I get it, we on the floor don't see what you see- gunshots, knife cuts, fights, rape victims. But you chose that. Nursing is a wide, varied profession and ER is just a piece of it. So you work with firefighters, paramedics, police. Okay. But you're not a firefighter, paramedic or a police officer. You're a nurse. When you call the floor for report and we say we're too busy right now, we'll call you back, please don't call your boss, or the House Supervisor, and tell them we refused report. Again, I get it. Nobody is as busy as you. But we may have had our hands deep in poop, or in the middle of a dressing change, or with a doctor, or administering chemotherapy. Or we may be already getting report from the offgoing shift. And yes, another nurse is just as busy and can't take the report I would rather get first hand anyway. When we get report from you for a hip fracture patient and you say the BP is 191/92 and she has a history of hypertension, please don't get offended if I ask if you've covered the blood pressure. I know she's being admitted with a hip fracture and not for hypertension. But hypertension is something we're aware of, because it is also bad. If you send the patient up without covering the BP, by the time she's moved from gurney to bed that BP has spiked to over 200 and I have a possible stroke to add to that fracture. Will it kill you to walk over to your MD, the one with whom you enjoy a closer relationship, and ask for some Vasotec? And while you're at it, could you not forget some pain meds before you send the patient to the floor? You see, I have to call the admitting MD, that very MD your doctor just spoke with to admit the patient, and wait until he calls back, before I can give any medications. That can and does take hours. Meanwhile I have an increasingly uncomfortable, unstable patient and a family who is getting very concerned that this new nurse can't help their mother.
I'm sorry for the long post, but I just read another Megalomaniac ER blog slamming floor nurses as stupid and lazy, refusing report, fighting with ER because they're uncomfortable taking unstable patients ER wants to move because they need the beds. There is more than just you, ER.
oh please. That is ridiculous and you know it. MOST Er nurses would give you a basic neuro assessment on a stroke patient. SERIOUSLY. Don't put out this misinformation when you know it's absolutely false.
Seriously. :smackingf
Not meaning to offend, but these are two example of reports that I've gotten from 2 of the ED's on this campus in the last 8 moths or so. The thing with the pupils was last week.
Well, TBH, I go to a lot of chat sites..................well, three counting this one (Gamfaqs and another gaming site) and this is the only one where "OP" is used, at all. I don't see it in emails, texts, facebook..................no where except here.
So stop laughing at me. I feel like I need to eat worms.
Please don't eat worms. An ER nurse will have to take care of you if you do.
RNCCRN9706, Let's not forget that the "E" in ED stands for emergency, so if you are getting my pt in the ICU, chances are that pt was a true emergency. That said, we don't have time to hunt and peck for a more convenient site, we take what we can get fast. Policy in my hospital for emergencies is minimum of 2 large bore PIVs, and usually the best place to get them is the AC. And if someone is intubated, chances are good that the pt will need 3 or more for all of the drips he/she will be on, so you may be lucky to get those, let alone have them all somewhere besides the AC.
Then you have your morbidly obese person who might take an hour or more just to get ANY access, so we are happy with whatever we can find, and again, the AC is the most likely spot.
I could go on and on with those who refuse IVs in the hands and the elderly who have few veins that will hold up without blowing, etc., etc., but hopefully you get the picture. If not, then I can't help you.
The food thing too...it sucks for us and the pts when they roll up at 0100 and all we can give them is graham crackers and sugar free jello. But when it's in question what tests may be needed during the ED evaluation, it makes sense to not feed them.
Exactly! If you are getting the pt to your floor at 0300 but they were in the ED in the afternoon, that would likely have put them start of the evaluation process, at which point almost all patients are NPO. You should have already known that one.
The report thing and the dirty room issue etc...I try hard to work with the ED staff and not jerk them around. I have to admit, just on our floor, there are a few who have perfected that to a fine art. They generally don't get much slack from the ED b/c they have that reputation. But those of us who try to work with the ED nurses by calling back promptly for report or calling as soon as the room gets done being cleaned can usually get some extra leeway when we need it, b/c we don't ask for it that often. I try to embrace the philosophy that if I scratch your back you'll scratch mine, and that you catch more flies with honey. There's a handful of ED nurses I'd gladly do without...but many of them are pretty good to me.
As for waiting 2 hours to bring the pt to the floor, I don't know why you would think that the ED wants to hold a pt for 2 hours just to screw second shift, but that's your issue, not mine.
I don't know how it's done where you work, but when we call for an admission, we have to wait for the floor to give us a room. That is supposed to happen within 30 minutes, but it often takes much longer. So yes, it might well take 2 hours to get the patient to you since we still have to track down the receiving nurse for report once we get a room assignment.
There are also times when we know a pt will be admitted from the time they hit the door and we give the supervisor a heads up as soon as possible so everyone is prepared. In this case it might be much longer than 2 hours before you get my pt because we have TRIED to be considerate of everyone involved.
And don't forget the times when the doc has put in orders for admission, but then adds some tests or treatments that need to be done before the pt can leave the ED, and you have many valid reasons for a pt to take 2 hours to get to you besides trying to screw you.
Several of us on my floor have made it a habit to check the ED census at the start of the shift. If there's 50 pts in the ED and we've got seven open rooms, we know that we've got to get down to business b/c we're about to get hit hard and fast. It helps us prioritize and plan our shift so we can take report and get those ED pts right away.
Just had to add more two cents.
RNCCRN9706, The point you made below is actually a good one. Nurses floated to the ED are next to useless because they "don't know anything" when they get there and refuse to take an assignment. But guess what, the m/s nurses are not the only ones who do this! I can almost understand m/s being out of their element in the ED, but the one group of nurses that you would think most likely to be able to transfer their skills to the ED is ICU nurses, but they are just as guilty as the rest of them.
It's also not unusual for certain ICU nurses at my hospital to refuse to take a pt in ICU because they are too "unstable." Seriously? Or they want to tell us what meds/treatments/tests that THEY WANT DONE before they will take a pt. Maybe when they get their MD!
As I said in my original post, I work in a SMALL COMMUNITY HOSPITAL. Meaning that pt's admitted to my ICU would normally be admitted to the floor at the larger hospitals down the street from where I work. Most of my patients would not qualify for ICU care at larger facilities. They do here though...any pt on a nitro drip/cardizem/dopamine drip is in ICU regardless. ALL overdoses come to ICU before going to psych.
So, the 45 yr old with chest pain but negative first set of cardiac enzymes with PERFECTLY good veins all over his arms, so good I could put a 10ga in them? Yep, he's got a 20ga in his AC. Generally speaking, the nurses in MY hospital automatically go for the AC vein on ALL the patients....and that's generally the ONLY access they have. Doesn't matter HOW many drips they've got going. If a pt needs a pressor, I'll push for a central line, which requires the on-call anesthesiologist or the on-call surgeon to place. A lot of times that Dr will request that the pt stay in the ER until they get there to perform the procedure.
I perfectly understand when a pt has poor venous access...but that's not the case for EVERY SINGLE PATIENT that comes through our ER doors!
As far as med-surg nurses floating to my ICU...most of the time they are LPN's and couldn't take a typical ICU pt assignment anyway but more often than not, there are fairly stable, should-be-on-the-floor-but-the-Dr-likes-the-care-in-ICU-better patients that they are assigned leaving me with an utimately crappy assignment. Then when that LPN outright REFUSES to put my orders in on my new admission(they know how) I really get irritated and would just rather be alone than have triple the work to do.
Some m/s nurses are not cut out for ICU nursing...especially a lot of the ones where I work because they are all used to having a secretary AND an aide doing all the scut work that we ICU nurses have to do ourselves because we don't have those extra staffers doing it for us. It's frustrating at times but it is what it is. I've done m/s nursing before. No where did I put them down. Just saying what I see at MY hospital with the m/s nurses I work with.
I've been floated to our ER before. Only ever been there once before. Totally different paperwork than inpatient. Didn't know where a THING was. The ER charge nurse couldn't be bothered to show me anything. I got more help from the ER tech than the charge nurse that shift. Not one true 'emergency'...more like walk-in clinic type stuff, which is typical where I work.
seriously, you being an ICU nurse know that a patient coming into the ED without a diagnosis, we start lines in a LARGE vein to give meds/fluids rapidly - usually 18 gauge. Most CT's you have to bolus a patient with contrast and it has to be in an AC site. Trauma's and any unstable patient are going to get a large gauge IV in a large vein. Period. That is common sense ER nursing. Sorry if the site beeps with the patient bending their arm, but that is not our concern when we're trying to figure out what is wrong with that patient that is confused when they arrive and we know nothing about the reason why.... you can put some sort of elbow restraint to restrict bending if it's THAT bad.
Sounds like YOUR ER experience isn't great, but certainly don't clump that into ALL Er nurses are that way, just like I'll try not to group all ICU nurses into the group that all they care about are bowels and keeping cords untangled.
Keep in mind, a patient comes in, there are trauma docs, neuro team, etc ASSESSING the patient and their lung sounds. There a bunch grouped all over the patient, so you are writing their assessment as they call it out in their assessment. Often times you barely have time to write anything before a patient is wisked off for intervention or the floor. That's just how it is. There isn't any time to do a head to toe assessment on a trauma/critical patient that is just being stabilized and moving on. That is HOW IT GOES.
Your tone in your post is just nasty, I have to say. You have such disdain for ER nurses and it is quite misguided. You really don't know what goes on in an ER by what you posted.
MassED...
Please read my initial post...I WORK IN A SMALL COMMUNITY HOSPITAL...meaning, we are not a trauma hospital..we don't have neurosurgeons or trauma surgeons.in the ER...just a Dr who might still be in his or her last year of residency at one of the programs offered at my facility.
I never said I expected a complete head to toe assessment from the ER nurse. I DO however expect an assessment of whatever presenting system brought the pt to the ER....stroke? I want a neuro assessment...whether it's yours or the Drs. I don't think that is too much to ask. I've been told that when being given report that the nurse didn't check pupillary response. Really? Come on now. Even you'd have to admit that's basic nursing 101!
Prior to coming to this facilty, I worked in a level II trauma center SICU. When I was charge, I had to go to the ER to respond to trauma calls. So, yeah I DO know what goes on in the ER having helped out and also as a patient.
I guess dealing with quite a few nurses who seem to lack basic nursing abilities really brings out my nasty side.
So, the 45 yr old with chest pain but negative first set of cardiac enzymes with PERFECTLY good veins all over his arms, so good I could put a 10ga in them? Yep, he's got a 20ga in his AC. Generally speaking, the nurses in MY hospital automatically go for the AC vein on ALL the patients....and that's generally the ONLY access they have. Doesn't matter HOW many drips they've got going. If a pt needs a pressor, I'll push for a central line, which requires the on-call anesthesiologist or the on-call surgeon to place. A lot of times that Dr will request that the pt stay in the ER until they get there to perform the procedure.
I'm sorry, were we supposed to magically know the first set of cardiac enzymes were going to be negative? What if he was short of breath and the MD decided a PE study was needed? Need an AC vein for that.
A chest pain is the perfect candidate for an INT in the AC. I'm sorry we cannot instantly know the diagnosis at the time of triage so as to determine the most convenient site for you.
But, hey. We didn't realize we were the only ones able to start lines. So if you need multiple lines, we'll get them for you. You may not know the answer to this, but why would an MD prefer to start the central line in the ER? It's one of the dirties places in the hospital IMO.
I'm sorry, were we supposed to magically know the first set of cardiac enzymes were going to be negative? What if he was short of breath and the MD decided a PE study was needed? Need an AC vein for that.
A chest pain is the perfect candidate for an INT in the AC. I'm sorry we cannot instantly know the diagnosis at the time of triage so as to determine the most convenient site for you.
But, hey. We didn't realize we were the only ones able to start lines. So if you need multiple lines, we'll get them for you. You may not know the answer to this, but why would an MD prefer to start the central line in the ER? It's one of the dirties places in the hospital IMO.
At MY hospital the Dr's(usually DO's) would rather NOT take the elevator up to ICU on the 2nd floor. Why? I dunno. Laziness.
As for the guy with garden hoses for veins...we don't have a cath lab in house for emergencies so if a pt does have to have a cath, they get shipped to the Heart Center down the street. My ER doesn't do anything in triage other than take a quick history and a set of vitals...any procedure, like putting in an IV gets done if needed when the pt is brought back to a bed for further work-up.
All I'm saying is that if a patient has decent veins as stated in my example, the AC shouldn't be the FIRST place to insert an IV, from what I was taught.
All I'm saying is that if a patient has decent veins as stated in my example, the AC shouldn't be the FIRST place to insert an IV, from what I was taught.
As someone else mentioned, chest pain patient=possible CT Angio, which requires contrast. I don't know about the radiology department at your facility, but where I work, they will not inject contrast into anything less than 20g. in the AC. It's policy.
Additionally, the most common cause of cardiac arrest in adults is AMI; the chest pain patient is a patient at risk for coding, in which case, you don't want to be hanging NSS wide open into a 22g. in the metacarpal. In the ED, we're thinking worst case scenario.
Like you, I was taught to start distally using the smallest gauge possible, but that was in nursing school where the emphasis was generalized IV therapy, not specific to ED practice.
As someone else mentioned, chest pain patient=possible CT Angio, which requires contrast. I don't know about the radiology department at your facility, but where I work, they will not inject contrast into anything less than 20g. in the AC. It's policy.
Additionally, the most common cause of cardiac arrest in adults is AMI; the chest pain patient is a patient at risk for coding, in which case, you don't want to be hanging NSS wide open into a 22g. in the metacarpal. In the ED, we're thinking worst case scenario.
Like you, I was taught to start distally using the smallest gauge possible, but that was in nursing school where the emphasis was generalized IV therapy, not specific to ED practice.
Hope that helps.
For AMI at my facility, they get shipped to the hospital down the street as we have no emergency cath lab available as they do at the Heart Centers down the road... But as I've also stated 100 times, I work in a SMALL COMMUNITY HOSPITAL. we're not gonna do the CT angio..they'll do that down the street where they'll put their own IV's in anyway.
I believe the policy where I work is that the pt MUST have a 20ga for a CT angio, it doesn't have to be in the AC, at least not in my facility.
I wasn't taught to place IV's in nursing school. We were told any hospital we'd work at would have an IV team... ha ha ha NOT!! I learned IV therapy at the 2nd hospital I have ever worked at and was taught to start in the hand and work your way up. I rarely put in anything smaller than a 20ga and almost NEVER use a hand vein..I only use 22ga's on LOL's/pt's with no veins.
For a pt who does NOT have chest pain and is not a trauma/mechanically ventilated and HAS decent veins that Mr Magoo(and for those who are too young to know who Mr Magoo is, he was a blind cartoon character from the 1970's) could cannulate, does the IV HAVE to be in the AC? Just sayin......
Not meaning to offend, but these are two example of reports that I've gotten from 2 of the ED's on this campus in the last 8 moths or so. The thing with the pupils was last week.
But they are the absolute truth.
Does every report from ED suck? No.
Do some things get missed that oughtn't? Yes.
I think that's a fair criticism. While the type of report given by the ED is going to be, by nature, down and dirty, there are certain basics of nursing practice, such as an assessment of the specific system affected by the chief complaint, that ought not be neglected. There are good nurses and bad nurses in every area of nursing, and even good nurses can have days where they are not at their best.
And sometimes, the ICU nurses get hung up on details that aren't really relevant during the course of stabilizing the patient in the ED. I once had an intubated post AMI/cardiac arrest patient that, in the hustle and bustle of resuscitating her, assisting with intubation, confirming ETT placement, placing a temp probe foley, starting therapeutic hypothermia, and taking her for a head CT (all in the span of maybe thirty minutes tops), I had neglected to do a GCS on. When I called report to the ICU nurse, she wanted the GCS score. I had just told her the patient was intubated and nonresponsive without any sedating gtts (wasn't even making any attempts to bite or pull the tube), and her first question was "What's the GCS score?", not "What's her rhythm?", "What's her ETCO2?", "What's her core temp?", "What's her most recent set of vitals?", or any other more relevant (in my mind) question. Sheesh!
We can all come up with examples of poor communication or negative interaction with other units. I think it's far more constructive to try and remember that we're all on the same team, working for the benefit of the patient.:redbeathe I try to remind myself of that every time the ICU nurse wants to know what the patient got for their fifth birthday of what kind of toilet paper they use.
And sometimes, the ICU nurses get hung up on details that aren't really relevant during the course of stabilizing the patient in the ED. I once had an intubated post AMI/cardiac arrest patient that, in the hustle and bustle of resuscitating her, assisting with intubation, confirming ETT placement, placing a temp probe foley, starting therapeutic hypothermia, and taking her for a head CT (all in the span of maybe thirty minutes tops), I had neglected to do a GCS on. When I called report to the ICU nurse, she wanted the GCS score. I had just told her the patient was intubated and nonresponsive without any sedating gtts (wasn't even making any attempts to bite or pull the tube), and her first question was "What's the GCS score?", not "What's her rhythm?", "What's her ETCO2?", "What's her core temp?", "What's her most recent set of vitals?", or any other more relevant (in my mind) question. Sheesh!
I'd KILL for a temp probe foley!! Those are deemed "too expensive' where I work :0
More often than not though, I have to pull the report out of the ER nurses at my facility almost EVERY time. So are they ALL having a 'bad day' EVERY day?? I have to ask for a set of vitals...I have to ask about their labs but don't need a whole run-down, just want to know abnormals. I have to ask for an assessment of the presenting problem system. I don't think any of that is being 'hung up on details' but generally the basics so I know what to have ready in the pt's room BEFORE he/she arrives to the unit.
So stop laughing at me. I feel like I need to eat worms.
313RN, BSN, RN
1 Article; 113 Posts
Not meaning to offend, but these are two example of reports that I've gotten from 2 of the ED's on this campus in the last 8 moths or so. The thing with the pupils was last week.
But they are the absolute truth.
Does every report from ED suck? No.
Do some things get missed that oughtn't? Yes.