Erin 321

Holy....that would definitely be enough to have me refusing the job. I think one of the most insulting things I ever heard a doctor say was "A nurse is a nurse", referring to this sort of situation. This attitude completely disrespects the amount of knowledge nurses carry in their respective specialties and on their own units. How is it that ICU nurses are off the hook for floating to peds, OB and psych but you are expected to go to ICU? Is it not just as much of a unique specialty? Doctors don't float between specialties, why should nurses? How could this possibly benefit the patient? It doesn't, of course, it's just convenient for management but that should never be the only reason for putting in place a policy this potentially unsafe. Sheesh.

Obtaining informed consent is the responsibility of the person performing the procedure (in this case, the surgeon). You truly are just witnessing a signature when you ask someone to sign a consent form. It's a tool, but if it ever went to court, you would not be held responsible for ensuring the patient was informed about the procedure prior to having it done, whether or not you wrote 'witnessed signature only' by your name. That being said, I never ask patients to sign a consent form for surgery. I do it all the time for CT scans and stuff like that but surgery is too big and I think it's a good reminder for the surgeon to be sure to have a discussion with the patient if the consent form is left unsigned. Our surgeons usually take on the responsibility themselves, and get the consent form signed in the ED. If not, I ship the patients off to the OR without it, clearly indicate on the pre-op checklist that the consent form has not been signed, and have never been given grief about it once. Who in their right mind would want to be asked to sign an informed consent form if they haven't even seen their surgeon yet?

If you give a medication to a patient who has a documented allergy to that medication, you are the one responsible. No sense looking for the allergy information after the fact.

If it actually came to a code, at this point, as others have said, the code would be handled as per usual and the doctor would decide how long to proceed for. The thing about these cases is you gotta think that if the patient really understood what it meant to be coded, and what his chances were, and quality of life, etc, etc, he would likely make a different choice. We all would, wouldn't we? Anyone who's seen it, and has some understanding of the likelihood of retaining your quality of life even IF (and it's such a big if) the code is successful, would likely choose to die with some peace and dignity. Remaining a full code doesn't change the fact we're mortal. For this reason, I would consider accessing other resources for this patient - a talk with the doctor, hospice, social work, pastoral care, whatever - just to ensure he's really making an informed decision. If he's fully aware of what a code means, including the stats on outcomes, and he still wants to proceed, then more power to him. I can't help but wonder if maybe he's scared, or perhaps feels he has some unfinished business, and could use some help working through that stuff, before it's too late.

Thanks, everyone, for the support and great advice. As an update, I've notified my educator and supervisor of the situation. My educator says she will focus on some pediatric education and better equipment availability next and my supervisor wants everything in writing so she can follow up with ICN. Some sort of system where a nurse could be on-call for true emergencies like this one is a great idea and hopefully will be arranged. I'll definitely take your advice and get my PALS next. We do have S.T.A.B.L.E classes here - I'd never really considered them as applicable to me before but I'll reconsider that now. I'll take any training I can get so this is never so awful again! The baby is still intubated and being oscillated (?) at a NICU at a larger hospital. I'm just happy he's still alive - they're querying aspiration pneumonia - and the feedback I've received from the nurses at the NICU there is that they were happy with the care he was given in our department (knowing how out of our league that was), although they felt the neonatologist failed to recognize the seriousness of the situation (he never did intubate - it was the transport team that did that). Either way, it was the neonatologist who ended up putting in the feeding tube that day so I'm grateful to him for that. I just didn't have it in me and I never could have justified it as the safe course of action. So in conclusion, thanks again everyone. I was really feeling like a reject and you've helped enormously. I'll be sure to do my best to get some good now out of what was an ugly situation.

I work in a smallish (26 bed) community hospital ER that has the fortune/misfortune of being very close to a large specialty hospital. What this means is that trauma and peds go to the big hospital and not us, which is fine by me, but of course there's always the odd walk-in we can't predict and which is sometimes difficult to be prepared for since we don't see that stuff much. I've been an ER nurse for 2 years. A couple of days ago, a mom came in carrying a mottled infant in respiratory distress and screaming "help me, my baby's choking!". The story was that the child was 7 weeks old, born premature at 2 pounds, 5 oz, recently discharged from hospital. At home, he'd had some formula and then taken a nap. When he woke up from his nap, he spat up and then seemed to choke. I was the resuscitation nurse that night so this baby was automatically my patient but as I'm sure you can understand, I was really scared. We managed to improve his sats and color quite quickly with a bagger and CPAP and a nurse from the intensive care nursery upstairs came down to help with the IV and drawing bloodwork. She left as soon as the IV was established but neonates are so out of my realm, I didn't even know how to follow the order NS TKVO (what is KVO if you weigh 3 pounds? Turned out be 2 cc/hr. Who knew?). Anyway, things were starting to be okay when the neonatologist comes down to consult on this patient and asks me to put in an NG tube. Well, I gotta be honest, I would take my chances on the IV start any day over being the one to do the NG tube. I was trained on adults, all my experience has been with adults and while I'm comfortable with adults, I'm pretty sure things change when you're that tiny. Feeling out of my league and not wanting to harm this baby, I called the ICN back and explained the situation and here's where my issue comes in - the nurse who answered the phone laughed me and refused to help. She said (in that sarcastic, demeaning tone - you know the one), "You don't know how to put in a feeding tube?" and left it at that. Sick baby, a neonatologist looking at you expectantly and a nurse with the knowledge of how to help laughing at you on the phone. So, I gotta ask - who's out of line here? How many of us (peds nurses excluded, of course) really would be okay putting in a feeding tube on a 7 week old preemie? I realize I'm an emergency nurse and that contributes to my dilemma. Technically, I need to be prepared to care for anything and everything (including the dog someone brought in last week!). However, I really don't know everything, and in a hospital that makes a point of sending out sick kids to other hospitals immediately for treatment, is it the best use of my time and resources to try to become proficient in this area? This is the first situation I've seen like this in 2 years. If I go out now and take neonatal resuscitation courses and the like, without the practical experience to back it up, will it really be of any good to me? Had this kid coded, I could have managed the basic ABCs, of course, but the rest of it is really beyond my training. I don't know. What do you suggest? I'd like to learn from this situation so next time it's not so horrifying but I have the feeling I'm never going to be comfortable with this sort of thing, and feeling like I can't rely on the nurses in ICN for help makes it so much worse.

We use an MD at our triage, five days a week from 10 till 6. What happens is we complete our usual triage assessment (generally without interference from the MD) and then after the MD will review the chart, possibly speak with the pt for a moment if they feel the need and then order things that can be done from the waiting room - bloodwork, xrays, u/s, ct, etc. The idea is that by the time a room becomes available, the results will be back and the patient hopefully won't have to stay as long. We've had TLPs (as we call them - triage liason physicians) for about six months and while I haven't seen any official report on how it's going, the reviews around the department are mixed. It largely depends on the doc, of course, but from a nursing perspective, it hasn't seemed to have made as big a difference as I would have hoped. The ones who need to stay for treatment still need to stay and the others we would have fast-tracked anyway. Plus, there's always the chance of the 2nd ER doc who actually sees the patient wanting just that one other blood test or xray that the initial doc didn't order, thus making the pt have two blood draws or what not instead of one. The physicians are quite highly paid for much less work than they typically do on the floor - I've always thought it was a position much better suited for an NP. I think sometimes they think so too. They get bored a lot at triage!

Interesting. Okay, thanks everyone. That thread mentioned above is HUGE - I'll go read it now and that should take care of any more questions. Thanks for the help.

Hi! I work in Canada and while nurse practitioners are commonly seen in practice here, we don't yet use physician's assistants, although we're starting to hear about them more. I was wondering if anyone could tell me the differences between these two roles? They sound very similar to me. Thanks!

Thanks for the good ideas, everyone. I particularly liked the thoughts about courteous transfer times, a flow nurse (that's a really interesting idea) and the stuff that Roy mentioned. That's very helpful, thank you. One post mentioned a reward system, which I'd considered in the past because of course there's no real incentive for the floors to take patients any faster than they have to (why take on extra work when you're already hopping and the breather might give you time to catch up?). I'd do the same thing, so the question then is, what would be the reward? How can we provide incentives that encourage everyone to promote flow in the department? We see it even in ER, I know people who try to hang on to their admitted patients because they already know them, they're settled and it's easier than taking on a new ER patient and starting from scratch. Has anyone worked in a facility that's employed some sort of incentive for this? Also, one poster mentioned that she liked to receive patients within forty five minutes to an hour after the orders had been written. That's awesome but I just want to clarify that that's not quite the issue in our hospital. We consider being at 53% capacity with admissions a really good day, with waits in ER from less than 1 day to up to a week (!), averaging 2-3 days wait for a medicine bed. If it was just an hour or two, no big deal, but as you can imagine, after several days, both the patient and the nurse get a bit antsy when they find out there's finally a bed available! Thanks again for the tips.

I have a meeting to go to in a couple of weeks and I'm hoping some of you can help. The meeting is to help facilitate a good relationship between the medicine units and our ER. Things have gotten a little strained over the past few years - we get filled up with inpatients and put pressure on them to move patients upstairs quickly, they resist and take five hours to clean a bed....you know how it is. I've worked in both areas and so I understand the pressures of each. My question is have any of you come across innovative ways in your facilities of dealing with this sort of thing? My only idea for improving our relationship is to have them come see what life's like in the ER and vice versa, but that's not too realistic with the way staffing is nowadays. What do you think?

Until recently, I have always taken her complaints very seriously, as I feel one should when they are dealing with anyone in their care. I would be offended by my coworkers, who called her a "hypochondriac" and say that she was simply addicted to Tylenol. When your colleagues declared her addicted to Tylenol, you did remind them that Tylenol is not an addictive substance, right? This is the second time this week I've seen reference to a patient being addicted to Tylenol and it's simply erroneous. If it's plain Tylenol she's requesting all the time, and not Tylenol with codeine, I wouldn't worry that she's "faking it". Tylenol is not much of a reward for that kind of dramatic effort. Just because we can't identify the source of pain, doesn't mean it isn't there (as you obviously know, or you wouldn't be so conflicted about this). Regardless, it's not your job to diagnose this patient or the source of her pain, although your efforts are admirable. It is, however, part of your role to medicate the patient according to her description of her pain and the orders you have, and to inform her physician if her prn pain meds aren't adequately controlling her discomfort. He can take the lead on making sure she had suitable analgesia and investigations. Also, does your facility have a bladder scanner, or a more accurate way of seeing if this patient is fully emptying her bladder after voiding? You said you palpated to check this but I'm not sure how accurate that might be. If she isn't fully emptying her bladder, that might help to explain some of the pain, as well as the recurrent UTIs. Good luck!

I don't think this doctor's an idiot at all and it was never my intent to suggest otherwise. It's not that labs hadn't been ordered, just that they hadn't yet been drawn and so the bolus was ordered with no regard for the results, which were received 2 hours later. I asked for his rationale and it was, in effect, that it wouldn't hurt. This is where I'm unsure and why I posted this question in the first place. I agree, in theory, that the patient would likely not have been harmed but the rationale seems to me to be inadequate. You could give me 20 mEq of KCL over an hour and I'm sure I'd be fine but why bother? He couldn't give me a better reason than that and so I was wondering if any of you could. If not, forget it. I'd hold the KCL and just bolus NS till I get the results back next time and we can make an informed decision as to whether or not the patient really needs it.

Ok, thanks, everyone. I agree, it's not that the pt was likely to be harmed, but it just seemed like sloppy practice. Anyway, I appreciate the info. Next time I'll be able to more confidently make my point.

I know what you're saying. Of course working in ICU, you'd have developed awesome assessment skills. The big difference between ICU and the ER is that ICU is a controlled environment and the ER is not. If you struggle at all, that'll be why. It's juggling the needs of eight to ten constantly changing patients who you sometimes barely know versus knowing one or two very, very well. Time management, prioritization, and flexibility will be the biggest challenge. The concept of triage might be worth a review too, knowing what system your facility uses and what a triage assessment consists of. IV skills will be easy to obtain. Once you're on the floor, that shouldn't be an issue. You also already likely have a great understanding of pathophysiology and ACLS drugs, and are familiar with most procedures - cardioversion, chest tube insertion, arterial line setup, procedural sedations, etc. I think you're going to nail that interview! Best of luck!