Jen2

I never get sick of hearing these no matter how many old threads there are on this board. I want to share in the stupidity that I like to call, JOB SECURITY! "Walking outside and saw a bat fly by. I want a rabies shot." "I was visiting my neighbor upstairs. The nurse took my blood pressure and it was 132/80." My reply: How do you feel? Patient: Fine I just thought that was a little high. "I have an appointment for an MRI." "I was having sex with my boyfriend and I got really hot and could feel my heart beating all through my body, and I had These like jerky movements, do you think it was a seizure?" This is my favorite. Consider yourself lucky honey, you just had an orgasm.

The above would never happen in my ER. The second we get a bed, we have to call report no matter what time it is. I do not know one charge nurse in my department that would let any staff nurse wait until shift change to call report just to "hold on to the patient". There are times that If I am in another room working a code and I get a bed on one of my stable patients, my charge nurse or another nurse will call report if I am unable to do so. However, "holding on to a patient", in the ER just does not happen. Especially when the waiting room and hallway is full and there are ambulances comming in and three helicoptors are scheduled to do hot off loads with in the next 15 minutes. When we get a bed from our H.S. we call report upstairs. If that nurse is unable to take report we ask to give it to the charge nurse. Once we call report we take the patient up in 15 minutes. There have been many times when we have gotten a bed at 17:00. Call to give report and "the bed is dirty". Somehow the bed would not be cleaned until 19:00. Not my fault it took house keeping two hours to clean a room. We started monitoring this by sending up the nursing assistants to see if the room was actually dirty. We found that 8 times out of ten the room was clean. We initaiated a stat housekeeping policy in my facility that if the housekeeper on that floor was busy we could send another team to go and clean the room. Also discharges are a floor nurses last priority. If a patient is not discharged until 18:00 and the room is cleaned by 18:30, guess what time report will be called? It is always a no win situation. As an ER nurse you are the red headed step child of the hospital. You try to do the best you can with what you got. I have never had someone be happy to hear from me. However, on the opposite end we have a very good relationship with our EMS and flight teams and depend on and respect them to give us information to plan care for the patient. I couldn't imagine having EMS or flight standing in the next room with a patient and tell them, "I am too busy doing this dressing change to check in that patient right now". Also cannot tell the helicoptor to circle around a few more times until I finish eating my lunch. I don't know what the answer is. We just have to try a respect each other and understand. Even though it's so hard sometimes.

First I would like to say that I am so glad that friends hubby will be fine. I am glad to hear of a positive experience in the ER. We are mostly chastized for being cynical, and uncarring a lot of the times becasue of the way we feel about people using the ER as a PCP and so forth. However, when it is someone critical that is in need of the ER the experience is mostly positive. We rarely get to hear about positive experiences and least often an outcome of the patients that we work so hard on the save their life. I just called the ICU last week to ask about a patient that I worked on for 2 hours in the ER and was told that they were not allowed to tell me becasue of HIPPA! Anyway thanks so much for posting.

You got some excellent advice already. I will add a few. 1. Believe it or not and dare I say, (sshh! don't tell anyone). Every once in a while there will be down time in the ED. Ususally between 3:00am-8:00am depending on what time you are orienting. This is the time the nurses will be "venting". You will be introduced to a sick twisted sense of humor and will probably cringe. It's O.K. the nurses are only mildly psychotic. 2. During the occasional down time ask questions, stock rooms (the only way to find out where anything is in the ED in my opinion), discuss cases, ask your preceptor to quiz you. 3. When things get crazy, don't expect your preceptor to stop and explain everything to you. I myself will tell students, "Put your running shoes on and stay close behind me, I'll explain later.) Make sure you take mental notes and then ask questions when things start to settle down. 4. Being in triage is a great experience. This is one aspect of nursing that even many nurses don't understand. Unless you are an ED nurse and regularly do triage you cannot fully understand ER nursing. Even our critical care float people that are awesome nurses and great resources have no clue what goes on out there. This is probably the most important role in the ED. This is where you learn to assess a patient by how they look. Too many new nurses are going to the ICU's etc. and being taught to read monitors and calculate numbers. A good triage nurse will watch a patient get out of the car and call the charge nurse to find out where they can put the patient before they even make it to the desk to sign in. When I tell people what I do they are like, "Oh my you get those patietns right off the Helicoptor how exciting." I always say that it's not the ones in the helicoptor that worry me. It's the ones that drive themself to the ED. 5. You will use a little of everything you learned in nursing school. Be prepared to remember your Psych rotation and keep yourself safe. Just because someones chart says that they are there for "abdominal pain" does not mean that they are not psych. Always look for signs of agitation/escalating behavior. It only takes once to be cornered in a room with the door shut to never let your gard down again. 6. Finally you are in a very good place before you take state boards. I exterened in the ED before my boards, and found myself pulling from the experience the whole time I was taking that test. Have fun and enjoy. Post about your experience.

Thanks everyone. Finished the seminar today and enjoyed it. I want to try and take the test asap though, just found out they are changing it July 1st.

The unexpected, the organized chaos, the teamwork/support that is unlike anything that I have ever experienced, taking care of the entire lifespan instead of just one particular age group, knowing what is wrong with a patient without all the bells and whistles hooked up and before a single test comes back. Wow thats a run on sentance. I could keep going on, but those are my favorite things. I would say not having take care of the same patient for longer than a few hours, but times are a changin in the ED world with all the borders. Oh, and I love the adreneline rush of hooking a chest pain patient up, seeing the STEMI and rushing off to the cath lab. I also love having the freedom of working up patients before they are even seen by a doc. I think thats it for now.

We use it for every intubated patient. We are a level 1 trauma center. It is the trauma surgeons that request it.

During the "Golden Hour" so to speak, I will take a quick second Before going to scan and tape the eyes shut before I start pulling at monitors and tubes. Once the trauma resuscitaion is complete and before family comes in I will take the tape off.

Anyone ever take any of the Med Ed seminars? I am taking the CEN one. They boast a 98% pass rate on the CEN and money back if the exam is taken and failed within 90 days. I took a CEN exam prep course last year that was given through a local hospital and was too chicken to take the exam afterwards, because I didn't feel that it prepared me. I am hoping to feel prepared to take it this time.

Level 1 Trauma center 35,000-45,00 patients a year. We do A-lines and central lines on a daily basis.

I cannot take care of anything and actually said that in my earlier post. Not being arrogant and actually said that ER nurses are not ICU nurses, but they do critical care nursing to an extent. Also said that I was not an ICU nurse, never said that I wanted to be called one. We were given a 2 day advanced hemodynamic monitoring class which included IABP, and had to spend one day in the CCU with an experienced ICU nurse taking care of a patient with IABP. This does not mean that I am proficient in anyway and was on the phone with the CCU charge nurse during the patients care, as well as my charge nurse who was a former CCU nurse of 10 years. All I stated was that I took care of a patient in the ED with a IABP. I am glad that anesthesia is looking for nurses who deal with critical care daily. They should be! I personally have no desire to go to anesthesia school, but two nurses I work with, 1 ED and 1 flight nurse did get accepted without ICU experience. Nope, probably couldn't take care of a whipple. Have never had to before. Besides an ER nurse has no clue how to keep a patient alive especially long enough to get them to the OR or ICU.

Unit bed was available at time of acceptance. We are the only level 1 trauma center in the state. This particular patient had to be packed up and transported to us which took quite some time. During transport to our facility there was two codes on the floor that took the last two unit beds. Patient had to be boarded in the ED until things could get shuffled around upstairs. Nahna nanana!

Nope! We have still had to take them from other hospitals that were transferred to us when no unit bed was available. CTU doc comes to the ED and sees the patient, writes the orders and we wait until a bed is ready before we take them upstairs.

Actually, I do know of CRNA schools that except ER nursing as long as that ER is in a level 1 trauma center. I am a ER nurse and a critical care nurse, however, I do not work in the ICU and do not want to or thats where I'd be. I have taken care of patients with balloon pumps, LVADS, etc. I do not believe, I could just go to the ICU and take on a fresh heart. I also do not believe that just any ICU nurse could do it either. I highly doubt that the ICU nurses would be able to take care of half the heart babies etc, that we see either. I believe that every facility is different. I worked in one facility that if a patient had in a chest tube they were automatically in the ICU. In the facility I work in now, there are patients with chest tubes hanging them off their IV poles and ambulating in the hall. About the comment about the patient being too unstable to be in the ER. Thats pretty funny. However, I will say this: ER docs are just that. An ER doc is not an ICU doc the same as an ER nurse is not an ICU nurse. So, yes we have had docs wanting to get a patient upstairs ASAP because of their condition. We do have parameters however, before we can send a patient upstairs. Systolic BP must be above 70 for instance. We cannot, and will not transfer a patient that is too unstable for transport. It may be nice to have a doc in the ER however, they are not the ones running between all 30 beds in my ED. It is the nurses. I have had 4 and 5 vented/critical patients at the same time, and oddly enough when we are boarding this many ICU patients in the ED, there is a bad accident and the traumas start comming in. That ER doc is with those traumas. He could care less about the other "hold ICU" patients. They are no longer under his service. I am the one hanging/titrating gtts until I have a bed ready. I once asked an ED doc to write me an order for propofol for a vented patient and was looked at like I had 3 heads. Our patients have A-lines, we monitor end tidal CO2 etc. Am I a critical care nurse Yes! ICU nurse however NO!

If a room is empty, shut off the light. Never say the Q word (We all know that one is not a myth) Hanging a pressor at bedside for a hypotensive patient, epi drip for analphylactic patient, etc. wards off the evil spirits. The first time you don't jump on the frequent flyer and do the cardiac protocal within 10 minutes of hitting the door will be the time that they have their MI for real this time. There is one room that we leave empty until we absolutley must fill it. It seems as if almost every time we put a patient in it something bad happens. Thats all I can think of for now.

I agree with the systems failure part. There is only so much a nurse can do as far as workup. Yes I can order and draw labs/cultures etc., However when the white count comes back to be 18,000, I need an MD to write an order for that antibiotic. Even with the high white count and first round of antibiotics started by the ED, that does not gaurantee that the surgeons will get there any sooner. Basic wound care can be done by a first semester nursing student. The problem is and it is hospital policy that if the surgery has been less than 30 days. The sugery team that performed the surgery must evaluate the patient. Nine times out of ten the patient has already called the surgeons office and was told to go to the ER, becasue they have no appointments available for the day. Once the patient gets to the ER, the surgeon will not come and see the patient until all testing from an ED standpoint is done, and they are done doing their rounds, scheduled surgeries etc. I wish we had the luxury of an assessment bed, but that is not the case. We cannot turn a patient away and say, "It sounds like a problem of the surgeons, sorry but we will not be able to see you today." There is a thing called the EMTALA law.

Working triage the other day. Waiting room full of ESI 111 patients. Car pulls up and this middle aged man weighing about 120 lbs pulls up and comes running in through the doors. "I need help getting my wife out of the car , she can't move." The CA goes out with a wheelchair, well she weighs about 350 lbs and is unable to sit up straight. We get three of our most macho men, a flight medic, our charge nurse and the CA to go out with a stretcher, and "extricate" this woman from the private vehicle. They get her out of the car and onto the stretcher. As I am triaging her I ask how she got into the car in the first place. She informed me that her 120 lb husband "carried" her to the vehicle. Her chief complaint was low back pain x's 2 months.

There are several threads where this issue has been brought up. I cannot speak for your particular hospital, but I will tell you what goes on in our hospital. Scenerio 1. Patient comes in with post op-complications. They need to be seen by the ER physician since the surgeons do not magically live in our department. Before we are able to consult the surgical service, there is a workup we must do since calling the service and simply saying that the wound is red will not warrant a visit. So we work the patient up call the hopefully admitting service with the results and wait and wait and wait. We wait until they are out of surgery, done doing rounds etc. etc.. Once we consult on a patient it sometimes takes that particular service up to 2-3 hours to come and see the patient. The service finally comes and sees the patient and decides to admit them. The ER physician cannot admit a patient. There must be an accepting service. Scenerio 2. Patient comes in as a stroke page and neurology is at bedside evaluating the patient. We start workup and everything comes back to be "stable" from a neurology standpoint. Therefore neurology will not admit the patient to their service. The patient still needs to be admitted so the ER must then consult medicine to see if they will admit the patient. Well before the medicine team will come and see the patient, they want urine results. We get the urine results and wait and wait. Medicine then finally comes and sees the patient. Medicine does there eval and decides to admit the patient. Admission cards get put in and we wait for the H.O. to call us and give us a bed. Scenerio 3. Trauma comes in and is scalped because their head went through the windsheild and a tib-fib fx that needs to be reduced. Admission cards get put in right away by the trauma service and we get a bed right away. However, before we can take them upstairs trauma needs to staple the head lac, we have to wait for plastics to come and suture the face, and have to wait for ortho to reduce the fracture. Can't just send the patient upstairs with a bleeding head wound and an unstable fracture with possible vascular compromise. All of these things takes time. Scenerio 4. Have a very stable patient call report and start packing the patient up to bring them upstairs. Charge nurse comes in the room and tells you to hold on, EMS is at the door with a cardiac arrest. Work the cardiac arrest and then take the stable patient upstairs. Try and notice what time rounds are done in your hospital. It seems as if in our hospital rounds are done by the services before noon. However, discharges are not made until later in the day. If a patient is not discharged until 5:00 in the afternoon, then this will put a patient being put in that bed at the floors shift change. Sometimes we get into a war with different services where no one wants to admit the patient to their service or the patient has multiple complaints and several differnet services needs to see the patient. I have also noticed that in my hospital a few of the nurses on the floor will have discharge orders for a patient and sit on them for as long as they can to avoid getting a new patient. Often times we are given a bed number while there is still a patient in that room upstairs, and if that patient gets discharged at 6:00pm there will be an ER patient in it as soon as it is clean. Usually right at shift change. I understand that not all nurses on the floor do this and it is not done intentional, when you have 6 medicine patients and are teamed with an LPN that has 6 patients, discharges are the furthest thing in your mind. Don't know if I explained a little to you or not, but that is what this board is for, so that we can learn and try to understand each other better.

Just a thought, and I truly don't even know if this is true or if there is any literature to back this up, but I was taught in TNCC that if you put a #18g IV in the AC and then put a lock on it, it now changes your #18g to a #20g, and if you add a J-loop it will even change it to a #22g. So there is no sense in putting in an IV that large if you add the adaptors. I was just taught that every peice you add makes to gauge smaller. Like I said I'm not even sure if this is correct, but I know that you cannot run a level one rapid infuser through them. I am guilty for never adding a J-loop. Mainly because we don't even have them as stock in the ED, but I always put the lock on.

I don't buy the shift change thing. I stated before, the shift change in the ED means nothing. A lot of our shifts are 11a-11p, and 3p-3a. The floors at our hospital record report. When the 7a or 7p nurse comes in to start listening to report this means that either day shift or night shift is there until 0730a or 0730p. The half hour overlapping is supposed to be for getting a new admit in the room, and to be able to answer questions regarding the taped report if needed. It is not intended to give a half hour to change shoes, put coat on and stand by the time clock until it's time to punch out. Which I see often. I work 7a-7p also in the ED and when I am taking a patient up at 7p I will see people standing at the clock with their coats on. I go to the room move furniture around, turn the bed down, get the patient in the bed, go to the nurses desk to get the telemetry pack because I cannot leave a monitored patient unmonitored, orient the patient to where the bathroom is and call bell is, pack up all of my equipment, go back to the ED, and report on my patinets it is now 8p and the hospital has now paid me a half hour overtime. Believe me no one likes to take a patient up at shift change, but it has to happen that way sometimes. Holding on to my patients. Are you kidding? Thats one of the main reasons I work ER is so that I can get rid of them just as soon as I get a bed. Sometimes I cannot take them upstairs even after I know I have a bed until the bleeding headwound is stapled or the broken bone has been reduced under sedation. I cannot transport someone with blood spewing from their head. So yes there have been times when I have had a bed for an hour, but did not transport the patient until shift change because I had to make sure all the ABC's were covered first. When thats done the patient goes upstairs. Believe me there would be no better benefit than to not have to deal with the politics of taking a patient up at change of shift, because I would like to leave on time also, but sometimes it just has to be done.

I have not read all of the responses, so I am sure a few of these have already been posted but here are mine: 1. When I ask a new nurse if she/he wants to go see or help with a procedure and they tell me that they saw that once in nursing school. 2. One of the first things I do with an orientee in the ED is have them follow a nursing assistant around so that they can help them stock rooms, IV baskets, go to materials and pick things up etc. They look at me like I have three heads and are highly upset. I politely tell them that half of the battle in the ER is to know where everything is at and how to get it in a pinch and this is the only way you will learn. They seem to think that stocking is above them. Sorry but it's the only way you learn where everything is at. 3. When a peds patient or neonate needs an IV, meds, or a straight cath, and the orientee has watched you do about 20 and still refuses to try. Sorry but there has to be a first time. You will be off orientation in 3 weeks and will be expected to do it. 4. This one is not only for new nurses, but all new ED nurses. When you get argued with that putting IV's in the AC's is stupid, becasue the floors don't like them there and the patient can't bend their arm. Just not too long ago had a orientee that had been a nurse for a year and worked on the floor. She was putting #22g IV's in the hands of all patinets. Argued with me that it was the best place, because she worked the floors and how it caused less trauma to the patients, and how these patients were not even sick or being monitored (we start orientees on the non-emergent area of the ED). Well after our back pain turned out to be a leaking AAA, that eventually ended up being intubated and transferred to the CTU, she saw how worthless that #22g in the hand was when we had to resuscitate the patient. Please don't argue. I will tell you the rationale of why we do things. You can either listen or find out the hard way. 5. I am very hands on with orientees at first. After they learn where everything is at, what doc is what, have followed me around for about two weeks, etc. etc. If I am assigned to six beds I like to give them three of the six patients, and tell them if you need me I am here, ask for help. I have been acused of setting on my rear end and not helping by one particular new nurse. When I told her thats not the case, that I was doing this so that she could learn how to prioritze and know when to ask for assistance from co-workers she said she understood. I'm not just being lazy here. 6. All time favorite is "Thats not how they showed us in nursing school." I don't need to explain this one.

We call triage the Penalty Box or Tragedy instead of triage because everyone has a tragedy. Management actually tells us that we shouldn't think that way becasue only the best nurses get to work triage. Sometimes it feels like a punishment though.

It all depends on what you think you will like. In the ED you will see anything and everything across the entire life span from neonate to geriatric. From the sprained ankle to the traumatic arrest that has had both of their legs amputated by the dash board of their car and you have to put towels under the door in the trauma bay to stop the blood from runing out into the hallway. You will begin to initiate and titrate every drip on every patient population that exists. There will be times you will have MANY ICU holds as well as other step down patients that you are responsible for yourself. It is a high litigation high acuity area most times depending on what type of hospital you work in. You will have no clue what is wrong with your patients. You will need to assess the patient and come up with a worse case scenerio based on your assessment skills without all of the fancy toys hooked up to the patient. I feel a sense of satisfaction to work up an acute MI by myself and then walking out to tell the attending that he needs to fire up the cath lab becasue we have a STEMI in room 10, and do it in 30 minutes of less. The reason I chose ER was becasue I enjoyed all of my nursing school rotations and couldn't choose where I'd be the happiest. I decided to go to the place that gets to see all of those things in small doses without having to deal with the same patient population and the same illnessess day in and day out. You gotta have ADD. My husband is an ICU nurse and he loves every minute of it also. He likes knowing every single thing there is to know about each of his patients. He likes having the time at the bedside and managing the drips on more of a long term basis to see the effect that they have on the patient. He also wants nothing to do with a patient unless they are 20 years old or over. He loves his high acuity patients but likes the controlled environment in which he gets to practice. We both agree that we couldn't do each others jobs, but respect them and like them equally. Its about finding your own niche.

Had a bad day and would like to have some fun. Thought I would try to put together a disclaimer upon signing into the ER that almost sounds professional enough to hand patients. Thank you for choosing __________ hospital for your emergency care. You have rights as a patient (list patients rights). We also have rights as a facilty to protect you while you are here in our care. We are unsure how long your wait time will be as our patients are seen on level of acuity and not time entering the department. We are seeing ambulance patients as well as patients comming off of helicoptors at any given time through out the day. Please place your cell phones in the box located beside the triage area. You may pick them up upon discharge or we will get it for you if you are admitted. There may not be no more than two visitors at your bedside at any given time. We reserve the right to remove anyone from your bedside that is being disruptive to your care. If you leave your exam room for any reason other than testing purposes, you will need to be re-triaged and made to wait again. We will try our best to make this experience as pleasable as possible for you. Once we get your emergency taken care of we will make every attempt to make you as comfortable as possible. Please do not stand in the hall way once you are in your exam room, all of our patients have a right to their confidentiality and this will not in any way expedite your care any faster. Thanks for your understanding and cooperation. AKA: I don't know how long it will be before you get seen. You have had that ingrown toenail for 3 weeks and it's not more important than the patient I just took back in the wheel chair. I don't care that you have been waiting for 3 hours and no I will not tell you what was wrong with that patient because the law will not allow me. If youre in your room and text messege all of your sorority sisters on how cool it is that you are in the ER getting I.V. fluids because you are dehydrated from out drinking/vomiting all night than you are not sick enough to be here. If you leave your room every 5 minutes to go outside amd smoke than you are not sick enough to be here. I am a pack a day smoker myself and laid in one of these beds for 8 hours with appendicitis and never once thought about a cigarette. Your second cousin here kids and here two sister-in-laws can kindly wait in the waiting room. You do not need that much family support for your genital warts. I understand that you are tired, sick, hungry, and cold, however once I get your BP above 60 systolic I will get you a warm blanket, call your sister in Florida for you and something to eat if you are allowed. If by any reason you find it necessary to stand in the hallway and stare at me, you will be introduced to the #16 or #14g angiocath so that I may give you the Toradol for your back pain. Whew I feel better.

Our rule is 2 at bedside. If I have a critical patient, I don't care how many are at bedside, as long as the charge RN is with them answering questions and they are not being disruptive and I have everything done that I can do for them. I also don't agree with family members staring at grandma stark naked in the trauma bay while you are doing chest compressions. I think we should consider a patients dignity and take into consideration that they probably would not want their family to see them that way. If the family understands that CPR is is progress before they come into the room then I will try my best to cover the patient with a blanket to maintain that dignity. I have mostly found that it is almost always the 19-year-old female with the UTI that wants 10 of her friends in the room talking on cell phones and ordering pizza. Our problem is that even though our ED doors are locked, people will stand in front of them and wait for someone to come out and then run back demanding to see their loved one. This is a huge problem with our domestic dispute cases. Irrate husband that just beat his wife, stands in front of the doors and as soon as someone leaves, he runs back. I also have a huge problem with patients in the ED who are their to be seen for some BS complaint and they run out and smoke every 5 minutes, or to use their cell phone or what ever, because this allows our doors to be open without good reason and gives tons of people the chance to get through the doors. Maybe I just had a bad day today, but I think that if you leave your exam room for any reason other than to potty or go for testing, you should have to be re-triaged.