At what point do we realize that the ER is not all about dealing with emergencies? We constantly complain about 3 things:
People using the ER as primary care
People coming in with really stupid complaints
Drug seekers
We have a system that encourages people to use the ER as primary care. Think about the chronic ER pt's, and the care they are likely to get outside of the ER. The clinics and doc's they go to just cannot provide the standard of care we give them in the ER.
From the perspective of the chronic ER pt: Sure, I could go to a local clinic- or I could go to the ER. I will get a doc, who, by definition is at least pretty good. 50% of the docs out there graduated in the bottom half of their class, but they aren't practicing emergency medicine. Any labs, studies, etc will be done then and there. Even if I sit in triage for 6 hours, I will still get care sooner than if I got an appointment. And, it's not like I had anything really pressing on my agenda.
I have worked in 4 ER's and in all, the pt's have received top notch care. I trust the ER docs a hell of a lot more than I trust most of the family practice docs I see admitting pt's.
Let's say I am a chronic ER pt. Why should I go to anywhere but the ER? Either way it's free. (Most of the folks I am talking about pay nothing out of pocket) If I go to the ER, I will get great, immediate care.
As far as people coming in with ridiculous, micky mouse complaints: You may have noticed that these folks are not super high functioning in any aspect- work, finance, relationships, etc. It's not realistic to think that they would be any higher functioning in managing their health care.
On to drug seekers: Of course they are seeking drugs. They are addicted. If they were wealthy and addicted, they would just buy street drugs. Or shop docs till they found one to treat their fibromyalgia and anxiety. With luck, they can find a few docs willing to write Rx's. The drug seekers we complain about come to the ER because we give them drugs. Getting upset at an addict for fulfilling the needs of his/her addiction is pretty silly.
We treat every little pain with narcotics, it's no surprise how many addicts there are out there. We are part of the problem.
I am an ER nurse. I would love it if all my patients were like TV patient's: Normal people, minding their own business when all of a sudden, something out of their control happens to them. They aren't.
If I just wanted to work with sick people, I could work in the ICU. Those people are sick. Even on the floor, most of the patients are sick and in need of medical care. I choose to work in the ER. By making this choice, I know that I will be working, to a large extent, with people who really don't need an ER.
So- is there a point at which we stop being angry or frustrated at our patients? Think of it this way: If the only patient who came in were the ones who really needed emergency care, at least half of us would be out of work. Or working elsewhere.
to my fellow er nurses-please don't waste your time debating er nursing issues with med/surg, icu, non-er nurses. they only come into this er section because they are bored and want to ruffle feathers. we er nurses know that they will never know what we are talking about, how things go, or how we handle what we handle. we know that 85% of what comes into our er are real, emergent, life-or-limb threatening illness/injuries, and that no one else could handle these cases like we do. we know we are ranting about the small percentage that are tstl (to stupid to live). please remember they only come here because of their own feelings of inadequacy. they only state opinions, not facts, because they don't get it! i know that in all of my years coming and participating on this site i have never gone to a med-surg, or ccu, etc.. forum because i not only do not specialize in that type of nursing- i also do not care about it. i personally would never want to go there because i risk maybe making myself look stupid since i don't do those things that they do everyday. we know that our assessment skills are the best because they have to be, we have to figure out what is wrong fast, often with little info from the patient or family members. we understand that they keep quiet sometimes, and try to test our skills, even when it is not in the best interest of the patient. we know that the things that we encounter in one day, on one shift, no one else could even imagine. just remember that we know, keep using the er specialty area, and if you just ignore them, they might, just maybe, quit trying to come here and poo-pooing on our space. for we also know that unfortunately one day they will find themselves or someone that they love will require our quick-thinking, and compassionate life-saving skills-and then and only then will they be forever grateful for us er staff members. i would personally like to thank you all for what you do everyday-especially for putting up with all of the drug-seeking, non-emergent, system-scamming, fd cases that impede us trying to save the really sick people. they are only trying to “get your goat” and we have more important things to do!
Specializes in cardiac, psychiatric emergency, rehab.
Hmm,, maybe if you like emergency medicine you could come and work in the cardiac step down unit with multple system failures that often code. We need experts ! Come and join us!
I would love to work in the ER and did for many years providing psychiatric admissions. The ER is a frontline of medicine. Judgment is the front line of misdiagnosis and death!
We keep discussing this,.over and over and yes, I must admit that I do occasionally get on my soap box and rant on a bit myself. I believe that many of you are missing the point though.
To the OP, it is foolish to think that a pt with chronic health issues will receive better care in the ER than from a PCP. If you have DM, HTN, COPD or any chronic illness you need the ongoing, consistent care of a PCP. You need a doc who knows you, knows what meds your on, what meds work well, which meds not so well. You need a doc who can follow up with you and manage your care long term. You need the support of education and preventative care. This is not the role of the ER doc!
The examples of the child with belly pain and strep throat, aren't the types of pt's that drive us crazy in the ER. A child with belly pain could be an emergency. Now, I do often question the parents who swear their child has been screaming in pain for hours, and is running around playing, eating chips and soda and has completely normal VS.
The examples that irritate me, are the 22yr old, tripped and fell while walking to the mailbox, c/o R ankle pain, calls 911 and is brought to ER by EMS! When he arrives at ER and we see that this is his 23rd visit in 2yrs and is rude, loud and swears at the staff. He then explains (loudly) that he hasn't eaten all day and wants dinner, then when he has his 15th xray for the year and, again, there is no fracture he is furious when we explain that he needs to elevate the ankle, use ice and take motrin. After he screams and swears enough, he gets his RX for vicodin #10 and swears again about how we "don't care", about how he has a "tolerance" for pain meds and 10 won't get him through the night. Then he doesn't have a ride home and expects us to pay for a cab to take him home!
Those of you who aren't ER nurses, who haven't spent 14 hrs trying to get pts ready for cath lab, the blood hung for the GI bleed and a NTICU bed for the 50yr acute stroke,...all while listening to 22yr old ankle pain swear at us and threaten to sue for such horrible care,....please don't make judgments until you've been there, don't that.
As far as the poster who stated that it isn't in my scope of practice to diagnose. You are right it isn't. I can't diagnose and treat, then send you home. It is however my job as triage nurse to use my critical thinking skills to come up with the most likely diagnosis and treat accordingly. It is my responsibility to decide who needs immediate care and who can sit in the waiting room for a few hours. It is my job to collect as much info as quickly as possible and make a quick judgment as to what degree of care you require. If it's 2am, all 60 ER beds are full along with 15 hall beds, and there are 38 people in the waiting room, I must decide who needs to be treated next. The key here is that I am the one who makes that decision. This decision is not based on who makes the most noise, who has been there the longest or who thinks they're the sickest. I have a college degree, I have ongoing training, and education that qualifies me to make said decisions. There is a method to my madness and I know what I'm doing. My livelihood depends on me making the correct decisions.
The frustrating part about people using the ER as a PCP or free clinic happens when at midnight we fill the ER with colds, back pain for 3 yrs, had a car wreck 3 days ago so I thought I'd get checked out, drunk fell down (for the 12th time this month) etc,...then at 0100 we get three class I trauma's from an MVI on the highway just blocks from the ER. Now we are scrambling to move people into the hallway, the drunk is ****** because he wants his sandwich and the back pain needs more dilaudid but no one cares. Meanwhile, I have a 4yr old who is bleeding faster than I can pump it in and I need to get him to OR now. The poor nurse in triage is trying to explain to the Mom of the 2yr old with an earache that we have several traumas and she will have to wait longer and then in walks a pale diaphoretic chest pain who collapses on the floor.
My point here is that we in the ER are trained and staffed to treat emergencies. That is why we are here. That's what we do. I want to be there for you when you get broadsided by a speeding car. I want to be there when you are having chest pain. I want to be able to see your Mom when she suddenly has slurred speech and can't seem to make her fingers work enough to unbutton her shirt. When our resources are tapped with things that could wait until the next day, it makes my job very difficult and as far as I'm concerned, those who require true emergency care should be furious at those who take advantage of 24/7 service, and the laws that make us see everyone who walks through our doors no matter what the complaint.
Ok,..I've done it again,.....off my soap box,..for now.
I was the one that said we should not diagnose. It was not directed at you; but, was an attempt to make another poster realize that a judgement on an emergency room visit being warranted was not in the final diagnosis, rather in the presenting signs and symtoms along with the chief complaint.
This poster did not understand what triage is all about. My statement was made to advise the poster that the way the hypothetical scenarios were presented as being unwarranted ER visits, were actually quite warranted to bring the patient to the ER. That poster was using backwards logic by making a diagnosis which negated the chief complaints, something a good triage nurse would never do. I am sorry if you misunderstood my intention. I just wanted to bring that poster back on track to the reality of ER nursing.
Your post is well said and very accurate. You are saying what I was trying to say by referring to the differential diagnosis model that is used in the ER. What I didn't mention is that the rule out method is also used, going from most acute possiblity downward-why so many with indigestion get a full cardiac workup before being sent home with mylanta.
We spend way too much time defending ourselves to "non-ED" nurses....there is a reason we have "specialty" boards!!!!!!!! Like Adam Sandler so profoundly said "Go to your home"! Love you all,
It is however my job as triage nurse to use my critical thinking skills to come up with the most likely diagnosis and treat accordingly. It is my responsibility to decide who needs immediate care and who can sit in the waiting room for a few hours. It is my job to collect as much info as quickly as possible and make a quick judgment as to what degree of care you require. If it's 2am, all 60 ER beds are full along with 15 hall beds, and there are 38 people in the waiting room, I must decide who needs to be treated next. The key here is that I am the one who makes that decision. This decision is not based on who makes the most noise, who has been there the longest or who thinks they're the sickest. I have a college degree, I have ongoing training, and education that qualifies me to make said decisions. There is a method to my madness and I know what I'm doing. My livelihood depends on me making the correct decisions.
The frustrating part about people using the ER as a PCP or free clinic happens when at midnight we fill the ER with colds, back pain for 3 yrs, had a car wreck 3 days ago so I thought I'd get checked out, drunk fell down (for the 12th time this month) etc,...then at 0100 we get three class I trauma's from an MVI on the highway just blocks from the ER. Now we are scrambling to move people into the hallway, the drunk is ****** because he wants his sandwich and the back pain needs more dilaudid but no one cares. Meanwhile, I have a 4yr old who is bleeding faster than I can pump it in and I need to get him to OR now. The poor nurse in triage is trying to explain to the Mom of the 2yr old with an earache that we have several traumas and she will have to wait longer and then in walks a pale diaphoretic chest pain who collapses on the floor.
My point here is that we in the ER are trained and staffed to treat emergencies. That is why we are here. That's what we do. I want to be there for you when you get broadsided by a speeding car. I want to be there when you are having chest pain. I want to be able to see your Mom when she suddenly has slurred speech and can't seem to make her fingers work enough to unbutton her shirt. When our resources are tapped with things that could wait until the next day, it makes my job very difficult and as far as I'm concerned, those who require true emergency care should be furious at those who take advantage of 24/7 service, and the laws that make us see everyone who walks through our doors no matter what the complaint.
I do believe that we have made our point since no one has come back for more, that is also part of our job, educating the poor, ignorant, non-er folks about ways that they can help us fix this epidemic so that the real, emergency patients can get our undivided attention. Kudos er nurses on another job well done. This has actually turned out to be a great thread after all!!
As the OP, I just figured that at some point, we just have to accept that these pt's that drive us nuts, are just a reality. Given the structure of our health care system, it makes sense for for folks to use the ER for primary care. Bottom line is that, from their perspective, they get the best care in the ER. If, from their perspective, they got better healthcare from a PCP, they wouldn't go to the ER.
To the OP, it is foolish to think that a pt with chronic health issues will receive better care in the ER than from a PCP. If you have DM, HTN, COPD or any chronic illness you need the ongoing, consistent care of a PCP. I think pt's would get best care from their own PCP. Feel so strongly about the subject, I actually have one myself. Obviously it would be better if we had a primary care system that worked better. This guy has some thoughts on the matter: http://voodoomedicineman.blogspot.com/2009/01/emergency-department-abuse.html
Regarding addicts: Addicts of any kind will do what they need to do to get their needs met. As long as we give drugs to addicts, they will keep coming.
Regarding dumb complaints: Again- we have a system that does nothing to dicourage people from coming in with dumb complaints. Everybody has their own definition of a dumb complaint. How about: Anything you would not come to the ER for if an ER visit actually cost you something.
My main point is just that we have a system that doesn't work well. Getting angry or frustrated at those who participate in this system is pointless. (Venting may be therapeutic, but doesn't adress the issue.)
most ER nurse know what the problem is. What is the solution?
My main point is just that we have a system that doesn't work well. Getting angry or frustrated at those who participate in this system is pointless. (Venting may be therapeutic, but doesn't adress the issue.)
most ER nurse know what the problem is. What is the solution?
hherrn
Wouldn't it be nice if we could come up with a solution? A large part of the problem is personal accountability. People want something for nothing and expect someone else to step in and take care of them. I think this affects many issues in our nation, not just health care. Why would it be so hard to stop some of the blatant abuse of the system, for instance if Medicaid sees that you have 18 visits to an ER in 30 days, why can't they put a stop to that?! Is there a way to give you the option of 3 or 4 PCP's that you can choose from and tell you to see your PCP unless it's an absolute emergency? If an EMS unit is called to a home for an otherwise healthy person who tripped and has ankle pain, they should be able to say drive yourself to the ER, call a friend, call a cab! Calling 911 for ankle pain should be the equivalent to calling in a false report of fire or filing a fraudulent crime report.
I don't know the answers,..and yes it does help to vent to those who feel my pain. I honestly don't think the average person has a clue what goes on every single day in most ER's. Your normal, average, hard working citizen would be appalled by the millions of dollars spent by Medicaid for non emergent ER care. Coming to the ER at 2am for a pregnancy test should not be allowed and we as working citizens shouldn't have to pay for it!!
A nurse who makes a medical diagnosis is practicing out of his/her scope of practice. The ER works by consideration of presenting signs and symptoms, with a medical practioner using the differential diagnosis model. The diagnosis comes last, not first. By the time the patient gets to the floor, there is usually a diagnosis (or at least a r/o)- this is probably why you are having difficulty with P & P of the ER.
As I said before, you have some serious misconceptions of the ER environment & no matter what I say you seem to be fixed minded in your opinions. If you did not understand the point I was trying to make, I guess I would be wasting my time trying to explain things further. You are entitled to your opinion; but, please, as not to mislead people into thinking your opinions are fact, voice them as opinions. To call into question others' character or make blanket determinations from limited knowledge needs to be presented in a way that does not degrade.
Some ER nurses' posts here seem pretty degrading, as Loricatus pointed out. I understand the ER staff' frustration but the gallows humor of some of them is as distasteful to me as what I've heard from some cops who talk about the people they encounter. I guess we all have our pet peeves. Hey, I think you all do a great job. God bless!
We have a system that encourages people to use the ER as primary care. Think about the chronic ER pt's, and the care they are likely to get outside of the ER. The clinics and doc's they go to just cannot provide the standard of care we give them in the ER.
From the perspective of the chronic ER pt: Sure, I could go to a local clinic- or I could go to the ER. I will get a doc, who, by definition is at least pretty good. 50% of the docs out there graduated in the bottom half of their class, but they aren't practicing emergency medicine. Any labs, studies, etc will be done then and there. Even if I sit in triage for 6 hours, I will still get care sooner than if I got an appointment. And, it's not like I had anything really pressing on my agenda.
I'm an ED volunteer. Boston has a huge doctor shortage; PAs and NPs can't be primary care providers, thought at may change soon. Until last fall, there were no "Minute Clinic"-type walk-in clinics in my state.Boston;s Mayor is actively blocking them in the city; he wants to funnel people to Comunity Health Centers, which have very limited walk-n hours. When my last PCP dumped me, it took me 6 months to find another one, and I don't live in the boondocks. I ended up going to the ER for a strep test.
A lot of people come to the ER because they can't wait 3 weeks for an appointment with their PCP. Others get sent there because their problem would take longer than a 10-minute office visit. A lot of people get sent there for x-rays and MRIs. We also see a lot of tourists.
Hubby is developing an eye infection. He called his PCP, and they said they could see him in 3 weeks. Fortunately, we're relatively close to a Minute Clinic. He went this morning. They couldn't help him, but they called his PCP and got him a same-day appointment. How screwed up is that?
:flowersfo :smilecoffeeIlovecof :tku:
I_LOVE_TRAUMA, RN
185 Posts
to my fellow er nurses-please don't waste your time debating er nursing issues with med/surg, icu, non-er nurses. they only come into this er section because they are bored and want to ruffle feathers. we er nurses know that they will never know what we are talking about, how things go, or how we handle what we handle. we know that 85% of what comes into our er are real, emergent, life-or-limb threatening illness/injuries, and that no one else could handle these cases like we do. we know we are ranting about the small percentage that are tstl (to stupid to live). please remember they only come here because of their own feelings of inadequacy. they only state opinions, not facts, because they don't get it! i know that in all of my years coming and participating on this site i have never gone to a med-surg, or ccu, etc.. forum because i not only do not specialize in that type of nursing- i also do not care about it. i personally would never want to go there because i risk maybe making myself look stupid since i don't do those things that they do everyday. we know that our assessment skills are the best because they have to be, we have to figure out what is wrong fast, often with little info from the patient or family members. we understand that they keep quiet sometimes, and try to test our skills, even when it is not in the best interest of the patient. we know that the things that we encounter in one day, on one shift, no one else could even imagine. just remember that we know, keep using the er specialty area, and if you just ignore them, they might, just maybe, quit trying to come here and poo-pooing on our space. for we also know that unfortunately one day they will find themselves or someone that they love will require our quick-thinking, and compassionate life-saving skills-and then and only then will they be forever grateful for us er staff members. i would personally like to thank you all for what you do everyday-especially for putting up with all of the drug-seeking, non-emergent, system-scamming, fd cases that impede us trying to save the really sick people. they are only trying to “get your goat” and we have more important things to do!