avigail

gastrograffin=bedpan You're so right about that. Powerful enough to defeat some small bowel obstructions! Ugh, it's not a question of if you'll get the runs, but when. And you always know the wait is too long when the pt gets to the toilet before s/he gets to the CT.

Gastrograffin + Reglan 10 mg IVP = scan in 1 1/2 hours.

I have frequent visitors to my "fast-track" who are simply there to obtain narcotics; they know I'm a softy. But I gained this attitude in part from doing numerous diaper changes and avoiding airborne vomit while caring for someone in narcotic withdrawal (let's not even dwell upon the times I have had to put central lines in seizing IV drug users-no veins, you know). I have also come to believe that pain is vastly magnified in the opiate-addicted (how they keen like banshees just over being stuck for blood!) because their bodies want the stuff. Nonetheless, all of my chronic pain folk have to endure my speech on the high cost to the user of drug dependence. I ask if the 12 hour wait to see me really makes it worthwhile. I talk up the great times to be had with the local Narcotics Anonymous group (this is very effective when injecting lidocaine into a shooter's abscess that needs lancing). I mention how The Man is sending his kids to college while profiting from their addiction (works with tobacco, too). I also say that I have confidence that they can quit once they make up their minds to do so. So far, 6 of my patients have gone to NA and 4 are sticking it out. One is now in ...drumroll, please...nursing school.

Baptist Health System in San Antonio has a "winter RN" program with high pay rates and bonuses on completion, http://www.baptisthealth.org. There is a hospital about 30 miles north of SA which may be a good bet, http://www.mckenna.org.

St David's is owned by HCA and is for profit; Seton is a non-profit organization. Of the two systems, Seton wins hands down for pay and benefits. I think the nursing culture is vastly superior at Seton as well. I've worked agency at both institutions.

UTMB has alot of educational opportunities integrated with nursing in the hospital. I almost went to NP school there because of their work/school program. I don't know about pay issues in detail but I know that the benefits are the same as those who teach in state universities, i.e., very good, including the Teacher's retirement plan. Of course, UTMB lists pay ranges for all positions on their web site, http://www.utmb.edu. They do not appear to be noncompetitive with other hospitals. Galveston is great if you like water activities: swimming, fishing, boating. The city of galveston has a web site as well:http://www.cityofgalveston.org or http://www.galveston.com. I know the weather is fairly mild year round. There are some interesting historical places to visit. And, if you get bored, Houston is only a short drive away.

It wasn't clear to me when I read your first post that, because you contested their decision, TPAPN was ruled out. Ugh! I have never known anyone in that particular situation. Have you tried to talk to anyone on the Board about your case? Maybe they would reconsider? I know you are not exactly on top of the world financially, but I think you need a lawyer. You might try to talk to your Texas legislator also. Did the BNE not provide you any other information on appeal of their decisions? Your situation seems patently unfair to me.

The practise I work for never refers to me as "their" NP, but as the NP - i.e., a member of a different species. For example, if they are walking by my rooms and a pt asks when s/he will be seen, the answer is "Oh, the nurse practitioner will see you." This is usually said in a tone of voice that implies, "And what are you doing in an ER anyway? You don't even qualify to see the MD." I'd hate to see what would happen if they failed to turn every conversation into a means of stroking their own egos. Of course, the pt feels that she's getting a shoddy deal, when in fact, she is often getting better care (I don't hate humanity for a start).

Unfortunately, with TPAPN involved, you are going to have to comply with their requests. You might request a peer counsellor, which TPAPN provides. The counsellors have often gone through the same thing. They may be able to provide some insight on how to jump over the BNE hurdles. You should also explain your situation, up front, to anyone who interviews you. There are nurses in the hospital where I work (and probably in every hospital) who have restricted licenses. I don't know where in Texas you are writing from, but other areas may be less judgemental. Personally, I think that marijuana should be decriminalized. I would much rather deal with the stoned than the drunk. Besides, I don't think any agency should be telling you what you can or can't do when you're not at work.

I always wear 1-2 t-shirts and shorts beneath my scrubs. Here in south Texas, cold weather outside is not the problem. It's the blasted AC on the inside. It's probably 50-55 F in my ER. Yes, I know the staff is moving around with dizzying speed but this is ridiculous. Needless to say, the patients, who are not moving at all, are distinctly uncomfortable. Let me palpate your abdomen with my ice cold fingers....

Actually, in my flight nurse life, I must say that etomidate is the preferred drug for RSI in the trauma pt. Of course, this seemed beyond the scope of the initial question. Kevin is very correct in stressing the need to know the ins and outs of any medication being administered (forgive me for repeating myself). That said, I have never had a pt vomit after etomidate. This may be due to the lower doses administered in ER or to lack of drug interactions. Nonetheless, I do not agree that anaesthesia drugs should only be given by the various forms of gas passers. I do believe that proper training and education is crucial for the limited use outside of OR settings.

Yes, I do think this nurse is possibly guilty of negligence, and therefore, malpractise. I think the standard of care is very plain for complaints of CP, and nitro with no follow up does not meet this standard. The question is whether the nurse informed the receiving floor of the complaint and whatever action she had taken. If so, the negligence would partially devolve onto the tele floor, although, arguably, the original nurse should have contacted the doc and waited to transfer until your Da was stable. I think you should contact a lawyer.

Etomidate is great stuff, although those myoclonic movements can be a bit freaky. Our ER uses it for intubation (no ICP problems) and for reductions and bone setting. I do not administer the drug until the doc is at the bedside and ready to go. The great advantage of Etomidate is its rapid induction-about 1 minute- and short duration. Of course, never give it to a pregnant pt. Our ER uses Etomidate in children (hello tachycardia!) but its effects have not been studied. I think nursing drug guides should include a section on anaesthesia drugs used by ER/Trauma/critical care RNs; the IV drug guides do. Of course, you should familiarise yourself with any drug you're giving. There's always the weighty PDR if you can't find an IV drug guide. Anyway, I think Etomidate will win you over once you've spent 6 hours trying to titrate Diprivan or to wake somebody from a Fentanyl/Versed slumber.

We had a liver CA pt come into the ER in need of a pericentesis. Equipment is set up and the moment of truth arrives. The man removes his shirt to reveal a huge tatoo mural of nazi symbols with the words "white power" above. The ER md was Hispanic, the charge nurse was African American, the nurse caring for the pt was Korean American. When the pt saw me passing by in the hallway, he asked if I would care for him, disregarding the amused glances of everyone in the room. I said, "Well, I thought I would be your last choice." The pt assured me that I was his preference. "Okay, but I think you should know that I'm pretty pale for a Jew." After that, everyone lost it. We all stood in a circle laughing. I think this guy limiting racial categories involved in the wife's delivery needed a dose of laughter. "Sir, I'm sorry. This is 2003 and we've come to recognise that all life came from Africa. Hee, hee, hee." "Requests such as that have been outlawed by the Homeland Security department and HIPPA, hee, hee, hee." I can't believe the hospital caved in to this foolishness. Pathetic!

Don't forget to make a complaint to the Board of Medical Examiners in your state. These complaints are subject to discovery, if Dr Nincompoop is ever in legal trouble. Besides, the Board will inform him that a complaint has been made. Issues on the local level are often reduced to good ol' boy gladhanding: "You know those nurses are on the rag, maybe you could be a tad more polite there good buddy, heh, heh." Attention from the Board is taken much more seriously (well, imagine receiving a letter from the Board of Nurse Examiners). I made a complaint to the medical board after a beastly ENT on call to the ER performed a procedure on a pt without adequate anaesthesia. Later, he was sued by a pt for that very thing. Wouldn't you know that the plaintiff's lawyers found that he had a history of this sort of thing based on the complaint that I had made? Of course, what I really want to know is why people who hate humanity are practising medicine.