lethargic). Long story made slightly shorter, the kid was admitted to the PICU. Transferred to another specialty kids hospital 2 days later and learned he had a metabolic deficiency, care was withdrawn and he died. As soon as we got him upstairs, I lost it and needed to compose myself for a while -- I felt stupid as well as guilty.

Moral of the story? I learned really quickly that just because a nurse with more experience says something, I don't have to believe it or even act on it. I'm sure coming from a critical care background you've already come to that realization, but it is something I feel very strongly about now and try to help the other new grads figure it out the easy way.....

[traumaRUs, MSN, APRN]

ParrottheadRN - you did great! THat pt was lucky you discharged him. Learned a big lesson didn't you? Even our frequent patients get sick.

[andhow5, BSN, RN]

You did great! Make your own decisions and trust your gut instincts. You'll figure out on your own soon enough which frequent flyers are working it, and which of them are truly sick!