I'm trying my best, but seriously stop putting me down on the phone

[Catch22Personified]

For other ED nurses out there, I don't mean any offense with this post. I'd rather vent here than take it out on someone who isn't even involved. I may have just bumped into a nurse with an awful day or something.

So I'm still in a LTC/SNF dealing with my patients at night we were overstaffed so we actually had a reduced patient load for once 29 instead of 38 to 40. I was so happy so I could catch up on paperwork. However about an hour and a half before my shift ends I have two patients acting up. Using ABC's I had to prioritize what patients had to be attended to first.

One is a patient with respiratory issues with audible crackles when breathing that basically with lower level of consciousness and lethargy. Pulse ox was 82 and even with the rebreather it did not improve so I arranged to get the patient sent out. I gave report to one of the ED nurses and she asked me what the blood sugar was. I said I didn't take a blood sugar because it didn't occur to me since the patient had audible crackles and a non improving pulse ox. She proceeds to go off on me: "It's standard procedure! Are you new or something? We'll be waiting for the patient"

The second one was complaining of chills and had a temp of 101.5, so I gave him the existing order of tylenol for fever orally and told him to call me if he feels worse. An hour later I took his temp and it went up to 103 so I paged the doctor. The doctor asked how his wound packing drainage looked like, I come to see the patient and I see the patient is in the bathroom looking as if trying to vomit. I tell the doctor about the new onset of nausea and attempted vomiting. Doctor orders to be sent to the ER. I have to call yet again to the ED for report. Sadly it's the same charge nurse I explain the situation and this time she decides to blast me again: "What is it with you people? Don't you understand oral tylenol won't work in older patients. Next time do a suppository first before calling, not even worth sending him at this point." *I explain the doctor ordered the patient being sent out* "You should have still done the suppository, still does not change things. You nursing home nurses are something else."

Seriously, I've been working for less than a year and these are the first two patients I ever had to send out. Was I in the wrong in my actions? I wanted to lash out at the nurse for being an ass but I was seriously too busy trying to help my patients out. Giving a suppository to a patient who is alert and oriented as well as able to swallow pills did not occur to me anyway.

If my patients don't get admitted, I'll be happy to take the writeup from administration for wasting time waking up doctors, clocking out 15 minutes late, and ******* of the ED at the affiliated hospital. I thought I made the right choice sending them out. But to be put down by another nurse, I can see why a lot of my classmates have switched careers already.

[netglow, ASN, RN]

Vicedrn, There is not a nurse on this earth who will make decisions based on what you've said. What I don't understand is why this is too difficult for you. If you are going to work, you just have to start to understand the profession you are in, who does what (who can and cannot do what). If you don't look beyond the tip of your nose, you will suffer endlessly and spend your life making others miserable. The ER is not a sanctified place.

[zorabanks]

Nursing in a LTC/SNF is a hard job. OP, you did the right thing by calling the doc and following his orders. An inceased temp followed by nausea can mean a lot of different things in the elderly. And as long as that pt is not vomitting, APAP by mouth is fine and has worked for me plenty of times. For you hospital nurses who have never worked LTC/SNF the doc is not in the facility and do not know the pt like we do. If I'm calling the doc, then something is very wrong with my pt. Many docs that I have called really don't seem to care about the elderly pt, esp an on-call doc. Some docs are so rude!!!! Rude without cause!!! I had a pt who was full of fluid after midnight, SOB, of course he didn't have an order for PRN Lasix which is what he needed. I had to call and wake the doc up, who instead of just giving me the order, hung up in my face!!!! Really doc??? I had to call this man right back to get the IM Lasix order to provide sx management for my pt, who BTY was A&Ox3 and very happy to be able to breathe after med took effect. My point is nursing can be a hard, stressful, thankless job esp in LTC/SNF. We as medical professionals don't need to trash each other, but lets help each other and show respect. Here it is the OP hasn't been a nurse for a full year yet and has to encounter rudeness fro another nurse over the phone and even some comments on this board. ED nurses we have to call you along with the "500" other things we have to do just because we are sending them out! And if we don't get everything perfect on our end we get blasted for that too. So, don't be rude when I call and just take the darn report and move on. BTY, i have gotten MANY worthless reports from hospital nurses when receiving a pt. Hospital nurses, FYI...when you are sending a pt to LTC/SNF and they are on a controlled substance PLEASE have the doc write a RX on his/her little RX pad with their DEA # , med, dose, freq, rout, # to disp. and signature and send it in the packet. If you don't we can't order the med and will have to CALL you back!!! LOL If we have to get it from our doc, he's going to be really P_s_ed Off and give us an ear full... So, you see we can all learn from each other. Oh, the wonderful world of nursing!!!

[TheCommuter, BSN, RN]

Hospital nurses, FYI...when you are sending a pt to LTC/SNF and they are on a controlled substance PLEASE have the doc write a RX on his/her little RX pad with their DEA # , med, dose, freq, rout, # to disp. and signature and send it in the packet. If you don't we can't order the med and will have to CALL you back!!!

Although it might be off-subject, this is very true.

LTC facilities do not have Pyxis machines where we can simply pull MS Contin or Duragesic patches for a newly admitted resident. Without a hard copy triplicate, the remote pharmacy will absolutely NOT deliver certain controlled substances. In addition, many LTC doctors will not provide the triplicate unless it is a convenient time for them. Therefore, the patient gets to suffer in pain needlessly.

This is not a facility policy. It is a federal DEA policy regarding the disposition of controlled substances in LTC facilities.

[ClearBlueOctoberSky]

Thanks for the clarification Zora...

Like I said, new to nursing. I try to be logical, but I understand sometimes that ... well let's just say I understand.

[VICEDRN, BSN, RN]

Vicedrn, There is not a nurse on this earth who will make decisions based on what you've said. What I don't understand is why this is too difficult for you. If you are going to work, you just have to start to understand the profession you are in, who does what (who can and cannot do what). If you don't look beyond the tip of your nose, you will suffer endlessly and spend your life making others miserable. The ER is not a sanctified place.

I make decisions based on what I think is best for the patient and not what is best for me. I am an RN with a license who goes to work every week so now you have met one nurse on the face of the earth who does that.

The ER is a place for emergencies and I think the day is shortly coming when we see emergencies and otherwise, folks will be admitted to the floor. Unfortunately, the ER is an expensive place to order stat labs and I assure the insurance industry and medicare/medicaid system is likely soon to cast its eye on the practices of the LTC docs.

A little story from my recent stint at work: Recieved from LTC: a recovering stroke patient with blood glucose of 40, recieved an amp of d5 from LTC nurse, an amp of D5 from EMS and two from us. Labs drawn, pt fed, returned to LTC. What precisely did ER need to be involved in this for?? (For the record, pt given lantus, only ate sparingly before and no snack administered by LTC. Pt generally at baseline aside from diaphoresis).

Also: pt admitted to LTC folowing fall/surgery. LTC RN informed pt baseline pulse 40-70ish. 6 hours later, they packed pt back up and sent to our ER with a pulse of...40!!! (note pt was asleep and lying down at 0400 or so) You know what we did? NOTHING! Discharged the poor thing after she sat on our stretcher for 4 hours.

All of you asking me to be realistic are simply sugar coating what you are actually saying which is the MDs and RNs have the right to dump their patients on us and we should just be "more realistic" and shut up and take it. Well, kids, since these are my co-workers, let me assure you there are rowdy crowd unlikely to continuing accepting this kind of stuff.

[VICEDRN, BSN, RN]

That is some pretty big leaps and assumptions you are making there! Is this how the conversations take place in your head? Taking quite a bit out of context. You know you should never assume.......

Logical reasoning is never out of context. Its reasoning, right or wrong. Since you are so condescending and insistent that my line of reasoning is wrong, tell where your original statement that a nurse who sends a patient to ER because "dr said so" leads us other than to note that it is devoid of nursing judgment.

[tyvin, BSN, RN]

Botttom line...when giving report to the doc initially when the change occurs rememeber when demonstrating R of the SBAR that you do so with absolute confidence. This is the time that will influence the outcome. If the doc is confident with your R and it's a fever, crackles etc... it's best IMO to keep them at home (the facility). If you come off sounding unsure like you want the doc to choose the care he's going to send the person out just because he's not hearing what he wants to hear which is nurses who know what they're doing. In LTC the docs depend on the nurses to be their guide.

Nurses need to understand that LTC patients don't do well when being sent out. When I worked LTC I only sent out residents if they had fallen and I knew there was a break of some sort or another injury type situation. There are many other legitimate reasons to send them out but it's usually better to keep them home.

The confidence will come with time and experience. When giving the recommendation to the doc on the phone tell the doc exactly what you want done or put it in a form of a question (know your docs). I guarentee you'll get what you ask for everytime.

[missladyrn]

Logical reasoning is never out of context. Its reasoning, right or wrong. Since you are so condescending and insistent that my line of reasoning is wrong, tell where your original statement that a nurse who sends a patient to ER because "dr said so" leads us other than to note that it is devoid of nursing judgment.

You have already identified yourself as "THAT NURSE". You think you are smarter and more clever and everyone else is a moron. It is plain as day how you treat other nurses on the phone (and probably in person), the same way you respond to their posts here. You probably mope around most of your shift complaining and people avoid you.

You actually stated more than once that other nurses should not follow the docs orders. You then explained why we should ignore their orders. How do you even have a license? I feel sorry for your coworkers. Your officially the crab on staff.

Here is some advice. Be nice. Lighten up. Follow the Golden Rule. Quit being a crab in a shell.

[MJB2010]

Vicedrn, There is not a nurse on this earth who will make decisions based on what you've said. What I don't understand is why this is too difficult for you. If you are going to work, you just have to start to understand the profession you are in, who does what (who can and cannot do what). If you don't look beyond the tip of your nose, you will suffer endlessly and spend your life making others miserable. The ER is not a sanctified place.

I agree. No one is going to disregard the doctors order. It doesn't matter how we feel about it, until we have MD after our name we do not get to make the call.

[MJB2010]

Logical reasoning is never out of context. Its reasoning, right or wrong. Since you are so condescending and insistent that my line of reasoning is wrong, tell where your original statement that a nurse who sends a patient to ER because "dr said so" leads us other than to note that it is devoid of nursing judgment.

You stated to ignore the doctors orders. Where is the logic in that? I think you might be a bit burnt out on ER, perpahs you should give LTC a shot? Think of how much better you could make by educating all these doctors. Really, I think you should try it and see how far you get.

[catlvr]

This is quite true! The LTC facilities that will thrive are those that reduce readmissions. LTC nurses generally know their patients very well and know what they need - if we use SBAR and "guide" the physician based on our knowledge, we may be able to prevent sending them out - which often *is* in the best interest of the patient. If the facility isn't set up to do stat labs and to get stat meds, then then it is much more difficult to keep the pt at home, but this is out of the hands of the floor nurse.

e

Botttom line...when giving report to the doc initially when the change occurs rememeber when demonstrating R of the SBAR that you do so with absolute confidence. This is the time that will influence the outcome. If the doc is confident with your R and it's a fever, crackles etc... it's best IMO to keep them at home (the facility). If you come off sounding unsure like you want the doc to choose the care he's going to send the person out just because he's not hearing what he wants to hear which is nurses who know what they're doing. In LTC the docs depend on the nurses to be their guide.

Nurses need to understand that LTC patients don't do well when being sent out. When I worked LTC I only sent out residents if they had fallen and I knew there was a break of some sort or another injury type situation. There are many other legitimate reasons to send them out but it's usually better to keep them home.

The confidence will come with time and experience. When giving the recommendation to the doc on the phone tell the doc exactly what you want done or put it in a form of a question (know your docs). I guarentee you'll get what you ask for everytime.

[netglow, ASN, RN]

I agree with a lot of what tyvin has to say. When all is right with the world, stars aligning and such this is how we all want it to be.

Thing is the docs you call don't really know the LTC patients as much as some think. If called they often are reliant on the nurse - but having said that, it's not for professional reasons all the time, it's more just to be done with that call... they know they have to be called, but hate to be called - looking for the option with the least mental effort - whatever you want. The ER is a way for docs to CYA, and dependent on the LTC, fluids and IV antibiotics can be got at hospital. Sure vicedrn, you'd want an admit to floor, but there are few docs that will make a trip to actually assess an LTC patient for floor admit. So, your beef needs to be between the ER doc and PCPs...

Look in the end, an LTC nurse has to call for just about anything. Who are we kidding here. LTC is not an old folks home. These nurses have to deal with 30-60 PATIENTS not just old people play'in cards. Guess who is gonna get blamed for not catching something early enough.

Vicedrn, I just think that you need to read more on AN, to sort of take a walk in other nurses jobs and what they are about.