Email4KH

The article is a great resource for BP info. The pause you're talking about, the auscultory gap, is discussed close to the end. One way to be sure you're not being fooled by it is to inflate the cuff to the point that you occlude the radial pulse, then release the air, wait a few seconds for pressures to normalize, and then inflate the cuff 20-25 points above the palpated point of occlusion, and let 'er rip! Hope this helps!!

Here's a funny one: A family brought in their pre-teen daughter after a copperhead bite and refused to allow us to treat her, saying that God would take care of it. Why didn't you just let God take care of it at home?

I think the law actually says that you can't refuse to evaluate in the ED. I don't think an ED is required to treat. The idea about the separate waiting areas would be great for avoiding waiting patients' perception that less-acute patients are being treated before more-acute patients! True, one patient's condition is not any other patient's business, but also true is that most patients can identify and do resent when they're not being treated in order of acuity (or order of arrival!). It's not anybody's business, but patients don't understand why obviously less-acute patients are treated before them (I completely agree), and, like it or not, patient perception is a key component of patient satisfaction. Those PAs and NPs who are seeing non-emergent patients could be treating more acute patients, couldn't they? There's no way aroung the fact that fast tracking diverts that resource and others from more-acute patients. Besides all that, it's just plain wrong for a less-acute patient to be treated first. It's a violation of the concept of triage. Not first-come/first-serve, but most acute/first-serve. Fast track violates that principle. I'm not sure how emergent patients are seen faster when limited resources are being diverted to treat non-emergent patients. Maybe you can clarify!

Here's an idea: Why not guarantee payment to primary care providers for all patients, and reserve the right to refuse ED treatment for non-emergent cases; referring them to their primary care providers instead? It seems that it'd be much cheaper than treating non-emergent cases in the ED.

. You're listening to a chauvinist failure?

I thought it was interesting that women often got very uptight about having a male OB nurse in the same room, but a male doctor could go in up to his elbow and the same patients wouldn't give his gender a second thought.

We STILL don't give pain meds until the MD assesses. Too many walk out after getting "fixed."

CPI here, too. As with others, our facility only approves reacting to assaultive behavior with CPI-designed techniques. My children, on the other hand, have no interest in seeing Daddy get hurt. I vote with them. Sure, I'll try the goofy CPI. But if it's necessary, it's any means necessary. I'm not getting paid enough to get hurt for a policy.

I like a variation of the question that is a favorite of one of our ED docs when the patient starts on their laundry list of symptoms: "Wait, wait, wait. What is the ONE THING that finally made you decide to come to the ER tonight?" PressGaney can bite it as far as I'm concerned. If my facility would take the money they spend subscribing to PG and spend it on extra staff, patient satisfaction would increase. Screw Press/Ganey.:yeahthat:

Our management wants ease of access. Our management wants fast turnaround. In one breath, our management complains about patient load. In the next, they're telling us about how they're trying to make the ED a better place to come for non-emergent healthcare. We have a "fast track." We are regularly trying to explain to people who are in misery in our waiting room exactly why people who have non-emergent symptoms are being treated before them. We are dedicating at least some amount of our limited resources to treating patients who do not belong in the ED. If I were suffering in the waiting area, I'd be pissed, too. Are we an emergency room or a clinic? ABOLISH FAST TRACK NOW!

I just triaged a Medicaid frequent flier who rode the 911 express because he has a runny nose. $400 ambulance service. $500 ED visit. I'm working my ass off; spending time away from my family to support this bullshit. I just sent an email to my county's Medicaid investigator reporting the situation and plan to continue to do so. Half of the problem is that the hospitals corruptly turn a blind eye to recipient abuse for fear of loss of revenue. I have plenty of suggestions to fix the problems, but many of them require balls our legislators don't have.

Here's the real sin in this issue: Multi-billion dollar, multi-national companies are allowed to pay poverty wages and offer absolutely no healthcare benefits.

We HAVE universal healthcare. Walk into any ED and be treated for any complaint, whether you have resources (or intention) to pay or not. We already have universal healthcare. It's just being delivered in the least efficient way you could possibly conceive. Think the hospitals are losing money? Think the insurance companies are losing money? Maybe marginally, but the bulk of the costs are simply being transferred to those who are self-pay or insurance premium payers. Guarantee payment for basic primary care and the tax/insurance premium payer will save a LOT of money. While I'm writing this in triage, a 20-year-old self-pay (aka: "no pay") frequent flier has just come in via EMS for a runny nose. Know who's paying for his ambulance transport and ED care? I AM.

This is a pet peeve for me. Our ED docs call admitting docs who then either come in and write or call in orders. Calling in orders isn't bad from the RN standpoint, but the ones who come in and then take over an hour to write floor orders create an unnecessary delay. I've been pushing for a policy that would have the admitting docs write very basic admitting orders such as: Admit to medical bed. Diagnosis Y. Continue IV at xml/hr. FLOOR ORDERS TO FOLLOW. Then, they should go up to the floor and take as long as they please to write the specific orders to be administered on the floor. Stop tying up ED rooms for this crap.

First born. Male. ETOH father who quit drinking before I was born, but was frequently absent due to his job. Very interesting observation.

If you could do anything to inpatient rooms (excluding making them bigger ), what would you change? Think in terms of patient comfort, nurse convenience, ergonomics, furnishings, storage, etc. What are your pet peeves about inpatient rooms?

What, besides size, are the changes you'd make in inpatient rooms? Consider patient comfort, ergonimics and staff convenience.

I've noticed that the incidence of frequent fliers is about the same among pre-teen campers as in the general population that frequents the ED where I work the other 51 weeks a year. It seems that about half of our contacts at camp are with the same 10% of the campers. I wonder what factors motivate kids (and adults) to (ab)use medical resources when they have unfettered access.

Counselors at the camp where I've worked are required to keep their meds in a locked cabinet in the medical hut. They present whenever they please and we give them their entire med drawer. It's up to them to take whatever they're supposed to take. The meds are kept safely and they maintain some degree of privacy.

MAP takes cardiac output into account. It's a good indicator of perfusion. Perfusion can be insufficient (a low MAP) even if BP is not, if cardiac output is too low. Here's a formula for MAP that gives a true reading v. the SBP/DBP estimation formula: MAP=(COxSVR)+CVP where CO is cardiac output SVR is systemic vascular resistance CVP is central venous pressure Of course, it's a bit harder to come by.

btw, every drunk, drug addict or prostitute i've ever seen or heard of has decided to drink, drug and/or whore. "nurse" does not equal "enabler."

Yes, and a damned good one. No anger. No rage. Just zero tolerance for violence against healthcare workers. If you were getting beaten up by some violent patient you're coddling, I'll bet you'd love to see me coming. :welcome:

I care about a worthless piece of crap as much as the next nurse, but, as a father of four, the well-being of violent ED patients is not my first priority. My going home safely is. If it truly comes down to a choice about whether a violent patient or I am going to be hurt, there's no choice about it. I'm not talking about hurting somebody just because they're a turd and you can. I'm talking about exercising all necessary measures. Here's a personal policy I strictly enforce: "Violent patient, if anybody here is getting hurt, it's not gonna be my children's daddy." As long as nurses and the law continue to accept assault as part of nursing, we will continue to be victims. Defend yourself. It's a basic human right.

If you're talking about tips for calming him down, I'd say the chemical paralysis and intubation is a good way to go. As far as you, I hope that seeing that asshole sentenced to prison will make you feel better. Zero tolerance. Pursue conviction. Contact your Congressman about initiating Federal legislation to protect healthcare workers.

Even if you're hanging a low-concentrate premix of 400mg/250ml (dopamine is completely compatible with NS, dextrose, NS/dextrose combinations, and lactated Ringer's), the flow rate to provide recommended starting dosages for a 150# patient, for example, is going to be below typically-accepted KVO. If the premix is a more highly-concentrated 800-1600mg/250ml, count on sites clotting more frequently if you're not piggybacking on a KVO rate. I'd be afraid to depend on a rate of 2 or 3 ml/hr to keep an access patent, but, if that's what your facility's policy calls for, go for it. I guess it actually goes back to the old question "how fast is KVO?" I don't trust anything under 10ml/hr (and like 20 even more!). Unless the patient is truly at risk for fluid overload, why risk the site by flirting with bare-minimum rates to keep the access patent?