auto5man

I love this one....great idea. And I would add the 12 hour shift they work must be walking in our shoes in the ER. Perhaps they could work as a tech in the ER pushing stretchers for those 12 hours. Regards, David

"Large Brown Trout",,,GI and ER docs use this one to describe, after viewing a KUB, an impaction someone is going to have to go after (manual disimpaction).

Wow, lots of great responses here and I can identify with all of these. But the number one thing on my list that absolutely burns me is the holding admitted patients in the ER thing. I don't have access to the actual numbers, but a significant portion of the shifts I work, the only reason the ER is actually busy is because a large number of our ER beds are tied up with "Admit Holds" waiting on an available room upstairs. Regards, David

I have been wearing crocs the past two months and really like them, but I do experience the "trip" thing.... Maybe wouldn't be the best choice in a trauma center ER, though (not enough protection). The past four years prior to wearing Crocs, I wore Merrell camp mocs religiously. They are awesome shoes. The ONLY problem I had with them was that my feet sweat in them. If you wear cotton socks then they get wet from sweating, then you lose the cushioning value of the sock (Bad when on your feet for 12 hours). I compensated for this by buying synthetic extra cushioning hiking socks, which don't lose their cushioning even when damp from sweat. Still two disadvantages,,,,the hiking socks are about 10-12 dollars per pair, and the feet are smelling RIPE after 12 hours! The merrells were more comfortable, but I don't have the sweating problem with the crocs (with all the ventilation holes) and was able to go back to wearing 100% cotton socks. Sorry to sound so anal about footwear, but after a year long bout with plantar fasciitis, I never want to have on the wrong footwear again. Regards, David

My opinion based on 11 years of ER (anecdotal) experience.....LEARNED BEHAVIOR. I think research has proven, however, that there can be a genetic predisposition as well. Having an addictive personality, for example, can be linked genetically. But that doesn't mean the next generation doesn't have a choice in the matter and its just fate that they will be addicted to drugs?! "My big point of wonder is how have we turned into a society of wimps? I really think that some people expect to go through life without ever feeling any inkling of pain or discomfort. At the slightest twinge of being uncomfortable, they come running in before trying any OTC remedies. C'mon people...get real! (Drug companies could save a lot of money on those ads...sometimes I wonder if anyone listens to them!)" (SJT) ......the answer is that our government, and its social programs (solutions? lol) has created an entire society made up of millions of people who totally depend on someone else (your and my tax dollars) to meet EVERY need and think for them. Regards, David

Going back to the original question....using diprivan/propofol for conscious sedation. At my hospital it is against policy to use unless a patient is intubated, only anesthesiologists can administer boluses b/c it is considered induction, and it should only be administered in a central line. That being said, ER nurses are pragmatists, and if I don't have a central line at the moment and my freshly intubated patient is thrashing about but doesn't have a central line, yes I will administer diprivan. I will not use a line someone else started though without carefully checking it first and prefer not to use a vein distal to antecubital as the drug is tissue-toxic. Infiltration can cause severe tissue damage. There seems to be much confusion about this conscious sedation issue with MD's. I have been asked many times by MD's, without fail one who is a specialist in the ER on a consult (not one of the regular ER docs in other words) who asks me to give a diprivan bolus for a procedure. They seem surprised when I tell them I can't b/c its considered anesthesia at my hospital and out of the scope of my practice (and theirs too if they are not an anethesiologist, but I don't say that). Regards, David

I worked at Baptist my first five years out of school. Never say never, but I cannot imagine finding myself in a position where I would want to work for any Baptist facility in Memphis again. There are many awesome doctors and nurses working for Baptist and they do have great facilities ("spare no expense"), but it is their coporate philosophy towards nurses that I despise. PM me if you want more specific information. Regards, David

Someone has already mentioned it but its happened to me to on more than one occasion. Patients who use the ambulance service for a taxicab. They call 911 with a made up complaint and get transported to the ER, then leave AMA. The pickup location was of course miles away and they simply wanted a ride. The boldest bolt out of the back of the ambulance without even checking in. Most selfish and ridiculous....As the charge nurse I had been called to the triage area to explain to an irate young lady why a particular patient was going back before her (she had checked in first with her chief complaint of hang-nail); it was an older man with known brain cancer and a mental status change/neurological deficit who had checked in after her but gone back for treatment first. She was escalating and accepting none of my explanation of acuity. I got frustrated and said...."look, he's got brain cancer, okay?". She came back with..."well, he's already dead then and you should have seen me FIRST!". I was speechless....That was eleven years ago and I still havn't forgotten it. This poster hit the nail on the head... "These trivial complaints are generally not covered by any form of insurance and even medicaid is cracking down on non emergent visits. The patients are usually very angry when they receive a bill for $600.00 in the mail. More and more hospitals are becomming more and more aggressive at collecting on these bills also. The way to treat under educated consumers who utilize a resource for the wrong reasons is to hit them in the pocket book. Paying a huge bill will get them to think about visiting their primary care physician first or trying home treatments. People just dont want to think any more. They'd rather go crying to "Mommy" aka the "ER" than to try to take care of it themselves. We've created a very dependent society." I for one will be happy when the undereducated and unemployed/receiveing tax-dollar paid for insurance and benefits are penalized in a real way for the ER abuses. Like coming to the ER for tylenol and saying they can't afford it, but they have a pack of cigarettes in their pocket plainly visible. I've said it for years,,,,if the average citizen new what went on in the ER on a DAILY basis, i.e. saw how their tax dollars were being spent, there would be a popular revolt! Stupid people do = job security in the ER to a point, stupid people with private insurance that they work for to earn. Stupid people without insurance or with tax dollar paid for insurance, on the other hand, are bankrupting the healthcare system. Hospitals end up closing from losing money and this is happening all over the country. Regards, David

RichW, I particularly enjoyed your comments and take on the discussion. My experience as a male in a female dominated profession... Choosing nursing for me was almost accidental when I remember back. My upbringing was very traditional with definite ideas about the roles of men and women. I always had a very close relationship with my father (a lifetime of hunting and fishing toegether forged a close relationship) but he had a problem with my choice of nursing at first....I distinctly remember the rift it caused initially b/c of his "old fashioned" ideas of male and female roles. Socially things were very different in the world he grew up in compared to the world I grew up in so I could understand his feelings. I think it was just the initial shock for him that was hard, b/c as soon as he was used to the idea he had no further issues with it (perhaps mom gave him a good talking to...lol). My study path in college was a little less than deliberate as well, so perhaps he thought it was just another fad. I floundered around with several different majors trying to settle on a course of study. Nothing felt right. I never would have come up with nursing as a choice on my own either, b/c I had a fairly traditional attitude on nursing roles myself (nurses are women). My meandering path of course study in college brought me to a crisis of sorts, and a willingness to think in different ways. I had lots of girl friends at that time who were all nursing students....I can still remember the conversations. Them... "Have you ever thought about being a nurse?". Me...."Are you kidding?? Men aren't nurses!". Them...."Sure they are, we have LOTS of guys in our class". Me ..."Really?" ....and thats how the idea was born in my head. I wasn't sure if I could even tolerate the sight of blood ( I was a business finance manager at that time) so I got a job as an attendant in a local hospital to test the waters. I loved it and the rest is history. There were about 10 guys in my class of 60 students so I had good company. We did get extra attention but it was welcome attention. I remember feeling a little funny at first, but it was an easy adjustment. My dean, school, instructors, and university all created a forward thinking environment so perhaps that made it easier. I remembered feeling a little funny about OB at first, but again it was an easy transition! My rotation was in the "charity" hospital with indigent type patients. Believe me, those women didn't seem to care if you were male, female, student or otherwise as their nurse! They were not uncomfortable with me as a male, so in turn I wasn't uncomfortable. They were just grateful to have someone caring for them. I loved OB and thought about going into it, but ER was my first love. The environment you work in (geographical, social) I've found plays a big part in attitudes towards males and particular tasks (like catheterization). The attitude at my first ER (management attitude) was to treat males and females no differently....as a male nurse I was expected to cath males and females alike and that was the expectation. That being said, precautions must be taken for legal considerations. There should always be two present in the room preferably opposite sex. If the doctor is female, then I will assist in pelvic exam situations, etc. This may not be politically correct or forward thinking, but believe me its legally practical and protects you as the nurse. Many people do not care WHOSE live they ruin with false accusations in their desire for easy money. The current ER environment I work in though, the attitude is a little different. As a general rule, males cath males, and females cath females- but this is a general rule. Being flexible is the rule of the day here. My choice of specialty (ER) has also made it very easy to be a male in a female dominated profession. Honestly, there are just as many male nurses as female nurses, and this has pretty much been the case throughout my career. I don't even think about it any more (being a male in female dominant profession), because it has become normal in my world. I still hunt, fish, camp, watch sports, (Monday night football is back!!), play poker, hang with the guys, without a thought that I'm any different from my bud sitting next to me at the poker table who happens to be a banker. I am happily married with two beautiful daughters and loving wife. I think my professional experience has made me a better person, a better father, and a better husband. One funny thing in closing....it gives me a unique and entertaining perspective. I can remember as a teen wishing I could be a fly on the wall close to where a bunch of girls were talking. Now its like....I AM!! You wouldn't believe the things I've heard over the years because the women treat us males as if we are one of them!! I can also identify with one of the posters who made the comment about remembering not to assimilate TOO much in being "one of the girls". Males and females BOTH bring something uniquely different to the profession of nursing. Regards, David

Wow, I'm surprised. Shocked might be a better word! I don't know if a geographical move is possible for you but you might consider it. Here in Memphis for example, you would virtually have your pick of jobs at any of 6 different local hospitals! BOTH of the ERs I work in hire new grads... What is the new grad "program" you are referring to. Here in Memphis there is no special program for new grads who have passed boards. You are an RN once you have passed boards. New RN's perhaps get a longer and more careful orientation, but no special program. David

All great comments...the other most common culprit for mental status change in the elderly pt when the neurological workup is negative.....Pneumonia. The same goes for the elderly and sepsis, the two most common infection portals of entry are the lungs or the urinary system. Your sepsis workup should always include a cxr and urinalysis. Both infants and the elderly have a similar problem with infection fighting....an immature immune system for infants and a "worn-out" or tired immune system for the elderly. Regards, David

I went to school m-f as well and worked at a local hospital on the weekends. It was tough but I made it. It does have an effect on the grades though. My last year I quit working all toegether for my critical care courses and clinicals, and took out loans enought to cover tuition AND bills. I'm still paying on those loans 11 years later, but no regrets! Good Luck and look hard for the right solution for you...its worth it! David

Hi All, Many posters have had great comments, there are a lot of correct answers. But to answer the original question what is the best location to check for pulses with a doppler during a code? In my 11 years of ER nursing experience, we dont use the doppler to check for pulses if the code is in progress and the pt has a non-perfusing rhythm. I palpate for pulses in those situations. If I doubt myself, then I put the "ears" on and auscultate for heart sounds during a pulse check cpr break. If the physician only trusts his own opinion, he or she can palpate himself. I DO use a doppler though to determine blood pressure when the pt is that critical and hypotensive that you can't "hear" a blood pressure manually. Sometimes patients just have quiet blood pressures, or the room is too loud from the ambient noise and chaos. Dopplers are invaluable in those situations when you need good data (like a blood pressure) but your normal methods of obtaining the data aren't working. For example, the doctor oders dopamine if the systolic BP falls below 90, but you can't determine a blood pressure by machine or manually. You know the patient HAS a blood pressure because you have a detectable femoral pulse. My solution is to use the doppler in that situation. Just my 2 cents, David