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nurse2033 26,666 Views

Joined: Jun 6, '07; Posts: 2,119 (46% Liked) ; Likes: 3,078

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  • Mar 1

    There is blood on the toe of my right shoe. It is not mine. It does not belong to the patient that is on the table in front of me who was in an automobile accident several hours ago --- surprisingly.

    Although it could have, but I know that it did not because all of his blood is rapidly running out of the blood vessels and into his abdomen. It is compressing his lungs and making it hard for him to breathe; making it hard for his heart to pump blood and carry oxygen to vital organs that so desperately need it.

    There are 8 people in this room and 7 of us are working to keep the 1 alive.

    He is no longer able to tell me where he is. The team works hard to supply volume in the way of IV fluids to keep his heart pumping. We have only one more bag of blood left.......

    Today wasn't supposed to go like this. Not for me and certainly not for him. I am exhausted. I want to cry. Every decision has a consequence. There is no room for what I want; not right now. How did we get here, to this moment?

    Earlier that morning..........

    We walk down the hall. I am talking rapidly to my collaborating physician with every detail --- everything I can recall --- and am struggling to reach the knowledge that may make a difference in this patient's life or his death.

    "What time did he come in?" "Where was the accident?" "What were his vital signs on arrival? On assessment? On admission?" "When did his condition change?" The questions come rapidly; one right after the one before. I realize how much I know ---- how much I have grown as a provider over the past two and 1/2 years, but also how much I do not know. She has an air of confidence and projects that with every word she speaks. I am glad that she is the one by my side.

    When I was in middle school and we played volleyball in gym class, my job (in any position) was to stay out of the way of everyone else so they could get the ball. I never wanted to let my team down by missing the "set" and losing points.

    Today, I am a key team member and "losing the game" means people die. I still don't want to lose and at this moment, the stakes are higher than ever.

    The ambulance crew has arrived. They work beside us. Everyone knows their role and position. Everyone plays their part. Decisions + actions = consequences.

    I look down at the splattered blood on the floor once again. Someone brings in a towel and covers it so that no one will slip in it.

    My patient is now on the stretcher and headed to the ambulance so he can get the surgery he needs that will save his life. Maybe.

    After the ambulance is gone and I have called the patient's spouse, I grab a sheet of paper and step out of the ER. I go to the cafeteria and make some toast.

    I sit down at a table with a pen and my paper. For the first time in a long time (ok, 6 months), I question whether I can do this. I take a deep breath. A tear rolls down my cheek. I wipe it away. There is no room for that today.

    I pick up my pen and poise it over my paper. I stare at the floor right in front of my feet. There is blood on the toe of my right shoe. It is not mine.

    So, I begin to write.........

    ** Details have been changed for privacy.

  • Mar 1

    The COACEP document contains great information and is worth reading and appears to be one of the main sources of information from which CHA developed their pilot.


    According to the CHA (2017), "the vast majority of those who become addicted to opioids, both prescription and illicit, received their first dose from a doctor".
    ^ An (un-cited) factoid mentioned in the COACEP document (meaning COACEP makes the statement somewhat conversationally; it is not referenced in their document either). I understand it's important for physicians to understand their role in the current state of affairs, but I find this sort of thing really unnecessary at this point. A significant number of people admit to various alterations in "prescription" use, too - not taking the medication as prescribed, taking medications that are not prescribed for them, etc. I find this (quoted) statement either "duh" or, at best, unhelpful, depending on how you look at it. Correlation does not equal causation, and this unfortunate statement implies proximate cause based on...? Nothing. Since we have been increasingly pressured to give narcotics even to children with run-of-the-mill pains in the ED and elsewhere, it's really no surprise that anyone who (eventually) becomes addicted to opioids may have received their first dose from a doctor.

    I work/have worked with too many physicians who I believe truly feel "between a rock and a hard place" - - we need to stop this vilifying of physicians right along with improving the way we treat patients. JCAHO/TJC/JC, IOM, plenty of other entities, patients, hospitals (and their associations), drug companies, physicians, and nurses are "responsible." The end. Time to move forward.

    Anyway, not so much a fan of hospitals and their associations (they're the same ones who will be lobbying against things like safe staffing and other issues directly important to nurses and patients, BTW)...but the COACEP document includes useful information.

    Thanks for posting!

    Colorado Chapter, American College of Emergency Physicians. (2017). 2017 Opioid prescribing & treatment guidelines: Confronting the opioid epidemic in Colorado's emergency departments. (D.E. Stader, III, Ed.). Retrieved from

  • Feb 13

    Interesting question, RNrythm. No, I haven't but am interested in the replies.

    However, I think I'm getting dementia from working with geriatric psych patients. Or it could be the aging process.

    And I'm only partially kidding about this, too. It's like my Dad use to say: "It's hell to get old!"

  • Feb 12

    Quote from Clucas19
    Thanks for the information. I'll just have to come to grips with the fact that I have missed my chance to do certain things.
    But! You can still serve the servicemembers by working for the VA or at a military hospital. LOTS of opportunities there. Check for jobs on, the VA and military hospitals post openings there.

  • Feb 7

    I just went through this. Took a job at the va. The day I applied I told my manager. Gave her notice. I was in her unit for 6 years. She appreciated the notice. Longer notice the better.

    However I don't see myself going back ever. 2 weeks notice is sufficient in normal business. Probably 6 weeks to 12 weeks for nursing.

    But at the end of the day don't jeopardize your opportunity in the VA for your old job. If your old job was great you wouldn't of applied to the Va right?

    if the offer is in writing and you accepted you could ask for start date to get pushed back. Va where I'm at is very flexible. But really I wouldn't change it. The job is too good of a job to jack around with start dates. The manager will appreciate you earlier than later.....

  • Jan 31

    I would contact the state BON, describe the situation, and ask their advice about what you can and can't do in those circumstances. I would ask them to provide me with a written statement (on the regulatory limitations on your situation) and show that to your director. I agree with Guy -- if you just go along with what your director wants, in violation of state regs, your employer will throw you under the bus in a heartbeat as soon as something goes wrong. Your director is not going to stand up and say oh, wait, it wasn't her fault, I made her do that. No employer is every going to care about you or your license as much as you do. You have to be savvy about protecting yourself.

  • Jan 31

    The Board of Nursing isn't going to investigate a verbal disagreement with someone in HR, let alone pull a license over it.

    You can't abandon patients that you never assumed care of.

    You are entitled to pay for the shifts that you worked.

  • Jan 28

    Without knowing your financial obligations I can't have an opinion about that. My gut feeling here is to take the longer/slower/cheaper route and keep your current job as long as you can.

  • Dec 4 '17

    If air evac is what you want to do, you really need to do Air Force. The Air Force has the vast majority of the flight nursing positions. We have flight nursing, which is fixed wing med-surg patients. CCATT is fixed wing ICU patients. TCCET is rotary wing triage and damage control.

    TCCET and CCATT nurses have an ER or ICU background; they are completely patient focused and are not considered flight crew. TCCET and CCATT are deployment teams, and the needs are high; it's likely that if you want to do either you'll be able to.

    Flight nurses come from a variety of backgrounds. Their focus is really more on in-flight safety and mission planning; they are flight crew, get the aeronautical badge, and crew rest. Flight nursing is a full-time job and they are always short-handed (due to their constant transient lifestyle)).

    Beyond the flight stuff, the AF has SOST (Special Operations Surgical Team). It's a formalized elite medical team of 6 members per team that travels with special tactics/spec ops personnel. They have try outs and have physical requirements far beyond the AF's standard PT test.

  • Oct 25 '17

    I'm a current active duty AF nurse. I can't tell you what the current recruiting climate is, but we have historically taken a limited number of new grads who didn't do ROTC (i.e. via direct accession). By the way, we consider you a new grad if you have less than 1 year of full time RN experience.

    I would highly recommend that you get 1 year of civilian level-1 trauma center ICU experience first and then start applying toward the end of your first year. If you join before that, you will need to do at least 2 years of med-surg at your first AF base before you'll be allowed to do ICU.

  • Oct 25 '17

    HooBoy that's a tough one.

    According to this very website the newer nurses are not feelin' the love. They're taking anything they can get, with some having to actually move away from home to get even an icky low paying beginner job. So there's two strikes against nursing already.

    And working with people is almost a given. Crabby, sick people or stressed out, short staffed co-workers.

    What about a morticians assistant? Dog walker? Fire tower lookout?

  • Sep 16 '17

    There needs to be an assessment of the patient's competence to make medical decisions in order to answer your question. These are sometimes referred to as the 3 "magic questions" required to make your own decisions: Does the patient understand what we believe to wrong them, do they understand the purpose of the medication/test/procedure in question, and do they understand the risks of refusing this medication/test/procedure. They can be totally kooky, but so long as they meet these three criteria then they can refuse. If they can't meet these criteria, then that must be documented, and questions about tests/treatments/procedures/medications must be directed to a surrogate decision maker or in emergent situations medical necessity may be used.

    I have seen situations where the solution is essentially 'lets wait until they can't refuse and then just do it', which is an illegal act.

  • Sep 3 '17

    "Please don't ask me to shed the impenetrable cloak of mystery which shrouds me"

    How's that?

  • Sep 3 '17

    Deep breaths. You can do this. Listen and learn.


  • Sep 3 '17

    Just like you, I went from ICU to ER. The first 6 months is rough. The flow is different, the documentation style is different. What do you mean you give antibiotics without a pump? :0) In such a fast paced environment what I have learned is to acknowledge when I need help and ask another nurse to help me with starting the patient care tasks while I document. This is great when you get 2 ambulances one after another. Or get a STEMI, code etc. Another thing that helps me is memorizing what questions are needed for your initial documentation and asking the patient while you are performing initial patient care. This takes time! But once you get it down it makes the process faster.

    For example, I'll walk into my pt's room who just got here by ambulance for abdominal pain. I will get quick report from EMS then ask pt "What brought them to ER today"? As the pt is talking I will be listening and doing initial vital signs. Then setting up for IV, labs. Based on what the patient tells me will I then ask more detailed questions.

    "I've been having diarrhea and I have stomach pain".

    From what the pt states I will then ask how long this has been going on, color of diarrhea, frequency, last episode, description on pain. Sick contacts, recent travel, febrile, recent antibiotics etc. By now I'm doing IV, lab work. After time you memorize what you say and what patient says.

    When I was thinking like an ICU nurse working in ER I would ask nausea, vomiting, and more questions. Write every detail down or bring computer in room. But as time has went on, I focus on what brought the pt here and what they state the symptoms are and what questions are the most important to ask regarding their chief complaint. If a pt does not state they were nauseas or having vomiting I am not going to ask on my initial assessment.

    When I am doing line/ labs I am asking the patient the questions that are required for triaging per my institution ex. Have you thought about hurting yourself recently. How much alcohol do you consume per week. Smoking status etc.

    Once I am finished I can document -not at bedside! The only thing I document bedside is if I am going over medication list and the pt does not have an updated list. If a pt has a med list bring it with you to nurses station, document them when you get a chance and then give it back to pt.

    As a resource the best thing I could have done is on my badge make a badge of references. One important reference is range dosing for RSI, even though you come from ICU I found that the ER can use different RSI meds- some that I've never used on the unit. It's always good to have a quick reference badge.

    Recently the most helpful thing to me was the "Dirty Epi drip". I had that written on my badge.

    After 2 years in ER I will never go back to ICU, I love it and have found my calling. I wish you luck and hope you get past your orientation. Message me anytime.