amarilla

I am leaving nursing for another health profession and it is the ONLY reason I'd leave the ER, *laugh. I could never go back to floor nursing and have no desire to work for a doctor's fiefdom in ambulatory care. I've worked in same day surgery and pre-admission testing/OR holding, which was fair (because of the pace - hustle all day!) and awful at the same time (unit culture of misery). Returning to school this fall, I'm wondering whether I should try for a per diem ED job to keep one foot in or just give it up entirely. It just feels too weird to not do anything at all.

Hmm. While I may not be one of the more eloquent posters here, I'll try to be succinct: I triage people in danger of dying or nearly dead as '1', indicating immediate lifesaving intervention needed, i.e., arrests brought in in progress. Emergent treatment - like reviving an altered hypoglycemic patient with D50 - I would still triage a 2. Urgent with many resources a 3 and so on. In your example, I would triage the hypoglycemic patient who has already received interventions based on my assessment when I receive them. If that second finger stick on arrival is now 180 (from the D50) and they are awake/alert, they are a 3 and will be roomed accordingly unless there was a fall, LOC or some other issue at play dictating more immediate care (found down? poor vital signs?). I don't usually care how they looked an hour ago unless it's something like head injury or trauma which could have other implications, (internal injuries, shock etc) that may impact patient's status and resulting treatment going forward. Just my opinion and will look forward to reading others'.

I think the best thing to do may be to look up your local hospitals to take a look at the job descriptions posted for ED techs. It will tell you exactly what they want in terms of experience, certifications and the like. The few EDs I've worked for have varied in terms of what they want; of the two per diem places I work now, one hires EMTs and the other seems to prefer nursing assistants who have phleb experience. As for what recruiters are looking for, I can't say but I do know what my ED managers and peers look for: willingness to help and work as a team. Many things in the ED aren't an emergency and sometimes new employees sour on setting up that 13th abdominal painer of the day, dipping urines, putting grippy socks on our fall risks etc. It won't be adrenaline all the time and sometimes is mundane and even annoying. If you can keep the patient's best interest in mind - getting them treated and dispo'd - you won't have that problem but there are those days that even your last nerve will be stepped on. Just being honest. Duties vary by facility policy, I imagine. In both my jobs, ED techs usually help us set up the patient (move to stretcher, get vital signs, change and set up monitor, collect urine or straight draw blood) and respond to needs as they occur, (EKGs, dip urine, urine pregs, throat swabs, transport, pick up blood/meds, compressions in codes, move equipment to rooms where it's needed, help clean up pts, etc.) The ED is a great place to work and I wish you luck on your search. Cast your net far and wide and don't be picky - experience is experience and you can always move on.

Oh, so many things here that irritate me on a regular basis (and now I've been reminded of them on my day off!). Here are mine: Cosign the many who have posted about the cutesy cartoons and cut-outs that are posted on the walls. Just no. This is not elementary school! I don't want a sticker next to my name - maybe a raise or use that $ to hire more staff? In my ED: -I cringe every time the phone is ringing nonstop (we all pick it up) and someone sitting at a computer says "SOMEONE PICK THAT UP!". I always think in my head, (usually because I'm already on the phone), why don't YOU?? -Please don't tell me that you can't help or do something I've asked for a patient because you're doing something ridiculous like stringing Christmas lights, writing out your bills or downloading an app. "In a minute, it's almost done, okay?" Really? REALLY?? -Can we please stop being nice to one another's faces and then start talking about them the minute they walk away? Some of us really don't care. Just stop. Thank you for the vent....refreshing!

Please take this gently, OP, but sometimes we aren't always doing as well as we think we are. A month on med-surg to work on your skills may just mean that you're lacking the assessment skills and time management of your more experienced ED peers at this time. It's just something that comes with time. No knock on you, but I can't tell you how many clogged NGs, missing or overlooked labs and unfinished stats I've received from new(er) nurses who handed them off to me without even mentioning what was undone. While I try to mention these things as they come up, not everyone does and I've seen new(er) nurses blindsided by complaints later on when they otherwise thought they were doing well. Sometimes you just don't know what you don't know. Not saying this is the issue in your case, but try maybe to get some specifics to work on from your manager before you go to the floor? Last thought: make contacts while you're on the floor, in case this isn't just for a month. You'll want to be able to keep a job - even if it's not the ED - rather than be let go entirely. Best of luck.

When you put it that way, definitely! I suppose it's just been surreal that none of the other nurses there seem to be bothered by the way things are there. I come home and feel bad about the care some of the patients have received because I couldn't do any better for them, given my role. On a brighter note, I received another offer last week elsewhere. Hoping for greener pastures!

ICURNmaggie, I feel like a number of my free text entries in the chart are 'pt ______. Vital signs now _____. MD ____ made aware. No further orders at this time.' You can actually see the situation deteriorate through my notes. Ugghhh

Hi TLC, Thank you for your reply. Perhaps I should give a few examples to better illustrate the scenario? Let's say you go up to one of the docs with an update and as you open your mouth to speak, you get a finger held up to your face and then a 'WHAT?'. As you tumble the words out - pt is vomiting / febrile / etc- the doc says 'fine'. That's it. There isn't discussion; that's part of my problem. Yes, I understand I'm 'only' a nurse, but I am a team member and don't deserve to be shushed like a child or ignored when I speak on behalf of the patient. Your suggestion of breaking the ice with question/teaching is something I've already tried; it got me a doc asking the charge nurse to assign him nurses who aren't so chatty. Charge told me 'don't ask the docs anything and don't make suggestions; they don't want to hear from us. Watch the EMR for their orders.' It feels really silly. They don't want to engage. There isn't a relationship other than 'they order, you do it', and it's been made clear that's what they want. Does that change anything?

You might not always need consent to disclose to law enforcement though; know your state laws and hospital policy first. JME. Another link, this one specific to LE from HHS: http://www.hhs.gov/ocr/privacy/hipaa/understanding/special/emergency/final_hipaa_guide_law_enforcement.pdf

We get these - call them 'detainers'. For whatever reason, the police place the detainer and make us aware when we accept the patient into the ED. They leave and we treat the patient. When dispo approaches, we call and advise same and two officers arrive to take the patient into custody. If the patient figures this out and decides to elope, we don't stop them but we do call the police immediately to advise.

I feel your pain, OP, and yes, I would LOVE to have a discharge specialist to coordinate rides home! My regular job does not give out vouchers or bus passes, (we're nearly bankrupt as is), but my pd job will do so if the patient isn't on the usual offender list. I agree with others that it only seems to encourage bad behavior, unfortunately.

Hi all, I could really use some advice. I've been a nurse four years or so; a few years on the floors and about 18 months in the ED. I started a second job a few months ago for more hours and am contemplating whether to stay or to go - help me decide? Hospital is suburban and much less busy than my current inner-city job. Flow is good, patients are nice enough. Problem: the nursing culture here is so subservient to the docs; I've really never experienced such a thing, especially in the ED! Docs want nurses to wait for orders, won't hear suggestions and sometimes seem to plain refuse to act, even when patient or family is standing right there at the desk. I've witnessed a few situations already that resulted in poor outcomes and am wondering how I can do my job if we're not on the same team. Before anyone asks, yes - management is painfully aware. Any advice appreciated.

Agree with the previous posters to ask yourself why you want off the floor and what you're looking for. I started in med-surg, went into float pool and pursued an ED position for about six months before one finally gave me a chance. Like you, OP, I 'wanted off the floor.....NOW', *laugh. Mostly: I wanted to be challenged, to advance my skills and learn new ones, to turn and burn patients and have some variety in my day. JME. I cosign Stargazer 100%: every ED is different when it comes to staffing, teamwork, acuity, autonomy, etc, but I too would be concerned with a department with high turnover. The department which gave me my chance also was one of those 'challenged' units; I received less than two weeks orientation and was one of the only three nurses in *four* hiring cycles to stay through probation. The experienced ED nurses I met in my hiring cycle and the subsequent ones quit on their first or second shift. I should've bolted as well given this but didn't want to start over in the job search, still with no 'real' ED experience to offer. I stayed almost eight months and secured another position elsewhere, but the experience has been really rough. I'm not sure I would do it this way again, honestly - learn the right way with a supportive orientation because these patients NEED you to know what you're doing. Regarding acuity and teamwork, specifically: my first department tied nurses' hands. You triaged at bedside, MD on your heels, and you had to literally stand there and wait for initial orders - IV, labs, diagnostics, etc. It was frustrating as all get out but it was the department's protocol. One of the day MDs would write all his orders and you basically could not touch that patient until he was finished; one of the night MDs expected you 'to do the important things', (sometimes without orders), and would be upset if you didn't start that line or draw a certain lab. Total miscommunication and total mess. My new job: mostly order sets that can be nurse-initiated, thank God. Biggest thing that I've noticed different than the floor: teamwork. On the floor, we all had our assignments and when we could help each other, we did, but mostly it was every man for themselves. In the ED, I can't tell you how many times we grab labs for one another, transport a patient up, call a report and so on - it's like we all share the load so no one gets buried. It was very welcome but hard to adjust to - at first, I wondered if they were helping me because I was too slow or 'not getting it'. Personality types: I've met so many different types of nurses, so not sure there is any one type. As a previous poster said - you can be any type of nurse but you have to be able to 1/ move and 2/ be assertive when necessary. Things change very quickly and there have been a couple instances that I never saw coming - like the walky-talky fast track patient with the visitor who all of a sudden dropped to the floor. @&^@^!%% There really is no routine and getting used to things changing all the time - taking over patients for others who are swamped, having patients elope, being forever interrupted and having to quickly change priority while dealing with the inevitable complaints those changing priorities create...THAT is what I had to adjust to. Oh - and knowing nothing other than '45, male, c/o stomach pain x 2 days' when trying to set that patient up, assess him and get moving while managing my others with the doc on my heels already asking 'what's this guy's story?'. For me? Totally worth it. For you? You'll have to try it on for size. Good luck!

1. NJ 2. 3 3. ED 4. 34.00 5. 2.50 for nights 6. Non-union

Hi all, I'm about to start in a new ED, (ordering those scrubs must have manifested the offer, seriously), where they're utilizing a block schedule. Days are grouped and change every week; excluding holidays, you'll already know when you're working, say, next March. I've mostly worked per-diem and have always self-scheduled, so I'm not sure what to expect. Anyone here work on a block schedule? Have you had any issues with scheduling PTO, trading shifts, etc? I'm concerned if staffing is crap, I'll be stuck to try to get a day off here or there, (already been there, done that.) Any feedback appreciated!

I (try to) do all the stats and anything that seems like a biggie to move treatment forward, i.e., giving units of blood, starting that heparin drip, making sure the blood cultures / ekg / trops / whatever got done, etc. You'd be surprised what seemingly unimportant stuff gets left out that ends up being a RRT or code later on in the shift for the floors. The stuff I don't do: start the floor orders - we usually don't receive them. I do my orders and set them up - make sure those labs got in, all samples taken if possible, good access established, diagnostics done if ordered on my time - but once they have an admitting doc, that's where the floor should take over, IMO. If the department gets slammed and I have to move that patient asap, I will let the floor nurse know that and send along any meds not given if available on hand. When I was on the floor, it was a big deal to get a patient with leftover ED stat orders and biggies not given. We usually had to fill out an incident report and remedy the situation with the house sup within two hours - only to then do this ridiculous 'huddle' with the NM after shift on 'how we can improve so this doesn't happen again.' Blarg. So - the floor would get dinged for not being able to hang that heparin drip for the new patient, say, who needs to be admitted, have the admission paperwork put in, activated by bed management, have EMR created by pharmacy, all orders received and transcribed by MD, orders approved by pharmacy and then the looonnng wait for the actual drug to be sent up. If it's an admitting order, that's one thing, but when the order was from six hours ago in the ED and now it takes an additional 2 hours to sort out after admission, it becomes a risk management thing and no fun for anyone.

Oh...how sweet it is to check in and see this thread still going. :) Recent ones: Male pt, 50s, found in wheelchair in front of ED. Had IV and bracelet from another facility. Hrm. Called them up and they said "you're welcome!!" and hung up. Oh noes. At triage window: female pt c/o feeling agitated. Let her in and turns out she is 'agitated' because her son was our patient the week before and "one of you stole his jacket." Male pt, 30s, brought in by EMS after found wandering, incoherent. Proceeds to fight with security and EMS. I run over there to give IM and he lunges toward me, stares me straight in the face and says "YOU'RE CUTE AS HELL!!", sits right down and offers arm for shot. Bitten by a duck. Didn't break skin and couldn't even tell where bite occurred. "Saw what thinks was rat". This was great because she had no contact with presumed rat, but wanted to be checked out because "rats carry disease ya know". Ok. Note for work, too, of course.

Samesies OP!! I had an interview followed by a contingent offer and bought new scrubs in anticipation. I've been trying to get into this particular ED since spring and felt so close to clinching it. I went to the 'hiring day' activities today - it must work.

I am three years in and agree with a few of the previous posters: yes, you settle in with a job and once you get comfortable, you begin to look for challenges once again. I worked the floor for over two years before moving to the ED; I've just accepted a job at a new ED and have the butterflies all over again. I've enjoyed being a nurse and volunteer frequently to keep that sense of joy I felt as a new nurse eager to help and learn because yes, it can fade. JMO, but getting experience is important, OP - not just so you can learn, find your niche etc, but so that you can *feel* like a nurse and know if this is really for you. I've done per diem float pool, given flu shots, worked at a clinic, and done health assessments when work hours were slim to stay employed, keep my skills and stay on employers' radar. I've found it to be sad but true that the longer one's gaps of employment, the fewer calls you receive for acute positions. I don't know you and can't know your reasons, but I'll tell you what my first preceptor told me: make the best of things - learn what you can, try out your skills and find opportunities to learn new ones and then get out of here when you're ready. She was right - I did those things and left for a (better) position after 18 months where I was happier and had more to offer another employer. Good luck.

I spent several years on the floors in float pool and have now been in the ED for the past six months or so. Depending on the floor, YES...unfortunately this is absolutely possible that the first you hear of a new admit is when the call is transferred to you and the ED nurse says 'so you're the nurse taking Mr. XYZ?'. For those who have pointed out that empty beds mean admissions, let me add something: you can have no empty beds on a floor and still get admissions if the patient is appropriate/MD demands specific unit/needs monitored bed/chemo/locked unit etc. We would get about ten minutes lead time to figure out which patients could be moved to other floors, fight with the MD and the patient to get orders to do so, fight with the (uncooperative) accepting unit who refuses us the bed, have our charge fight with their charge and then fight with the house sup to get the transfer moving... all while the ED called and called, yelling at us for refusing the admission we just learned about ten minutes before with no bed available. I've had a new admit just left in the hallway (with no bed available) and been told 'figure it out, your problem now.' Patient was aghast and it was embarrassing for all of us. *sigh. It happens - this and much more. If you want the floors to understand you, you have to extend some understanding as well. JME: It's not your (ED's) 'fault' for sending the admission and it's a petty, annoying nurse who takes it out on you. What I wanted to know: when and why patient came to ER, what you worked up, anything you treated and what's left for me that's undone. Bonus if you can tell me the extras: are they escorted by 15+ family members, are super demanding, speak ___ language only, are they a man dressed as a woman (that was an unnecessary surprise that created quite a fiasco with the intended roommate at 0300), have they been hostile/combative toward you etc. Knowing what your floors can see in the system is also important; if we were told anything prior to the call for report, it was only the name, age, gender and admitting dx. We used a different system than the ED and could not access nursing notes, orders, labs, etc at all. The report we received was all we had to work with until the packet arrived with the patient to the floor and sometimes only then did we figure out there was a serious issue with admission criteria, (say, to unmonitored bed or to floor which couldn't admin ordered drips.) Few nurses want to fight the admission just to fight it - unfortunately, once the patient is 'accepted' to the floor, it's not cool to be on the receiving end of a cluster...jam involving incident reports, calls to the MD and house sup for transfer, aforementioned fight with appropriate floor to secure bed, etc all while that patient waits for care and your seven, eight, nine, or ten other patients also wait for their care. Of course, JME, but I hope it gives another perspective. It's interesting now to see things from the other side. I try to give the receiving nurses the report I always hoped for and take things up the chain if there's a problem. Can't we all just get along?

Rant respected. I'm expecting a dress code change myself and am preparing my pocketbook. I'm just hoping it's nothing too ugly or, worse yet, all white. Ug! Maybe you can sell those gently used scrubs on ebay and make a few dollars for them? I've sold off lots of gently used/hardly worn sets after changing facilities this past year. Just a thought.

I've only been in the ED a few months myself but agree with others that your ratios are outrageous! I'm not sure how much better you can be at 'prioritizing' if you're babysitting a handful of admits as well as *ten* or more new patients - there is only one of you and only so much can be done. If it were me, I'd start applying elsewhere and see what you can come up with. IMO, the experience isn't worth being stretched so thin. Good luck.

Apply in the outer boroughs - Manhattan is overrun with applications and no harm, no foul if you're planning on living in Brooklyn or Queens. If you have recent (within the last year) acute experience and three good references, perhaps apply through an agency? You have the needed 2+ years in specialty and should be able to qualify to get your foot in the door. Good luck!

The orientation offered will differ according to the hospital, their available resources, and the background of the incoming nurse. I've worked for large, level 1 teaching facilities with strict programs in place for both new graduates and nurses new to specialties that ranged from 4-12 months in duration, combining classroom and clinical hours on the floor. I've also worked for small, lower acuity facilities which basically offered two orientation days and three shifts on the floor with a preceptor. Since you're coming from a stepdown unit, I'm assuming you have/will have many of the skills and check offs you will also need for ICU. That being said, you will still likely have an orientation 4-12 weeks with another nurse on the floor until you're comfortable to be on your own. Unlike new grad orientation, you will probably meet with your educator and preceptor to determine what you already know and what you will need help with using checklists and skill stations. You'll go through your orientation signing off these skills as you observe and then do them yourself with (hopefully) meetings every week or few weeks to discuss your progress. Good luck!

I wouldn't worry; I sign my regular 'civilian' name on work documents for HR, payroll and the like. I save the 'RN' for times it is necessary to indicate my position - like patient records, union forms, nursing education hours at work, etc.