Dempather

Hi all, Just wanted some advice from y'all about the difficulty I've had finding a new position in the ER. I have a couple assignments already under my belt + 5 yrs nursing experience (almost 4 in the ED). Is anyone else having difficulty finding positions, particularly in that field? I'm working with a couple agents that are saying the same thing -- there are less positions now than before -- but other RNs I've talked to on my current assignment are set up in their next spots. I know assignments are definitely there, but the ones I'm putting myself out to just aren't calling back. I have several certs including CEN, great references. I was a little pickier before, but I feel like I've been very open to all shifts, different places, etc. There are a couple places in the country I really want to go-- I wonder if it would be a good idea to apply for local agencies around there and work through them? Should I look for more agencies? Thanks!

::sigh:: Five years into nursing and I found that we have plenty things to blame ourselves for (i.e.: our OWN mistakes, how we respond to certain things, etc) and we work hard to control how often they happen and how we can do better next time (often I find this comes from just slowing down and thinking about what I'm doing -- which can be difficult when the time we're allotted is just enough for us to work on auto-pilot... no questions, just do do do !) However, somewhere along the way, we've decided to carry the burden of feeling responsible for the mistakes of everybody else. I understand where you're coming from... you missed seeing that the patient should have been tapered off Decadron. But, in all honesty, where in the heck was the person who wrote the order? I'm going to try to keep in check here, but did the MD/NP/PA decide to write the order and then take three weeks off?? If a day went by, ok. But a week? As important as it is to write an order for a medication, isn't it just as important to follow-up with these things? We're held accountable for the things we ask others to do, right? Delegation, delegation they tell us!! And if we don't, we feel bad. But look, if somebody else doesn't, we feel bad, also! Right, right... so it got through the MD, and got through the Pharmacy, and got through you... and you feel the guiltiest because you were supposed to be that final checkpoint (I used to be a soccer goalie and felt plain awful when somebody scored on me until I realized it passed by every other person on the field, as well). This, by the way, doesn't make mistakes acceptable-- I'm not saying that. But they happen, and we're human. Healthcare is a team sport (bear with the corniness)... and just like soccer, I'm coming around to learning this myself now (I still write posts for support ). I've been in your spot, and I'm sorry it happened to you, and the patient, and the whole crew but you can't carry all that responsibility. BUT, you can learn from the error, try not to drag yourself down about it too long, and do better next time. I thought the post that mentioned to "Be part of the solution" is very helpful. Having a clinical educator on the floor was something else I've learned can make a big difference. Make yourself better so you can avoid this, and maybe catch it for somebody else. We do the best we can with what we have and what we know. I read this over and I feel like I sound like a ramblin' woman. Ohh well...

"The fact that a lot of us have to do our learning on the job, in the moment, is unfortunately the nature of the beast. Better clinical education would help immensely! " I agree with this! I spoke with a couple nurses from the hospital regarding Fentanyl gtts-- which they state do happen, but with less frequency in this ER d/t a specialized pump that's used for controlled substances (that you have to be trained in to use?). Fantastico. As a traveler, I'm not sure if I'll be seeing one before my assignment is up. Thanks for your knowledge!

This forum is a great educational tool for the person presenting the case, as well as the people contributing to the discussion. I feel compelled to add that identifying what's "wrong" serves absolutely no purpose, and is quite frankly, irritating. It neither changes what has happened or promotes openness in others when they want to share their cases. In addition to what I mentioned before: I work in the Emergency Room and was waiting for an ICU bed when the patient went into failure. He had arrived and the dopamine was started on the previous shift. There was no CVP monitor at that point, UOP was approx 300cc from when the foley was placed during the arrest and transfer to the ICU approx 2-3 hrs later. The patient was also incontinent of a large amount of urine during the arrest, ? seizure activity which led to it?. ABG showed pt. was in respiratory acidosis. Appropriate changes to the ventilator was made to accommodate for that (change in tV and RR). Lactic Acid was elevated, and with the concurrent hypotension, I'm suspecting the patient was suffering from a later form of septic shock, which (to my understanding) increases SVR? If I'm wrong, please correct me. In regards to the atracurium, this drug could very well be outdated. This hospital is outdated (no computer charting yet). I've worked for other hospitals where this isn't on formulary. While the patient was restless and out of synch with the vent, my thoughts were on improvement of ventilation and CO2 clearance. I found it interesting that you mentioned "the medical directors hanging on to personal preferences" because the ordering doctor was a previous medical director who, I strongly believe, was hanging on to his personal preference. With all the hubdub, his repeat ABG was normal prior to transfer to ICU. Thank you for your feedback, guys.

Hi, I had a large male patient (~120kg) with a dx. of PNA/sepsis who went into respiratory failure. He was on a dopamine drip prior to this episode for hypotension. Normal RSI took place and he was intubated. Once his respiratory status was stabilized on the vent, it was difficult to sedate him with propofol and atracurium without dropping his pressure drop further. The Dopamine gtt was changed to Levophed because Dopamine was making him tachycardic, and his heart rate went back to SR after the switch. I titrated both the Levophed and Propofol accordingly, but I found myself balancing out his blood pressure and sedation levels the whole morning until I could get him to the ICU. He had also received a total of 2L NS in the ED. I'd like to get some of your thoughts on maintaining sedation in agitated patients who have been intubated. Especially those who struggle with hypotension. Prior to transfer, his blood pressure dropped and I had to hold the propofol. While I delivered him to the ICU with a stable blood pressure (which I'd prefer over perfect sedation and unstable vital signs), the sedation had begun to wear off and the ICU nurse was shooting me glares (we're not talking severe agitation, but becoming restless). I feel like I couldn't get the right balance prior to transfer. In my attempts to do this better next time, I'd appreciate some feedback from some of you guys -- what are your thoughts/what would you have done differently? Thanks a lot.

Somethings just have to go unexplained... we went three months without one motorcycle accident off I-95 and then separate incidents three show up in one shift. For the full moon theory, I had a well-seasoned ER doc explain it to me in such a matter-of-fact way. Full moon changes the ocean tides, why wouldn't it change our body if so much of it is composed of water? I can't argue that...

You know what? Once you're a nurse, your patients and colleagues won't respect you less for it. You sound solid, so do whatever you have to do to finish with little worry about what you need to do to get it done -- as long as you feel confidant in your education wherever you go.

Great-- thanks for the advice and laughs! :)

In the most impressive show of verbal diarrhea that I can recall in recent history, I thought I'd share this-- So I was trying to fuzz up my cover letter and was brain-storming things to throw in. I asked myself what the heck I've learned in the ED in the past three years. So I just let go and typed out every thought that came into my mind. Here's what I found I've learned when I let my mind go-- - how to move as quickly as possible - how to not make mistakes - how to stop saying i'll be back in five minutes when we all know there's no way i'll be back in five minutes - how to deal with a--holes - how to deal with people when i'm being unreasonable and now i'm too far in - how to be professional (sort of) - how to not cry when a patient dies and i'm dealing with the family (work in progress) - how to say i'm wrong - how to say i'm right (work in progress) - how to not freak out when i'm stressed - how to prioritize (ABCs,ABCs,ABCs). - ivs, ng tubes, foleys, moderate sedation, traumas, codes, cardioversions, drips, blood tranfusions, transfers, admissions, discharges, comforting, vital signs, fluid boluses, meds, meds, meds, shots, iv pushes, crowd control, priorities, following my gut, FOLLOWING MY GUT, learning colleagues are not always my friends but they're still my colleagues, continuous bladder irrigations, recognizing bullsh-t from actual DTs, learning to sound confidant even when i don't feel confidant, how not to cry in public, ekgs, rapid fluid infusions, wound care, blocking punches, biting tongue, letting tongue go, triage, triage WELL, restraints, vents, trachs, respiratory txs, suction, delegate, supervise, not yell......... Let your mind go a little crazy and add something... then we can be a little crazy together

I'm currently an ER nurse with some experience on tele. I'm considering a shadow experience in the OR or an eventual change over. Can somebody explain some of the tasks one would experience throughout the day? Do you perform assessments (lung sounds, heart sounds, bowel sounds) as a scrub nurse or circulating nurse like you would on the floor? I'm assuming in a sterile env't, you wouldn't carry stethoscopes... yes? no? My understanding is that you assist the surgeons with instruments, count supplies.... but I could be missing a lot ( I have a feeling that I am ) :) Thanks!

A GI doctor once told me to place an NG tube in warm water for a couple minutes before inserting it. Simple enough, reduced patient discomfort, and made the whole process a whole lot easier. What's yours?

When I used to work on the floors, it was free water flush q 6 hrs to lower sodium, like Suzanne said. The amount doesn't seem so concerning - usually they would say 200cc or something of that sort. Think about it. Would you drink normal saline (or salt water)? It's all going to the same place. :)

We had a patient come to us a while ago who was injured after a particularly gruesome accident. After the incident, word got out and people have called me about it, including well-intentioned family members of mine. What makes this wider-scale for me was that it made it's way out of the hospital and into the community. Even a close friend called in a mild hysteria stating she knew the patient well and wanted to know if I was there and if the patient was okay. I was able to handle the situation well and maintain the patient's privacy.. but I think my friend knew I was holding back information she knew I couldn't share (which hurt more). I think I can handle a lot, and I'm proud to be an emergency room nurse, but this floored me. I've been a little hazy since it happened. Can I call myself a good ER nurse if I don't let this brush off my shoulders and forget about it? Are we all supposed to be indestructible? I don't necessarily want to talk to co-workers because I don't want them to think I can't handle tough situations. An example here: One of my co-workers afterwards cried out, "WOW, I wish I was there.. that would've been AWESOME.. what a great learning experience!!!". I felt like reaching over and smacking her. But I caught myself wondering whether that "I'm hardcore" enthusiasm makes a person a better ER nurse? Or better ER doctor? Is that how we're supposed to be wired? Traumas are exciting. And it rushes the adrenaline. Mine was definitely rushing during the whole event, but I would never call myself enthusiastic. I would never leave a situation like this and call it COOL. I did well .... I know that's what matters. But is it enough?

Thanks much. That's what I needed to know. :)

Okay, let's talk a bit about this protocol. I had a young patient come into my ER s/p fall approx 20ft with impact to back Upon arrival, pt with no sensation below waist, no rectal tone, absent reflexes. Airway patent. Confirmed damage noted on CT and later MRI. Steroid protocol was initiated. This is my first encounter with the protocol. I'm familiar with steroids used as anti-inflammatories and using the med in this situation makes sense. However, after reading several articles, I'm finding that most research shows it's more harmful for the patient (infectious process, longer ICU stays). Does anybody have input on this? Does your hospital embrace this policy? Are there alternatives?

A close friend of mine is a medical student at Johns Hopkins. They recently created a new show called "Hopkins 24/7", which follows around the residents well... 24/7 :). He said everybody needed to sign a release to be on the show. I'm assuming the same would go with the patients. :-)

And oh lordy. I got a week longer than anticipated. A prolonged orientation sounds more like a crime on this post than what it actually is... the identification that one needs more help and actually comes forward and SAYS it without shame. How sad. I didn't think I really needed to drive that point home.

I leave the post for a couple days and it goes.. a little haywire. I don't wish to bring down management or complain about older nurses.. so nobody needs to get upset or feel like they need to defend one group or another. But I also can't control how my posts make others feel. I ask questions to learn from the experiences of others (right? that's why the board is here?).. not to rally troops against experienced nurses who teach through negativity and fear. Although, in a perfect world, maybe somebody should. Thank you for those offering your support. I'll take what you said with me when I have to confront this (or any other) unpleasant co-worker in the future.

Thank you for all the wonderful responses! Of course, these are things that I one day will pursue (and consulting you all further about!).

Hi Guys, I'm new to the ER. I've had experience in other specialties.. but have been on a slightly prolonged orientation since my transition to the ER has taken longer than I anticipated (as the manager put it, "I"m greener than we thought.. but that's ok!). I have this co-worker that keeps getting on my case.. asking me how much longer I'll be on orientation.. why I'm not off yet, etc. It seems so trivial, but it's bothersome to meet somebody negative when you just start your job. Anyway, this particular co-worker was charge one day. I was one of the floats and had a serious patient that I was trying to send off to the unit (the nurses on the other side were pushing off taking report for this patient for as long as possible). I guess my charge nurse thought he wasn't as serious and expected me to help other patients.. and went off on me for staying with that patient for too long. So, in the end.. she pulled me from the float position and put me with another nurse for the rest of the day. To boot, the floor nurses are annoyed because I'm persisting about giving report... my charge is annoyed because I'm not helping other patients... it's like a lose-lose. I don't know if she's going to go to the manager about all this... it doesn't seem serious.. but she seems like the kind of person that's never going to get off my case, period. She's also very clique-y. I hate to admit this, but it bothers me that she could turn the other nurses against me. I don't know if she's like this with all the new people. Has anybody had similar experiences? If so, what are some good ways to handle people behaving like this? She's making an otherwise incredible job seem burdening.

Do you think working in the ER has helped thicken your skin? Or is that something that's a pre-req for being in such a high intensity place?

Maybe a quote would help: "You'll always have your back faced towards one side of the world." Some days it just rings true more than others. It's impossible to make everybody happy. Just gotta do whatever it takes to sleep well at night. :) I would've done the same thing.

Hi folks, Has anyone (preferably females, males are okay, too :)) experienced nursing or traveling in Central America? I'm going on a medical trip to Belize and will be flying into Cancun, Mexico. To get to Belize, I'm taking a bus on my own and will be meeting the group in Belize City (it's about a seven hour bus ride with one stop to change buses). Please send tips for a sole woman traveler. How much money to carry, what to carry (are money belts useful?), what to look out for, what to be aware of.. etc. I've traveled on my own in the USA before.. but never internationally. I'm freaked... and excited! And for all you caretakers (i.e.: everyone on this darned site, I just know it), resist the urge to tell me what a crazy idea this is to do on my own. I've got two parents, two sisters, two roommates, and three best friends that can (and have) done that for you already. :nuke: Thanks!

Everyone has different perceptions of things. In my head, the image of a nurse may be different than yours. There are less spiteful ways of saying that, though. :)

Stamford Hospital is wonderful. It's a planetree and magnet hospital. The planetree qualification ensures that their care of holistic. They focus on respect, teamwork, accountability, honesty... all of those traits other hospitals talk about, but they actually do. Stamford as a city is a couple different things. Downtown Stamford can be a little run down, but around the hospital and other areas is nice, woodsy. Very nice drives around there. I'd do it. Good luck!