ozinurse

Sounds Hideous. I certainly don't envy you. If you are supposed to be the shift coordinator, you can't do it when you are in the thick of it. You need to be objective and available to all the staff. It sounds like you have pursued most options already. If your going to stick with it, I'd suggest keep up the safe staffing reports. Make sure you keep a copy of any correspondence that goes up the chain as you may wish to it refer to later. Attatch literaure about 'ED overcrowding and increased mortality rates.' (one published in the last 6 months, but I can't remember off the top of my head which journal) It is good to know how your department works out its safe staffing numbers, who keeps the stats, and who they get sent to. If it is anything like where I work, actually sorting the staff numbers is a tmely pain staking process. But knowing what evidence you need and who's tree you need to bark up might be useful. Don't think you will solve it on your own. It will have to be a departmental approach to fixing the problem. Take it to the local authorites and make your case. It is also good to take strategies. If you can give them a reasonable resolution or something that they can negotiate over, you will get further. If they (the department seniors) are not interested then you might be better saving yourself the stress and the risk of an adverse event happening on your shift. (Give them the finger)It's nice just to be able to do your job properly, and there are pleanty more opportunities out there.

The good thing is that you identify that you have deficits, and you are endeavouring to do something about it; read, ask and experience. The scariest new practitioners are those who think they know it all. From my own experience the first three months are keeping your head above water. One of the most important things at this time is time management. This is difficult, whist you are trying to learn about all the new things that you are administering and doing, and the different presentations. Prioritising is the other. Especially when things seem to be getting out of control, sometimes you need to stop and regroup and work out what needs to be done right now, compared to what can wait. I would discourage new entry clinicians from pursuing the overwhelming urge to learn to do cannulation, abg's and other technichal skills until you have the previous under control. Otherwise you are trying to encompass something else that can be time consuming into your time management. I had several stages of acute anxiety when I started in ED. The intitial 3 months, then another one a few months later, when you can start to pre-empt what needs to be done, as well as the technical skills, and then try and compress them into your current patient management. Then you go through move into resus and triage, in-charge etc, etc. Just remember - primary survey - Airway, Breathing, Circulation and Disability determins the acuity of the patient. Work with the presenting problem and think about possible causes and possible effects. From that you can determine the appropriate assessment and management. There will always be something new. Personally I reckon if you aren't learning something new or being challenged, it is possibly time to move on. All the best. Keep at it.

I am a huge fan of local anaesthetic. There are several articles that suggest the use of lignocaine decreases the pain of cannulation (and abg's (Lightowler and Elliot (1997 and Giner et al 1996)) by half. (Robinson et al 2007, Murphy and Carley 2000 and Harris 2001) and also if used correctly, that it doesn't effect the success rate (Murphy and Carley 2000). I use it when inserting 20-16g cannula, and have had an excellent patient response. Despite working in a 'best practice' driven environment it is still difficult to get people to use local. The (false) perception that it makes it more difficult is one of the reasons it isn't taken on. As an advocate for the patients well being, simple measures to ensure that the patients hospital managament is as un-unpleasant as possibleis (I believe) it is important. Just because they have come to the emergency department, doesn't mean that we have a right to inflict unnecassary pain on them. We often think that they should just grit there teeth, or show some gumption, but from my experience, cannulas hurt. The same principles would also pertain to other pain inducing procedures, such as NG insertion. Female catheterisation (Chung et al 2007). If your department doesn't already have analgesia incorporated into these procedures, it is worthwhile at least having standing orders so that you have the option. Chung C, Chu M, Paoloni R, O'Brien M and Demel T 2007, Comparison of lignocaine and water-based lubricating gells for female urethral catheterisation: a randomised controlled trial, Emergency Management Australasia, 19, pp. 315-319. Giner J, Casan P, Belda J, Gonzales M, Miralda R and Sanchis J 1996, Pain during arterial puncture, The American College of Chest Physicians, vol. 110, no. 6. Harris T, Cameron P and Ugoni A 2001, The use of pre-cannulation local anaesthetic and factors effecting pain perception in the emergency department setting, Emergency Medicine Journal, 18, pp. 175-177. Murphy R and Carley M 2000, Prior injection with local anaesthetic and the pain and success of intravenous cannulation, Emergency Medicine Journal, 17, pp. 406-408. Lightowler, J and Elliot, M 1997, Local anaesthetic infiltration prior to arterial puncture for blood gas analysis: a survey of current practice and a randomised double blind placebo controlled trial, Journal of the Royal College of Physicians of London, vol. 31, no. 6, pp. 645-646 Robinson P, Carr S, Pearson S and Frampton C 2007, Lignocaine is a better analgesic than either ethyl chloride or nitrouse oxide for peripheral intravenous cannulation, Emergency Management Australasia, 19, pp. 427-432.

I would imagine the use of 18g cannula on everyone is a generalisation. I think the size of the cannula inserted needs some discression. It is not necessary to insert large bore cannulas in stable patients only requiring maintence fluids or intermittent antibiotics. However, I am in agreement that caution should be made, and insertion of a larger cannula when the patient is or potentially unstable, and/or requiring fast fluids or blood administration. The nature of emergency department, is that patient diagnosis is often unclear and an 18g cannula in these patients is appropriate. It is admittedly a lot more annoying to see inappropriately small cannulas insert into sick people. I have heard the excuse, that it is all they could get in. Maybe they should have gotten someone who was capable of stick the correct size in to do the job.

This is a very interesting topic. Obviously, as has been discussed, it is not illegal to take someones photo without permission. and as someone mentioned it would be impossible to stop the people who really want to take photos. Like trying to stop people taking photos/videos at a concert. It creates a bit of an environment of, 'Big Brother' is always watching, which means that you are always on the defensive (which is frustrating and exhausting). All you can do is deliver the best care you can and maintain your integrity. How can anyone fault that? Intimdation, by taking the photo, is an obvious issue. This should be dealt with like any form of intimidation; Stay calm, usually people are after a grand response - don't give them the satisfaction. Set boundaries - if you think it is intimidation, point out that is you understanding of the situation and tha you don't appreciate it, this might be your opportunity to ask them to remove the photo, they may or may not but you probably can't do that much more. Set the rules - this is helped with a supportive department or institutional policy and security to back you up - let them know that the individual will be asked to leave if the behaviour persists. (Our department has a huge sign in the waiting room stating that aggressive behaviour will not be tolerated). Then again, maybe the kid thought you were hot:redpinkhe. He may have thought with his mothers behaviour, the likelyhood of getting a second glimpse of you was pretty slim.

If you are apprehensive when before you start, you will probably miss. Start on the sure things, then progress to the more difficult as your confidence builds. Get some one you can take criticism from an is good at cannulating to watch you. If you miss, critique yourself. If you can identify the problem, don't do it again. Some simple points to success. - technique should be fluent/fluid - be confident - be comfortable - Don't rush it. - picture the vessel in your head and the cannula in relation to it.

I woul have to agree with some of the other posters that attitude and confidence often contributes to about 90% of success rate. Another big cause of failure that I have noted, is clinicians not being in a comfortable and inline position. Generally the technique of sticking in an 18 is much the same for the smaller guages except that the receiving vessel also has to be adequate to accomodate the size. One thing to keep in mind though is the length of the bezel is consideably longer in the 18 compared to the smaller, which means that you need to be careful as your needle can pass through the vessel, especially if you are on too sharp (no pun intended) an angle. This is the reason that technique changes slighlty when you reach size 16. The tip of the bezel can be most of the way through the vesel, before the 'flashback' is capable of traveling up the bore of the needle. You generally have to use a shallower angle, and the signalling flashback is generally only a small spurt, rather than a flow into the flashback chamber (unless you are in something huge). By the time there is a good flow the tip of the needle is peircing the far wall of the vessel. The distance from the end of the cannula relative to the end of the needle is also imprtant to keep in mind, as if the needle has not been inserted far enough before advancing the cannula, the vessel may be pushed off the end. These are often those ones when you were sure you were in and you blow it when you advance. Getting the technique right on 'the sure thing' helps with confidence. Just don't limit yourself to the anterior cubital fossa, as it will drive everyone nuts. Local anaesthetic (0.1-0.2mL 1% lignocaine for injection) goes a long way as well. There are some articles out there, suggesting that it decreases the pain by half and doesn't impede success rate. It will make the patient more comfortable and relaxed, and take the stress out of the pain you inflict if you miss or 'have to dig' a bit (hopefully not too much).

It might be questionable whether you would base the diagnosis of base of skull fracture on the halo test or positive glusose anyway. A significant head injury with blood from the ear/nose would be of high suspicion and most likey score a CT.

It sounds like this girl needs a performance review. I don't know if anyone has had serious discussions with this girl. I get the impression that the manager isn't all that interested. However, for the functioning of your team and the morale of the department, some one needs to. Consider sitting her down and asking how she thinks she is going. Does she know she is struggling, or does she have no idea? Let her know that it is causing stress with her coworkers? Give her the opportunity to come up with some solutions? Make some suggestions; experience in another area might be a good one, especially that might be suited to her. Even if she aspires to be an Emergency Nurse, some other experience may develop skills and/or possibly identify a new career path. Give her time frames for improvement/outcomes? It is important to give her some limits, as well as a measure to see how she is going. always sandwich bad with good; e.g. good attributes, how others are percieving her, but she is full of potential.No good beating around the bush too long, because either she or you may end up getting linched by disgruntled coworkers. She may appreciate someone who can be a friend, honest, an ally, and did I say honest. Hope all goes well. :typing

I empathise, sounds like the pits, but I think a lot of people have similar stories. It sounds like you have good work ethics. Keep at it and always maintain your integrity. Lazy people are more than happy to pull you down, so that they look better. Like the other comments, ask for help if you need it. Particularly your in-charge. If it is anything like our environment, it is their job to ensure you have the resources to do you job safely (for both you and the patients). I don't know how you allocate your patients, but if their is a way or defining who are there patients and who are yours, concentrate on yours and people will easily see where the deficits are. If you don't have allocation of patients, maybe it is something you could suggest. This is hard to do when you know there are patients who need attention and you know are not getting sufficient. If these are senior people sitting on their butts, (which is often the case) you often have to be the person that they you want them to be. It can be impressive the motivation that 'being superceded' can promote. Also remember that there are other jobs out there, and if you are really miserable, try somewhere that will appreciate you.

I wouldn't take the mothers comments to heart. From working in an Emergency Department and nursing for a while, you realise that people often say things in anger, frustration, stress or fatigue that they don't literally mean. Sure there may be an element of intent, in what she had to say, but not necessarily the way it actually came out. The mother is obviously concerned for her childs welfare (Which mother/parent wouldn't be), and she is probaby fatigued, especially as you mentioned she was sleeping in the boys room. You can also guarantee, that if she has a health background, she is possibly going to scutinise anything the health professionals do, because they would never be up to the standard that she would wan't for her son. I would not be surprised that this woman had been the patients primary carer, outside this admission. I have kids, and I know when I am stressed from study, work and sleep deprivation, I can say ridiculous things in my rantings. When I yell at 3 o'clock in the morning, I don't really mean that, "I CAN'T STAND THEM ANY MORE!". I really mean, "Please go back to sleep, I am tired, and it is very early." (which is intended in a calm serene voice of course). I had a colleague who had a daughter who worked at McDonald's, who asked why she (her mother) got aggitated when clients complained. Apparently the McDonald's philosphy is "any comment, is constructive criticism, no matter how it is delivered." Therefore their employees should be greatful, for the advice so that they can deliver a better service. (I don'y know if they smile as they spit in your burger out the back). Sometimes you just need to grit your teeth, ensure you are doing the best you can, and reflect on the comments to see how you can do it better later. Don't forget the benifit in debriefing to a collegue over a beer at the pub (or equivelant), have a *****, then do the previous and move on.:typing

I have found another site that may answer some of your questions. http://www.health.vic.gov.au/nursing/career/overseas It is from the Victorian (South Eastern state of Australia) Government Health website. It has information on the process for interational graduates wanting to work in Australia, including the process. Despite having a national standard in Australia, nursing registration is still controlled by the states, however there is a plan to move to national registration. This also means that the nursing awards (pay rates and allowances) are slightly different depending an what state you live in. (Hopefully the state nursing award may be able to be located on this site as well. If I can find an example I will post it in this forum as well.) I can't say much for the cost of living, as I am not travelled well enough to give a relative comparison. The good thing about Australia though, is that it is relatively small, not hugely populated and relatively safe, however spread out a bit, which can make it expensive for the average backpacker, who wants to get around and see the sites. Rental cost should be fairly easy though, especially if you can buddy up with friend to share the costs. Sydney and Melbourne, as capital cities, are going to be more expensive, however also offer a lot more variety in hospitals and tend to be more multicultural. Quennsland has heaps of jobs going and some good incentives. Anyway, hope this helps.:typing

For information regarding working in Australia visit the ANMC website.

Integrity goes a long way. Even bad expereince counts as experience on a resume, as long as the long as you accept it as a learning experience. You still had nine months clinical experience which is beneficial. However a resume or job application is not the place to slander your previous employer. It is reassuring to know that your integrity remains intact after being tested, and that you felt that proper patient care is of higher importance than 'a job'.

I would always recommend experience outside of emergency, for two main reasons. It gives you a greater appreciation of how the organisation works in its entirity, without the blinkered perception, that your department is the only one that exists or matters. Secondly, the skills attained from working in other areas is irreplacable. Emergency being so diverse, it makes it difficult to attain specific knowledge of any one area of clinical practice. I have known nurses with several years (emergency) experience, not knowing how to accurately assess someones neurovascular status when they have a fracture. If you want to know how to be an expert at ECG's, work in cardiology for a while. If you want to be an expert an chest xrays and non invasive ventilation, work in respiratory. Secondments to other areas whilst working in emergency are also beneficial, especially as you realise your deficits. A stint in paediatrics (unles you work in a paed specific ER) can greatly improve your kid handling skills. A stint in Psych always goes a long way. Remember. Nothing is ever permanent and the opportunities are vast. Even if you don't particularly like an area, there is always something to learn. (if you have the right frame of mind). I appreciate that the systems are different between Australia and the US are different, but I am sure that you can extrapolate some of the principles.