one_speed

We use quite a bit of conscious sedation in our ED, both for Paeds and Adult as well. IM Ketamine for most paediatrics patients. IV Propofol for most Adults (dislocations, closed reduction of fractures), but sometimes Versed and Fentanyl depending on the procedure. We have very strict controls on the room we use (airway, monitoring), close vital signs monitoring until returned to baselin, RT at bedside, 1:1 RN at bedside until recovered. One bit of advice. Never draw up the meds until the patient is fully monitored and you are comfortable to procede. THe MD will be pressuring to go ahead, but until you hand them the drugs they have to wait until things are set. Probably the sketchiest conscious sedation I had ever been involved in was the elective cardioversion by a Cardiologist. He came to consult, called his Anaesthesiologist from the OR. Anaesthesia shows up with their own drugs. Pt isn't even on the monitor and he's pushing a full dose of sedation. I freak on him as RT isn't even in the department. "I don't need an RT" he says. Great !! 7 minutes later he walks out of the department, We are left recovering the patient (we're not a PACU here folks) with persistant hypotension, oral airway, and BVM. What a **** up. After that safety report anaesthesia is no longer allowed to come into the ER for elective procedures. What a Wanker...

nice... All I'd say is now she can't get any narcs or happy drugs through the porta cath... it's contaminated and too high a risk to use. sucks to be her... no more happy drugs.

A lot of good p[oints are mentioned here, particularly the last point about lay people trying to do CPR on a conscious victim with other problems. (funny aside - have you ever had to stand on the other side of a curtain of a VSA - CPR in progress dispatch that arrrived ambulatory, and listen to the pateint crying to their well meaning partner that their cheswt hurts too much after the chest compressions, trying not to laugh) Anyways, the change from pulse checks for the lay person goes hand in hand to assessing the casualty for "signs of life", you know things like gray skin colour, lack of breathing, decreased LOC, etc. that accompanies a stopped or inadequate heart beat. Just because you can feel one or two pulses in a 30 second pulse check doesn't mean they don't need compressions. If they look dead, start CPR...

Part the Second We often see a broad spectrum of philosphies concerning patient flow in ER's. Ranging from : let them rot in the waiting room for their sore toe, I need to keep beds open for more serious patients. to Gotta get those patients out of the waiting room right now to back up stretchers in the hallway so that they can be seen and wait (staring at my back) for the answer to all of lifes problems. There are negatives to both extremes of the scale, I think the happy medium is best, the challenge is dealing with coworkers who prescribed to different philosophies. Of course having the non urgent abd pain who codes in the waiting room really throws aeverything out the window. In my ER we tend to move peole through very quickly (perhaps too quickly in my opinion). Our ambulatory care patients will be in and seen by a physician long before an abdominal pain patient. (major pet peeve). Patient flow issues are being assessed and big changes are coming down the pipe both for Nurses and MDs. I was looking at the links posted fro the "30 minute Guarantees" and can't figure it out. It doesn't actually say anything useful. I think that the only "30 minute guarantee" in the ER we should be worrying about is perhaps the door to needle time for thrombolytics, even though that would be one slow ass ER. Eerything else is just minor details. 'nuf said Ian

Ah, the ever present argument about wait times... I think what every one is forgetting that we are always trying to compare appples and oranges in healthcare... The big thing in the media in Canada is wait times... wait times for surgery, ait times for cancer treatment,wait times for emergency care etc. The media never distinguishes between wait times for AAA repairs (I've never seen a team move so fast), trauma interventions, loss of limb etc., or non urgent care (hip replacements, knee replacements), sore toe. What exactly does "Wait time" mean (at least in an ER context)? ... Does it mean the amount of time to be greeted coming in the door (time X) ? ... Does it mean time "x" to registration or triage ? ... Does it mean time "x" to be brought in to be assessed by an RN (often with stretcher, IV, initial testing blood work)? ... Does it mean time "x" to MD assessment (or resident coming to see then discussing case with the ER doc), and orders received for diagnostics. ... then of course their is the wait time from time "x" to diagnostic imaging, blood tests, ultrasound and CT scan for that vague abdominal pain in your 94 year old grandma. Oh, and don't forget the wait time from time "x" to having the general surgeon (or surgical resident) getting away from the OR (love those knee replacements) to come talk to you and making plans to observe overnight in the ER. I get the feeling that most of the time wait times refer to the time from time "x" to the doctor just giving the paitient their bloody percocets for their sore toes, so that they can swear at me and get their taxi slip to go to their cousins house. Maybe wait times refer to from time "x" to beign admitted and having all of your lifes problems solved in the ER (sorry if I am getting more sarcastic as we go along). So what is it... what is your definition of wait time ? we need to sort this out before having a meaningful discussion about how to resolve wait times. Regards Ian (after 4 night shifts in the ER)

Actually, maybe "calling the bluff" and embarrassing the pants of your coworker might have been the jerk thing to do and shows a lack of style. (made you feel better, but did it really help the situation.) hows about the ""STAT" insulin order from the MD. Was it a stat situation, or can it be fit in with the "STAT" discharge in room 2 and the "STAT" telephone for the patient in room 3 that MD's like to leave orders for. Maybe he/she (the aide) didn't know any better, but the MD should have. And if the patient was that sick, maybe he should have intervened him / herself or called the RN him / herself. The education shows through when you can prioritise all the "STAT" orders flying at you on a day to day basis. That is why education counts in being an RN, you can make critical decisions to insure good outcomes for all you patients. this should be the focus of education for allied workers, not embarrasing someone hired into a valid position (ie, it is a paying job we let our employers create) wether we agree or not. Regards, Ian

Good point... resolution to this problem... Degree as entry to practice for an RN. Hey, can't tell you how to do things in the US, but I am secure in a well paying career, and not likely to be replaced with helpers anytime soon. The nursing (small N) trade is alive and it seems maybe not so well. The Nursing (big N ) profession has a lot of room to grow. But... ignore the problem, blame it on the soaps, Greys Anatomy. It's their fault that Nursing (big N) isn't as respected as we'd like. Never mind the multiple roles vying for the same title. Regards, Ian

On a similiar tangent.... Where do all of these new titles come from ? facilities looking to hire cheap labour to do a job (poor outcomes forthe patient be damned). Anybody and their dog can be Certified to do whatever... doen't mean squat in the end. I'd hope that BON etc issuing licenses are a little more stringent. I didn't find the Canadian Nurses Association License exam too difficult (but I was well prepared by four years of clinical and schooling). Is there really a nursing shortage in the US, or just a shortage of well paying and healthy worplaces that qualified persons want to work at... just a thought.. Regards, Ian

Secretary Edcuation: Secretary School (ie not a Nurse) Place of Employment: Starting Wage: Job Description: Helper Edcucation: ? if any (ie not a Nurse) Place of Employment: Seems like all over the place Starting Wage ? Job Description: MA / Medication Technician/ CNA Education: ? certificate (ie not a Nurse) - assistant maybe... Place of Employment: where ever people let them Starting Wage: ? Job Description: Licensed Practical Nurse / Licensed Voactional Nurse Education: Diploma (Nurse) Place of Employment: Starting Wage: ? Job Description: Registered Nurse (Diploma) Education: 3 year College Diploma (Nurse) Place of Employment: Starting Wage: Job Description: Registered Nurse (Degree) Education: 4 years University - BScN (Nurse) Palce of Employment: Everywhere Starting Wage: same as a 3 year college diploma (thanks for negotiating that one out of the contract ONA). Job Description: ------------------------------------------------------------------------------------------ Hey guys and girls, I've been reading a lot of what has been posted here and elsewhere on this forum, and there is always a lot of conflicting information floating around... specifically when we discuss job titles, wages, etc. While I realise that things change state to state, country to country (even facility to facility), please consider looking at the chart and fill in the categories so wwe can have an idea what things are like where you work. Consider this... why would a private facility employ X number or RN's at Y salary per year when they can employ twice as many helpers/ MAs for less cost and lump them all in as "Nurses"? Answer: We let them !! The fact that people will use the excuse " oh I started nursing school, but it wasn't for me..." then take a job as a "helper / MA" for the employment without the work and education and try and pass themselves off as doing the same job as I am pisses me right off. We (RN's) are really shooting ourselves in the foot by letting the infighting over " a nurse is a nurse is a nurse" to distract us while our employers can employ MA's, Medication technicians, CNA, for cheap to do our jobs. A degree as entry to practice is, in my opinion, the only way for new grads to become licensed RNs (We did it in Ontario) LPN is a diploma program, and other than that accept the fact that you didn't put the time and work to earn the title "Nurse". The rest is semantics and hair splitting. I'm not talking about all of us who are currently practicing, but new people coming into the workplace. If you keep bickering among yourselves and accept untrained personnel in to do your job it is small wonder employers will walk all over you to make more money and the US government considers Nursing as an unskilled trade. Input ? Disagree ?? let's hear about it... and no more us vs. them, Degree vs. Diploma, US vs. Foreingers debates. Nothing comes of them except people defending themslelves and other people making money off our backs at our patients expense. Regards, Ian

How does one lose their "certification". Do you literally pay for a certificate saying you can now start and maintain IV's, Do you carry a little piece of paper to show your patients on demand ? In my workplace it is considered an added nursing skill... you are trained, do a learning package, then maintain your proficiency. If you don't feel proficient in the skill, go through the learning package again (annually) and seek remedial teaching from Staff Ed. Ian

Not exactly, There is often room for improvement with the bystander where they might make a difference to improve the outcomes for an accident victim (not necessarily trauma). In rare cases, bad interventions by bystanders may have contributed to bad outcomes. sorry , I'm trying to formulate a response that makes sense to others and not just my sleep deprived mind. I think I am trying to say that in general, any intervention is generally better than no intervention, some interventions may accomplish very little, and there are some interventions that are better than others. The key is to learn what intervention will help the patient the most. ie. take a course. too much time can be wasted on ineffective treatments when better things can be done to help the casualty (hence the creation of first aid and prehospital standards of care, trauma care (TNCC, ATLS) CPR, AR, etc. I know the feeling of at least being there was good, but what if you could be there, do something proven to be useful and improve the outcome. (We can argue specific cases to no end, that's not my intent.) for example: Poking an unconscious drunk friend with a stick may be fun and feel good to be supportive (well... at least it feels good), but it probably won't help much. Where as placing them in the recovery position to make sure that the airway stays open so they can breath and they don't drown in their vomit is generally a more effective intervention. The likelyhood of them having a C-spine injury (depending on mechanism of injury and witness accounts of course) is low, so deciding to keep them flat on their back in an effort to protect their neck will generally be a bad intervention and may result in a negative outcome. clearer ?

I think that while your intentions are noble, they will prove to be ineffective and cause more harm than good. Then you will feel bad and cry... ( A general comment on many of the interventions described here, not you in particular, just using your case as a common example) I'm headed to bed after a particulaily crazy night shift in our adult rescusc room in the ER I work at. So I apoligise if this comes off sounding a little disjointed or sarcastic. Found this thread this am. Like I mentioned earlier this issue is a hot point for myself. I want to send a special thankyou to posting this where the most people can see it... obviously most nurses think about this issue alot. The sad thing is, in spite of this most will revel in their ignorance and say "what can I do? I'm just a nurse". :angryfire My hope is that this discussion might prompt someone (RN, RPN, lay person, whoever) to educate themselves and actually help someone some day. Granted the OP was referring to an MVC as an example, but I think that there is a lot of BAD advice, anecdotes being posted here. Please consider looking into taking a proper first aid class. Traumatic VSA is rare, 99 % of the time (random percent thrown out there to make a point) when some body is VSA at an MVC is that the person probably passed out before hand and ended up crashing the car... bystander CPR is what saves lives, not dagnosing cardiac tamponade, internal bleeding with your x-ray vision. In day to day life someone collapses in front of you, gets hit by a car, falls off their bike. There are simple steps you can take to maximise their chances of surviving without lasting harm. In my experience bystanders can do many things at an incident. Most of what they can do may be good for the patient or just not make them worse, In rare instances their actions can make things worse (bad c-spine injries, etc.) The majority of time when a person has a poor outcome in an accident is that the bystander tried something and it was ineffective d/t improper technique, or just not the best action they could have done with their energy. (Think a person chokes and goes hypoxic while someone is trying to get an IV started). ABCD !!!! A- Support the airway (literaly hold it open if you need to) B -Make sure they are breathing (breath for them if needed) C- Can you actually find a pulse ?? Do they look dead ??? start CPR... D- Disability (Are they uncoscious ? can you safeky put them into the recovery position ? B- Is there any major bleeding ? put direct pressure on it if you can, have the patient put direct pressure on it. Fumbling around trying to get the BVM you borrowed from work and that old 22 IV cannula is wasting time and asking for trouble. IV's never saved anyone, and a BVM never saved a choking victim. Hopefully my rant can have some effect and get some nurses off of their butt and do something for themsleves and their families, friends, and neighbours. Educate your selves in these simple measures. I'm going to bed. Cheers, Ian

An addendum to the last post I made... Graduating as an RN does not a first aider make. Please don't use the "Good samaritan law" or ignorance as an excuse not to help someone in need. any help is better than no help and sometimes two cluelessheads are better than one (at least for supporting one another). On that note... please take the time to educate yourself... inevitably someone will come looking for the "nurse" to step up and save a life. Nothing irks me more than the call for "Is there a doctor in the house ?" They are in the same boat... Grauating as an MD does not a first aider make. I've said it before and I'll say it again (consider it a challenge if you must - this is a passion of mine. I pay to volunteer as a first-aider in my spare time. It's what I do for fun) IT IS OBVIOUS TO ME THAT ALL THE POSTERS THINK THE SAME WAY ABOUT THIS... THE ONLY ETHICAL THING THAT YOU CAN DO NOW IS FIND A GOOD FIRST AID COURSE AND EDUCATE YOURSELF !! Yes, I know. The bold capital means I am yelling (pleading really) because someday soon the situation will arise and you can make a difference in saving someone or them dying. Ian

Holy crap !! two similiar questions on the forum in one day. I am going to advise the same as the LPN asking about emergencies in an ouitpatient clinic. The very best thing you can do for yourself, your family and anyone else is take a first aid course. No offence to any of the posters who took the time to respond to your question, but throwing comments out into the ether isn't going to help when the **** hits the fan so to speak. I have been an ER nurse x 5 years, (studied for another 4 years) but I have been a volunteer ski patrollers and first aid / CPR instructor x 10 years. Working as a "nurse" in the hospital or even the ER is more often than not totally different from stepping up at the scene of an accident (MVC, fall, what have you) and helping effectively. Different bag of tricks is how it has been described in the past. Taking the time to take a more advanced first aid course will fill you in on alll you need to know. Things you might not think about in a controlled ER / hospital environment can bite you in the ass if you aren't careful. Triage is different, priorities go back to the basic ABC's, and personal safety is key. IT IS OBVIOUS TO ME THAT ALL THE POSTERS THINK THE SAME WAY ABOUT THIS... THE ONLY ETHICAL THING THAT YOU CAN DO NOW IS FIND A GOOD FIRST AID COURSE AND EDUCATE YOURSELF !! A partial list of tips to keep on the top of your head in case you stop on the way to registering for that training... #1 - Look for Further Danger to yourself or the victim (you do no good if you get hurt or killed going to help someone don't put yourself in the position to get hurt yourself). #2 - Look for the number of People injured (You will definitely need help, and it sucks to miss someone). #3 - Look for the mechanism of Injury (sometimes the best thing you can do for the injured person is stay with them and keep them from moving -- see rule #1). Call the Red Cross, HEart and Stroke, NSP, CSPS (In Canada) and trhey can hook you up. Cheers, Ian CSPS PAtroller ER RN Cheers, Ian

Usually I don't quote text (too many people do in these forums do... what a waste of bandwidth)... anyways... It sounds like you are working in an outpatient clinic, but even if you were in hospital and working the ward and came across any of the situations my advice would be the same. Speak with your clinic manager and have them organise a first aid course for your staff... Scope of practice really means nothing (IV's etc.) if you don't manage the ABC's. Everybody thinks that they have to get all in depth right away and care gts complicated. People tend to forget the basics when they are worrying about the details that might be able to wait. Red Cross, Heart and Stroke, etc. all offer group first aid courses, they are inexpensive, are a great team builder and people will appreciate having the knowledge for their personal lives (rather than trying to remember protocols from work when you probably don't have the bag of tricks to work with). I have been an ER RN for 5 years, volunteer first responder / first aider for 10 years with the Canadian Ski Patrol System (In Canada obviously), and an first aid / CPR isntructor for 8 years. It was actually my volunteer first responder training and experience that got me into Nursing. Some times I get tempted to bust out the more advanced skills in day to day situations witht he patrol, but the basics are the most impoprtant amd will save the day everytime. If everyone in the clinic is up to date and can run a scenario as a team, things will go smoothly when it happens for real. CPR level "C" - Healthcare provider (O2 administration, CPR (infant, child and adult), and choking (infant, child and adult) is offered through Heart and Stroke of America, Red Cross, etc. and should be the standard you work at. It covers all the issues you were describing and as a group you can be done in one fun afternoon. I'd encourage you to conatact one of the above to organise the program (through your employer of course or get staff Education to run a similiar course). Ber proactive; Instead of taliking about it, take the steps now that can someday help out. Sincerely, Ian (RN - Emergency) Ski Patroller Superior Zone Canadian Ski Patrol System