granite109

I would be lying if I said I didn't throw a few back with my colleagues, docs included. I have seen, however, nursing management get absolutely plastered and talk shop with those that he/she supervises. I know there is role definition with CNAs, RNs and docs, but I'm wondering more about true administrative personnel, those who control raises, schedules, promotions, etc. You know, those persons that are no longer a part of the clinical team; their job description is clearly administrative leadership, not clinical team leader.

Congratulations! I remember when I got word. Gives me chills just thinking about it! It's a blast, the bet job ever, oh and nomex makes everyone look good-lol! Best of luck and fly safe!

Just wondering, how does everyone feel about management drinking with staff? I always felt it was bad practice, especially when shop talk came up. Even if the manager doesn't participate, it seems to lend itself to some nepotism and others feeling victimized or left out. Any stories to share, input, opinions?

We've been through a lot of change where I work. We have had some very dynamic leaders and some, well, not so much...I'm not sure how your department is run or structured, but I imagine like most EDs, that it is terribly busy, no one gets breaks on a regular basis, you have boarders for days (many unit players, too), the doctor's offices dump on Friday afternoons, and the staffing stinks. Oh, and let me guess, the floors complain constantly and avoid taking report even though there are 25 inthe WR and an eight hour wait. Been there, still hanging out... Anyway, I have found that the most important thing is that the staff has a voice. The traditional model of nursing and hospital management is not working. At some point, a core charge team was developed and implemented. This gave us some leadership opportunities and skills we had a part in decision making. It's really just an extension of the shared governance model in so many leadership courses. When the medical staff made a decision on how to run the dept without nurse input, they actually got told about it! It didn't solve all of the problems, as there will always be some even in the best of circumstances. What it came down do was that the nurses became empowered to do what it took to get their part of the job done. Bed management and patient flow became an initiative for the entire hospital. We had a manager who gave us a voice and stood up for us. If you have a lousy manger, it's a long road. I feel your pain and wish you luck!

About 3 years ago, our institution initiated the airway cart. It's like a code cart with the drawers and all. All of the RSI meds are in there, the standard ETTs and laryngoscopes; in addition to rescue devices; including the LMA, combitube (or King LT), and a Rhino brand trach tray. We have the lighted laryngoscope and the lighted stylet. They usually go to a trach instead of a cric in the ER; but we do cric in the field. It's certainly less than optimal; as the previous poster stated, hypoxia has usually set in by then and it's badness. On a difficult airway, anesthesia usually gets called if the patient can still be adequatley ventilated, rather than using a rescue device. However, more and more, the literature is supporting less attempts at ET intubation if difficult, and earlier use of the rescue airway. It's a paradigm shift, so it will interesting to see what transpires. When all else fails, a BLS airway still provides oxygen!

Good for you! Wishes for success and satisfaction!

Ugghh! The penalty box of triage is bad enough; when this happens it's a game misconduct! No, it's not just tourists, vacation is just the excuse for not having the info. I have tried to make use of this teachable moment and tell my patients the importance of carrying a med and history list. We started giving out the preprinted cards. If time allows, I fill them out so to make it a little easier and it strokes the patient a little bit, which makes them happy. I agree that it is a public health issue. It would make a great project in Community Health nursing. Not just passing out cards, but maybe a PSA during the local news or something. It would be cool if someone went out the the senior centers and handed out and filled out cards during a BP screening or something. (I know, it's not all seniors, but a lot are and it would hit a lot of people in one shot!) BTW, is anybody's ED involved in community service? I've tried, but no one seems interested here!

You can do this! If it is in your heart, than you must! Your kids will be fine. As a matter of fact, pursuing your dreams and being happy is probably the greatest gift you can give them. Of course, you must make sure their needs are met, but I am sure you will. Kids adapt, and happy parents make happy kids! Please don't fall into the trap of feeling they will suffer if you are not there 24/7. Many successful well adjusted kids and adults had parents who worked or were in school. It's the relationship and investment you have in them that matters. If you value them, they will know it. It is a balance that you and your spouse will have to work out and cater to suit your values as a family. Be confident in what you choose and tweak it as needed. On a practical note, as the other posters stated, speak with an advisor. The CNA is not necessary at this time and would probably just delay your goals. I would HIGHLY recommend taking your prereqs first. Then when the time comes for nursing classes, you can concentrate on them. Many L&D units will then higher you as a second year nursing student. They can get to know you and you can may be able to be hired as a new grad depending on the facility. Also, by taking your prereqs first, you can be a part-time student and the adjustment will be easier on your family. My guess is that your kids will be amazingly proud as they grow older and watch their mommy help others and take care of them. Kids are awesome at that kind of stuff!

This topic, while heated, brings up many important issues. In my experience, ENA has historically been realistic regarding ratios and considering the CC component. On an academic note, it seems the term, 'critical care' is an umbrella term, and therein is the problem. Where I work, we have 9 ICUs. Medical, Surgical, Trauma, Neuro, Acute coronary, Open Heart, Burn, PICU and NICU. With the exception of MICU and SICU, each one is highly individualized. It's highly doubtful that a career NICU nurse can drain a ventric or perform interventions on a Licox reading of 18%, with a pyretic patient who has good sats and an increasing ICP. Conversely, you wouldn't see an Open Heart nurse touching a newborn! When specific skills are named, it excludes everything else. The hospital setting has historically been territorial and competitive. Perhaps the issue here is the lack of teamwork and comaraderie among nurses. Each unit is its own unique place with its own unique skill set. Heck, different ERs have different skill sets. We are a pediatric trauma center, so we see a ton of sick kids. Our sister facility sees a ton of clinic kids. Each one is so unique. It seems to me that CC is less based on specific technological skills, and more on critical thinking and a mindset. Of course, ICU nurses have a depth of knowledge about a specific area that the ER is precluded from due to volume and a diverse patient population. However, to state that it is not a critical or acute care area is ridiculous! It demeans the work that is done and the skills required to function well in a busy ER. No, not all ER nurses can handle those patients, they turf it to the ones that can. Not all unit nurses can handle their patients either. Either you have it or you don't, regardless of the unit title....and I shall extract myself from the floor of my soapbox!

I would recommend the Classis or Classic II also as a starter. They are lightweight and the earpieces are nice. The Cardiology III or Master are excellent but heavy and pricey. Also, they often get stolen!

I work for HUP and they do require a BSN. I am not sure about Pennsylvania Hospital. Considering they are both part of the Univ. of PA Health System, it may be a problem. Jefferson, Temple, Hahnemann, and Einstein do not require a BSN. Starting salaries in the city are hovering around $30+ per hour. Don't forget though, there is a 4% city wage tax if you live outside of the Philly limits, and the parking is exorbitant! Abington pays considerably less because it is in Montgomery County; no wage tax and free parking. However, Abington has one of, if not the busiest L&D unit in the SE PA area. They also have a great NICU. It's a nice hospital with tertiary services. Not sure where you live or if public trans is available to you, but there is a lot to weigh out besides hourly rate. HUP is a world class research facility with deep pockets and has almost every service known to man, plus they are next to CHOP. If you love peds and get into CHOP, you can go anywhere. Also consider what you like about L&D. Do you like high risk? If not, Doylestown Hospital and Grand View Hospital are well financed suburban institutions. They do, however ship out most high risk pregnancies. I know Grand View will even ship out placenta previa's; not sure about Doylestown. St. Mary's in Langhorne is also nice, but they have lost a few services in the past few years. It's a lot to consider, and your first decision may not be the right one, but I'm sure you'll find your way. Best of luck!

Emmanuel- Very, very valid point, thanks.

Best Wishes to you on your final! I have an AAS in Chemical Technology and have found the concepts extremely useful in nursing, especially in cardiology; ie sodium-potassium pump, conductivity, e-lyte imbalances, etc. That being said, I have yet to use those pages of formulas you and I know so well in 7 years of nursing. The concepts are what is important and it sounds like you have a good handle on them. It just stinks that you're GPA will drop a touch. Good luck!

OK, this is an old thread, but I feel a need to clarify, so please indulge me. My first post on this thread was apparently inflammatory. That was the opposite of my intention, so my apologies for my inability to express myself. So....let's take 3 of my described traits and hypothetically theorize. I have noticed that many of my patients are women and homemakers and generally 35-45. (Even if inaccurate, just go with me here for academic purposes) Is it possible that there is an agent in the home that the victims are exposed to, causing the symptoms? For example, let's say that in 1985, Proctor and Gamble, Kraft, or whoever, came up with a new, innovative product. You know, stain remover, tongue tattoos, hand lotion, whatever...this new product is all the rage. Everybody has it. Now, 22 years later, there are a bunch of 47 year old women with fibromyalgia. Is it possible that the common products used by homemakers of the day caused these problems? Maybe it's in the fast food fries or the milk or the bottled water or the pesticides used on the fruit and veggies, who knows? Epidemiologically speaking, similarities MUST be observed and the patient must be described accurately. Trends in symptoms CANNOT be ignored. Why are most FM sufferers women? Is there a hormonal component? Yes, you will proclaim my ignorance again, but we know that PMDD is caused by the hormonal drop just prior to menses. Perhaps all of the female FM sufferers were on the pill and it is a late side effect. Perhaps they all had an epidural an intrapartum. Who knows? Why aren't there an equal number of male sufferers? Is testosterone a factor? My point in my original post was that I have seen a trend. In my small microcosm of the universe, I have seen the same thing over and over again. Maybe it's just a coincidence, but that's what research is for. I have MVP and hypoglycemia (DM runs rampant in my family). However, I feel that the FM diagnosis is inadequately studied, which is a disservice to the patient. A lot of FM symptoms are chicken or the egg issues, and we need to study more. It's the only way to make progress and help our patients. So, I stand by my position on demographic similarites. When diagnosing a patient, we must look at the whole picture and maybe we can perform a root cause analysis and maybe even find a cure! Let's hope!

My sincerest apologies for coming of offensively-that was absolutely not my intent!!! In fact, my intention was just the opposite. There have been studies correlating male pattern baldness to heart disease, apple shaped bodies have higher incidences of MIs, etc. I have noticed a pattern. Is it possible that there is more to the picture and certain traits correlate to certain conditions and symptoms? Mediterranean women actually were the first to have Kaposi's Sarcoma. Not a generalization, but a statistically relevant correlation. Light skinned people get more skin cancer, African Americans have a higher risk for HTN. I am NOT talking about the elusive gay gene, and I take exception to that reference. I am not calling anyone a hypochondriac, as many others have, in fact I am making an apparently weak attempt to advocate. I am merely stating a pattern I have seen where I work-for real. It was not intended to be derogatory. So many people with FM get blown off, perhaps there is more to the story and a new diagnosis is in order. Is it possible that because most sufferers are women that the research is not being done? I have seen similar traits in my patients and I wonder if there is more to the story. Perhaps I did not articulate it properly, but similarities in patients are noteworthy. I am sorry if you disagree.

EMIs course is excellent. It starts in January, concludes in July. It costs $1000 and can be paid in 2 payments. If you call 610-969-0259, they can hook you up. If you'd like, you can e-mail me and I can give you the goods. I fly for a different hospital though =:) [email protected]

don't know if you've moved yet...I work at LVH and for HUP. LVH has a great NICU and PICU. Level I trauma, peds and burn specialty certs. We receive patients from everywhere. LVH is considered on of the top hospitals in the state. However, I am not an LVH loyalist, just stating the facts. If your hubby is flying out of LVIA, you could move into Bucks county and drive to Philly and work CHOP, St. Chris's or Temple peds. If he's in Evoca, Geisinger is excellent. Good rep, good benes. I fly for Penn, so I get to go to a lot of places. Feel free to e-mail me. [email protected]

Oh, the joy of FM!! what a hot topic, but something that should be addressed. It seems apparent that there are real instances of FM, often with prior injury. In my youthful idealism, I would like to believe that we are nurses identify and are compassionate to those patients. It is not our place to judge, but to treat. That being said, I have noticed, anecdotally, a correlation with many, not all, FM patients: caucasian, female, pale skin, slightly overweight, empty nester, often a homemaker. History of low grade depression and perimenopausal, and a bad IV stick, you know, that pasty, kinda chubby skin with that extra subQ layer for no reason (not obese) and no visible veins. (Think back now, I'll bet you agree!) I know this is general and sounds judgemental, but it is not intended to be, bear with me here. It appears that there are patients with legit pain issues. They may autoimmune (lupus, MS, RA)age (osteoarthritis), or injury related, and they may be FM. On the other hand, I have seen the above pattern. Is it possible (on a limb here), that there is a body or congenital type that we don't recognize, that causes FM symptoms. There appears to be a general type here that have these symptoms. Unfortunately, docs often generalize with the dx and we need to have a broader look at the patient and investigate it further. Perhaps a new diagnosis would be in order. It would make a great research study. Any thoughts anyone?

I took ABLS and was not impressed. Granted, it was new at the institution, 2nd time I think. However, the place I work at already offered their own in house course and it was very in depth, so the info was redundant.

I agree with you, that it is amusing and that I, too get carried away. However, in the institutions I work at, it is an issue due to critical care pay and job opporunity. ED has to do the exact same 6 month CC course and carry MORE certs, but gets no CC pay and is repeatedly told they are unqualified for numerous positions, such as CC float. A new grad can go CC float pool, but an ED nurse cannot even be hired. A few months orientation would do the trick! I absolutely agree that they are separate entities, but you know as well as I, that the ED has a bad rap! PS-I still love every minute of it though!!!!!!!

Don't know if this was placed anywhere, but I had a patient with a scorching genital herpes outbreak and she couldn't pee. The doc told me to NEVER cath a patient with active herpes d/t the risk of introducing the virus into the urethra-OUCH!!. Thought it was good advice to pass along...

Hmmm, do tell. My first thought was myxedema coma, but the head CT and PE protocol threw me off...

Ok, I had to join in. This critical care issue has been my albatross for years. I have not read every thread, as I do not have all day. I do have this to add. I have worked ED and trauma at the busiest trauma center in PA for 7 years. I am also a flight nurse for a major University center. Either you have it or you don't. You can take some nurses and put them anywhere and they rock. You can take some and they can only function in their given area. ED nurses are NOT intensive care nurses, but they ABSOLUTELY are critical care. Yes, it's a matter of semantics, but I would never profess to be involved in the details that the unit nurses are so intensely a part of. I have worked the unit-shock trauma. Not cardiac, I admit. So are the burn nurses not critical care because they don't know IABP timing or the mechanics of a BiVAD? It all depends on your definition of critical care. Perhaps the term, "critical care" is antiquated and inadequate. The hospital can't make the ED critical care because the ratios won't allow it. It's a matter of money and liability. Imagine a bad outcome and the attorney gets up and says to the defendant: "What is your ratio for a critical care area?" The defendant responds, "1:2". The lawyer then asks, "How many patients did your ER nurse have?" The answer: "11". If the ED is considered a critical care area, the hospital is in deep doo-doo. Yes, I have had 11 patients, on more than one occasion. I have had 5 unit patients to myself. A-line, CVP, S-G, ventric, the works. We have turned on side of the ED into an ICU. Don't tell me I am not critical care. I am not intensive care, as I don't do O2 panels in the ED or adjust IABP settings, etc (Vent settings, yes). BTW, many anesthesia schools accept ED in large tertiary and trauma centers as critical care. Oh, and when my patient on shock trauma was having an acute MI that I recongnized, my preceptor, a 23 year "critical care" veteran told me that, "We don't read EKGs on trauma." Mmmmph!!!

We utilize I/Os in the air as a last resort. HOWEVER, a last resort on a critical kid is 3 attempts at an IV, no longer than 90 seconds total (good luck!) We are also allowed to use them on adults. We recently had a nine y/o brought in to the trauma bay. In this case, the I/O saved her, at least initially. They can be aspirated and the marrow can be used for CBC and Chem. We also infuse 0.5 mg/kg of 2% lido for peds prior to NSS flush, or 40 mg of 2% lido for adults. We use the tibia for peds, and the humerus or tibia for adults. We have the gun and the manual I/Os. They are relatviely simple to use, but yes, very creepy. More and more, they are being advocated. We have a 24 hour limit, but only if no other access if available. Being a trauma center, we can put a CVC in under fluoroscopy 24/7, so I would think that 24 hours would be a liability. My experience concurs with all the posts: they usually need a pump, they dislodge easily, they are prone to infection. However, they are a lifesaving measure and I have seen them put to good use. Also, to answer to ETT question. ETT drug administration has been around for years, promoted primarily by AHA via ACLS and PALS as a first round prior to line insertion. The old pnemonic for ETT allowable meds is NAVEL-narcan, atropine, valium, epi and lido. It then changed to OLEAN for oxygen, lido, epi, atropine, and narcan. The doses of epi, lido and atropine are double, but narcan is not. (No atropine in peds at this time.) Recently in PA, they did away with ETT drug admin, finding it to be largely ineffective. They are promoting early I/O use when appropriate. Also, meds cannot be given via a combitube airway. Hope this clarifies any questions, sorry so long-DFW

Anyone who says he/she hasn't made an error is either a liar or didn't know he/she did so. The latter is much scarier. It's important to recognize the potential severity of a med error, but not to the point that you are so scared that you over analyze and make even more mistakes. My advice would be to utilize your facilities procedures that are in place and then add your own triple check for yourself. Unfortunately, we all get into the habit of recognizing things by sight and then wonder, "did I really read that, or just recognize it?" I have worked in the ED for 7 years, and we don't have cardexes or MARs. I got into the habit of taking the meds out of the Pyxis and carrying them over to the chart and placing them on the written order. It added a step, but reminded me to read the label instead of simple recognition. While a near miss shouldn't be taken lightly; it's not a reason to beat yourself. It is a great opportunity to create your own style, safety checks and build confidence. good luck!