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

**canoehead, BSN, RN** · Feb 13, 2012

For the OP,

I'm an old cranky ER nurse and I think you did fine. Sure I'd like a glucose, but I can get it, and the resp issues will still be there even if the glucose is 2. I'm also aware that you may have docs that don't want to come in and do a full assessment, or you might not have the supplies, and you might not have the time/experience to do the emergency interventions and frequent reevaluations.

If you just say the patient is coming because the doc ordered it, I'll want more info. If you give me a chief complaint, and a baseline, I can suck it up. I admit to being short sometimes to people that didn't deserve it at all when the dept is going to heck in a handbasket, and I feel bad afterwards. Let ME apologize to you for that other ER crank, as I know others have smoothed the way for me. You did fine, she was having a moment, and I hope you continue to give the great care. Those residents are lucky to have you.

rjflyn, ASN, RN · Feb 14, 2012

IM an old ED nurse and can be short at times but: Personally just let me know 1) whos coming, 2) what you did 3) make sure you send paperwork- its aggravating to get pts from LTC and have nothing then to have to do total guess work as the pt has no history with our facility. Lastly and more importantly give my a phone number to call when we are ready to send your resident back, we in particular have a facility that has LTC, independent, and assisted living; its a total pain to return someone at 3AM and not know who to notify or speak to before you just load someone in an ambulance and send them out the door.

PS you do something I and others wouldnt do, as there are others who do many other things.

JSJones,RN · Feb 15, 2012

I have been and ER nurse for only a few years and want to personally apologize for the way you were talked to. I also want to say that not all of us think the way the nurse you gave report to and VISEDRN do. You absolutely did the right thing by sending your pt to the ER. I guess some may say that I am confused as what I consider as emergent. Sure a glucose would've been nice but we can look over that. A patient with a fever of 101 who was given an appropriate antipyretic, such as APAP PO, and an hour later their temp is now 103?? That doesn't concern some nurses? To answer a previous question posed by VISEDRN, if my child had a fever that didn't respond to appropriate antipyretics, and the child was symptomatic, I would absolutely bring them to the ER. Should I wait until the febrile seizure to do so? As far as the labs and XRays being done out-patiently, that is completely acceptable for the stable patient. However, a patient with a temp of 103 and SpO2 of 82% with audible crackles doesn't exactly fit that category. For those who don't think the patient deserved a bed at your ER, let me change the scenario a little: You're on your way to your grandfather's or grandmother's for a visit, upon entering their residence, you find them in the bathroom with nausea and vomiting, they tell you they've taken APAP an hour earlier but when you assess their temp its 103, you hear audible wheezes without a stethoscope and they're slightly cyanotic (as I'm sure one with a SpO2 of 82% was)....would you call 911 and request them to be sent to the local ER? Or would you say "You'll be fine, take some Motrin, try putting some Tylenol up your rectum, cough...etc" As for me, I live with my Grandmother who is a hemiplegic due to previous CVA, have a 92 year Grandfather who is in great health for his age, and if either one of them were in this very situation, I'm pretty sure I'd have them evaluated by a ERMD. LTC/SNFs are so understaffed and until you're in their position, you shouldn't form a judgement based on the 'quality' of report you've received! I know how frustrating it can be to take care of some geriatric people however, I also understand that when someone who sees these people everyday calls me because they are concerned and know that something isn't right, its my job to assist in the diagnosing and treatment even if that only involves a simple assessment (part of holistic tx=assurance) because when you call to give report back to that LTC/SNF nurse (which I hope you wouldn't consider that a waste of your valuable time), they're going to appreciate knowing that their patient is okay. My mom, a RN, worked LTC/SNF for years as did I, as a CNA, and we developed relationships with our patients far beyond what ERRNs understand. They become some sort of a family. I, now a ERRN, miss that certain relationship as now I get to see my patients for a few hours if that. OP, you did a great job! I can only hope that the RN you gave report to was just having a bad, though I highly doubt it. Some ERRNs forget that working in an ER isn't always about the MVCs and the excitement of trauma, its about caring for those in need. I agree that a big portion of our clientele's perception of true emergencies is false, however who are we to belittle them and tell them to go home and call their PCP in the am?

wooh, BSN, RN · Feb 15, 2012

Thanks JSJones, it was good hearing from someone that's been on both sides....

DebanamRN, MSN, RN · Feb 16, 2012

Honestly, as an ED nurse, I can say: she is that way with everybody and getting report from, or worse, giving report to, these types is horrible. And by all means, send the patient. We don't mind. Better safe than sorry and btw, I'd do a septic workup on pt #2 and work #1 up for CHF. We have Advanced Nursing Interventions in my ED which help give the care the patients needs. You have the responsibility of caring for and creating a home for the residents. We all have a place in nursing, we are all important, and to put you down was unprofessional and inappropriate. I can't work LTC and I give you a lot of credit. Keep up the good work.

VICEDRN, BSN, RN · Feb 17, 2012

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.

I am sorry that you guys can not read what I have clearly written several times over.

1. I never said defy the doctors orders. I said ask for clarification. Go ahead and look back over my posts and you will see that is what I have repeatedly said. If you don't understand why the patient is transferring, then clarify. If you think the MD is hearing you say something that isn't what you see, say that. Plenty of times MDs on the phone are thinking one way and you are seeing another but I NEVER EVER said defy orders. (in fact, I reiterated it several times.) Plenty of times, you can say, you know I was thinking just that the patient needed x,y,z.

2. I already stated that I am polite, even cheery to everyone. I often get compliments on how professional I am. I don't mope through my shift and people don't avoid me. Sorry to break it to you. I understand that the LTC nurse might not know and even still, might not have any choice in the matter but yes, I am frustrated at what I plainly see as patient dumping. There are more options than the ER. Direct admit and/or primary care.

3. I told the OP in my first post that I saw niether of her patients but I definitely agreed that one if not both of her patients should go to ER. (Go ahead, find my first post, please, I beg you. :yawn: ) Glucose would have been nice but as STATED, not necessary.

4. To the person who asked: I have been hanging around here since 2008 (which is in my profile but we seem to be having a problem with verifying information that is readily available) and have been in EMS before this for years and been a nurse for about two years. So been around the block and I think, developed some informed opinions about what others can and can't do. You ask the MD to clarify and explain what you think in LTC. I know you can do it!

MJB2010 · Feb 17, 2012

ViceDRN I think it is pretty clear who you are and how you treat people. I also can't help but notice how all of your posts have been edited.

wooh, BSN, RN · Feb 17, 2012

I have been hanging around here since 2008 (which is in my profile but we seem to be having a problem with verifying information that is readily available) and have been in EMS before this for years and been a nurse for about two years. So been around the block

You forgot to mention your LTC experience...

Or if you have none, take it from those that have been there. LTC nursing is about as far from ED nursing as you can get. There's nobody there to help in an emergency. Imagine running your ED with only two licensed people in the whole place. No docs. Possibly no crash cart. (The LTC I worked in as a CNA didn't have one.) If a patient goes bad while the nurse is busy with their other 20-60 patients, they literally CANNOT be in the room to monitor them. And help isn't a code button away. It's however far away the nearest ambulance is. L

The patients you've listed with quick turnarounds could have just as quickly and easily turned the other direction. And LTC does NOT have the staffing to monitor a patient closely enough to make sure they don't turn the wrong corner while the nurse is busy with their 20-60 other patients.

LTC nurses aren't going to be able to stop what you see as "dumping." LTC nurses don't have admit privileges, so they can't direct admit. They can't increase their staffing. THEY ARE NOT THE PROBLEM.

I wholeheartedly suggest you read (or reread) the post from JSJones. Been in LTC and been in ED.

Esme12, ASN, BSN, RN · Feb 17, 2012

ViceDRN I think it is pretty clear who you are and how you treat people. I also can't help but notice how all of your posts have been edited.

Just to butt in for a moment. My posts are edited frequently when they are long. The auto-save doesn't work for me and I have lost MANY brilliant (at least tome) posts. Once posted it won't be lost....sso I post then edit to finish. Just saying.

VICEDRN, BSN, RN · Feb 18, 2012

ViceDRN I think it is pretty clear who you are and how you treat people. I also can't help but notice how all of your posts have been edited.

The same could be said for you since you clearly display a judgmental attitude about people you don't know that you read a few posts from but don't really pay attention to on the internet but I don't judge you that way.

I frequently edit my posts because I catch typos or I want to clarify a point that isn't well stated in my original posts. On some of my devices, its hard to read the post until its posted.

VICEDRN, BSN, RN · Feb 18, 2012

You forgot to mention your LTC experience...
Or if you have none, take it from those that have been there. LTC nursing is about as far from ED nursing as you can get. There's nobody there to help in an emergency. Imagine running your ED with only two licensed people in the whole place. No docs. Possibly no crash cart. (The LTC I worked in as a CNA didn't have one.) If a patient goes bad while the nurse is busy with their other 20-60 patients, they literally CANNOT be in the room to monitor them. And help isn't a code button away. It's however far away the nearest ambulance is. L
The patients you've listed with quick turnarounds could have just as quickly and easily turned the other direction. And LTC does NOT have the staffing to monitor a patient closely enough to make sure they don't turn the wrong corner while the nurse is busy with their 20-60 other patients.
LTC nurses aren't going to be able to stop what you see as "dumping." LTC nurses don't have admit privileges, so they can't direct admit. They can't increase their staffing. THEY ARE NOT THE PROBLEM.
I wholeheartedly suggest you read (or reread) the post from JSJones. Been in LTC and been in ED.

At some pioint, it just gets silly. Like super silly. I was responding to someone asking me how long I have been around here. I never claimed any LTC experience and I never suggested that RNs in nursing homes can admit which they obviously can't.

Like all nurses, they have a role to play in the care of their patients and that includes helping facilitate their transfer to an appropriate area of care. This goes for the ER nurses as well. I am aware of the staffing in LTCs. Its appalling and I certainly don't envy any LTC nurses the staffing. On the other hand, your staffing grid is also not the ER's responsibility.

I have JSJones's post (several times actually) and remain unpersuaded. I think its his/her opinion and that's it. It has value but also, like everyone, a bias.

TygRNoef · Feb 18, 2012

3. I told the OP in my first post that I saw niether of her patients but I definitely agreed that one if not both of her patients should go to ER. (Go ahead, find my first post, please, I beg you.) Glucose would have been nice but as STATED, not necessary.

I'll find your first post, oh, here it is.

The nurse was incredibly rude to you and it wasn't appropriate.
On the other hand, since I actively work in an ER, I would offer the following insight: we get so many nursing home transfers that are NON-EMERGENT and totally a part of the patient's overall state of health AND as noted by another poster, are only made worse by a transfer, that its hard not to become inpatient.
I agree with the assessment that giving a good report would also help. A lot of times when we recieve report, its sloppy, indicates that the "nurse" on the other end of the phone has no idea why the patient is being transferred (hiding behind your MD who should be admitting to the floor his/her own patients is NOT the right answer) and doesnt actually explain what you expect the ER to do. Conversely, its suggests that you do not understand what the ER might do for your patient.
We recently took in a patient with a fever from a nursing home. Guess what? We do nothing for that except given tylenol (yup, I saw what you said) and send the patient out if labs and x-ray are negative. Labs and x-rays are non-urgent and could have been done in an outpatient setting. Would you bring your 2 year old in just because he or she suddenly has 101.5 fever? No. You wouldn't.
Its become a dumping ground for nursing home patients that the MD doesn't want to actually admit to the floor and for nurses that feel overwhelmed, understaffed and frankly, underqualified at what they do (sorry, just sayin' that SNF is a tough world and isn't for just any warm body out there). I am sorry you bore the brunt of that.
Usually, I just smile and listen and move on with my life. There is nothing I can do if they are sending the patient out.

Hmmm, I see NOWHERE where you said anything even resembling, "I definitely agreed that one if not both of her patients should go to ER." Your implication was clear, you capitalized "non-emergent," and related a story of another patient with a fever who was simply given Tylenol, despite the fact that the OP's statement pointed to another cause for the fever, which you so obviously missed.

I also see no mention of "Glucose would have been nice but as STATED, not necessary." The word "glucose" doesn't even appear.So, I am sorry that YOU can not read what YOU have clearly written, you made a mistake, then kept down the path of said mistake, and now you're trying to dig your way out by claiming you never made the mistake.

Then you go on to say,

developed some informed opinions about what others can and can't do. You ask the MD to clarify and explain what you think in LTC. I know you can do it!

Well, allow me to inform your opinion a bit more, I've worked in LTC, and I can assure you, when you call that MD at 2am, once he tells you to send the patient out, he hangs up on you. Sure, you can call him back, but that will result in your getting screamed at, and your having to argue with him to be able to "clarify and explain what you think." When I worked night shift in LTC, I was responsible for the direct care of 60 patients of my own, plus I was supervising LPNs that covered another 120 patients. You don't have the time to argue with an MD about that one patient, especially knowing the MD is also overworked, at my facility, we were one of 5 that our MD covered, the smallest of the 5 (with 180 total patients at our facility). I get that LTC staffing is not your problem, but blaming the LTC RN won't fix the problem, if you're tired of being the dumping ground, contact your legislators, impress upon THEM the problem, because telling the LTC RN that you "know" they can do something they actually can't do won't fix a damned thing.