jenfromjersey

I had a similar situation occur with a doc. It was a Percocet order. He told me to give 2 tabs and then when I gave it and asked him to put the order in so I could document I gave it, he said he only wanted one tab not 2. When I said that he clearly told me 2 tabs not 1, he argued with me that he would never give me that order for the particular patient in question due to their age/diagnosis. I am not crazy, not frazzled easily and know what I clearly heard. I took it up with my manager at that very moment and I guess since the patient was still in the ER being monitored and there was no adverse outcome documented, it was handled within our department wihtout incident. However, from that point on (which was several years ago) I NEVER, EVER take a verbal order from him for anything, not even Tylenol. When he barks out an order, I respond "When I see the order in the computer, I'll give it". I am not talking about code situations. I am talking about a pain med, fluids, etc. I had a doctor ask me once, while in the room with the patient, if I was giving the Ativan he ordered. He never ordered Ativan. I told him, in front of the patient, if you order Ativan, I gladly give it. I don't know why some doctors try to make it look like the nurse's fault that medications aren't given in a timely manner. He probably promised the med to the patient, never ordered it and then tried to make it look like it was the nurse who was the one holding out. I have to say that I have a terrific working relationship with the large majority of docs in my ED. I do still take verbal orders from them and never have issues. However, there are 2 or 3 that I will NEVER take a verbal order from and will only medicate patients or perform tasks such as blood draws or IV starts once the orders are visible in the computer. It's about trust and once that trust is broken, you need to procees with caution when dealing with them in the future. I am interested to know how this turns out.

We have a midlevel provider in triage every day from 11am until 9pm. After a quick triage (vitals, brief complaint and ESI level only) they are seen by the midlevel (in separate area) and orders placed in computer. After that, they are called into a separate room where there is always a triage tech from 11am until 11pm and if staffing allows, a protocol nurse. The nurse is responsible for placing lines, medicating, and completing the medical/surgical history, inputting medication lists and allergies into computer. If only a tech, then labs only are drawn and EKGs if ordered. There is an exam table in there and a dynamap for vitals. We do our reassessments in there when there is a long wait. Also, if the midlevel is discharging from triage then exams are done in there if required to be evaluated by a physician. We do not give IV narcotics in waiting room. We will give an occasional Percocet. We routinely lock and lab and give IV Zofran and fluids for gastroenteritis type complaints. We also drink patients for belly CTs out there and they need the IV for the contrast injection they get in CT scan dept. We also give tylenol/motrin out there for fevers. We often have 3+ hour waits so getting all of that accomplished in the waiting room may seem like a liability to some but in reality, it is less of a liability than sitting in waiting room for 3 hours with NOTHING done. Once labs are back they can be reviewed and someone who is walking and talking with normal vitals may have a potassium of 2.5 or a hemoglobin of 6 identified. When there are 20 people in the waiting room who are all level 3, it really helps to prioritize who needs to come back first. Usually the loudest complainers are the ones who have nothing going on and they end up being pushed ahead of the quieter ones who end up being sicker in the long run. I find it extremely helpful when I receive a patient from the waiting room on a hellacious day who has already been locked and labbed. The ER doc then only needs to review what has already been done and then fine tune the treatment plan. Additional lab studies can be added to the blood already in the lab. It speeds up the dispo time once they get to the back. I love it.

Don't be so hard on yourself. It sounds like you are doing fine and that you have the support that you need in order to be successful there. Don't get caught up in the little nuances of the doctors. That comes in time and right now your focus should be on mastering prioritization and critically thinking about the cases coming in the door as to what will be needed/expected and what to look out for as far as monitoring. I precept many new nurses and have worked with students as externs who ultimately end up taking jobs in our department. I always tell them to understand that the first year out of school is a learning curve and that what you learned in school may seem unhelpful but it was simply a base upon which to add to. You will learn new things every day. My advice to you is to ask lots of questions. I always learned a lot from the specialists when they would come in to consult on a patient. I would sit with them for a few minutes after they saw the patient and ask questions about the treatment on conditions and what types of concerns they have for my patient. Don't be intimidated. I have found most specialists enjoy teaching despite the fact that many of the nurses I work with are afraid to initiate discussions with them. I figure that if they are too busy to discuss a case or are not in the teaching mood then so be it. Otherwise, I have found that by initating these discussions they tend to view me as a partner in the care of the patient and will actually stop by my station before heading out of the ED to give me a quick "report" on what they think and plan for their patient. It really helps when giving report to the floor as well. Hang in there!

I have been a nurse for 15 years, the last 10 of which I have spent in my current hospital. I worked on a med/surg floor, then telemetry, then a holding unit prior to moving to the ED about 5-6 years ago. Having seen both sides of the issue, I can understand both viewpoints. The OP asked what can be done to make the receiving nurses more accepting and here are some suggestions based solely upon my experiences in my current hospital: 1) Our ED, as others mentioned, uses a different charting software than the main hospital. We use IBEX and the main hospital uses SCM. They do not speak to one another. We also use physician order entry making it difficult for the ED nurses to see the admission orders placed. Our secretaries are expected to go into SCM and print out the admission orders and place them on our chart. This way, we can see what has been ordered. If anything is stat, we can get to it AND we can give a better report because we know what diagnostic testing has been ordered for the future (which may affect NPO status or the administration of certain medications). 2) If a patient is allowed to eat, I try to feed my patients before they go to the floor. I work 11am to 11pm. Our main cafeteria closes at 7pm. Patients holding in the ED for hours may be starving when they go up to the floor and the floor has nothing to offer them. Despite the turkey sandwiches in our fridge, realize that graham crackers and juice may be all the floor has to offer them. If possible, get a patient a meal tray if you know they are going to be staying overnight. It takes me 15 seconds to call dietary and they deliver it to the room. Not a big time waster and much appreciated by the floor nurses not to have a starving patient on their hands. 3) If a patient has maintenance IVFs ordered on admission, I hang them on a pump and on pump tubing at the prescribed rate. We have a room that is stocked with a small supply of pumps that we can easily obtain. The ease by which we can obtain a pump is sometimes taken for granted in the ED. On the floor in our hospital, you must a call a department, provide the patient account number and then wait for a pump to be delivered to the room by the equipment department. When I tell the receiving nurse that I have initiated the IVFs ordered on admission and that it is already on a pump, they appreciate it. Most of the ED nurses hang fluids on primary tubing as a large majority of our fluids are hung wide open or at fast volumes. 4) If I suspect that a patient is going to be admitted from the onset, I try to obtain IV access in a forearm or hand. (There are limitations to this if patient is a trauma, getting studies requiring an AC site, etc. But a patient with an obvious leg cellulitis who failed oral antibiotics as an outpatient who is not septic and clearly needing admission can benefit from an IV not in a joint to prevent constant alarming on the pump when they get to the floor. ED nurses tend to run things off pump and do not get to experience the sound of an alarming pump all night as often as floor nurses. It is a pain in the butt. 5) If a patient hasn't taken ANY of their routine meds today ("because they were coming to the hospital") and it is 5pm, look to see if there are any important ones that you can give BEFORE a problem arises. I recognize that 160/90 may not be significant in the ED perspective, but 2 hours from now, once it climbs to 190/100 it may be an issue. Bring proactive rather than reactive is a good mindset to have. I work in the ED full time and I know that it can't always be addressed when the place is falling apart. However, I do try to get their meds in them. If getting the med from the pharmacy is problematic and it is not stocked in the Pyxis, think about what you do stock that can help manage the BP for tonight. I may not stock PO vasotec, but I have it in IV form. We stock clonidine 0.1 and 0.2. We have PO and IV Lopressor. If the patient takes an ACE inhibitor po at home, giving 1 dose of an ACE inhibitor IV in the ER may not be that big of a deal to ask the ER doc for. Do I care about their MVI, Calcium, Vitamin C, Colace? Their weekly Fosamax? Not really. But you better believe I am calling pharmacy for that PO dose of Risperdal grandma takes routinely at 9pm because her smiling face right now is gonna change RAPIDLY without out and I'm not waiting for a showdown. 6) Question the docs when you think a patient is going to the wrong level of care. We are comfortable handling pretty sick patients, but when you are sending a patient to a med/surg floor where the nurse has an assignment of 8 patients, it may not be as easy for them to manage. I think about the amount of care that patient is going to need and whether or not that patient may decompensate. Does the patient merit maybe a higher level of care for 24 hours until they're a little more stable. I have fought with many docs over who they deem appropriate for med/surg and who I know needs a tad bit more monitoring. There is nothing worse than sending a patient to the floor who gets rapidly responded later in the shift. If I fluid resuscitated someone and they now have a BP of 105/70, I may be happy, but I have to remember that they came in a few hours ago with a BP of 85/52. They look good now, but maybe we're not out of the woods just yet. When a patient is being admitted with a diagnosis related to cancer, I question why they are not going to the oncology floor. Maybe there are no beds, but sometimes admissions drops the ball. I know we are busy and they are on our butts to move the patient as quick as possible because the waiting room is full and there is a medic at the door. I know. But that patient is depending on us to make sure that they get better and have the best outcome. We spend a hell of a lot more time in the room with the patient than the docs do and we know the patient a lot better than they do. I advocate for what I feel is best for the patient. All I can say is that I typically don't have a problem giving report. The nurses know me and they know that although the patient isn't going to be tied up with a bow, I will do whatever I can to make their life a bit easier. Can I do it all? Absolutely not. That is why nursing is a 24 hour job. Do I know when their last pneumovax was? Probably not. But I can tell you what brought them here, what they looked like then as opposed to now and what I did for them in between. Ask me what you need from me to make your job easier. I am not a mind reader. But if it's something relatively simple, I can do it. I hear more often than not, "I love getting report from you" rather than hostility. I think it's because I consider both sides, don't have an attitude and genuinely care. As stressed as we are day to day, we need to help each other out because the shifts are getting rougher and the staffing shorter. Just my 2 cents.

My hospital has a detailed policy specific to minors presenting for treatment in the ED. We are obligated to provided emergency life saving care regardless of consent when the situation is warranted. However, if a patient presents with a non-life threatening injury without a parent we cannot provide care until a parent is reached and gives consent. Grandparents, aunts, uncles, babysitters, siblings all come with children requesting treatment for minor injuries and unless they have legal proof of guardianship in hand we do not treat. In my experience, most foster parents and school employees know the drill and come with the correct paperwork in hand. It's usually the family members that don't. We must locate the legal guardian of the child, name and phone number and document that verbal consent was obtained. (Now, granted, I have questioned at times that we are not proving that we are actually speaking with the real parent by calling a number provided and asking for someone whose name was provided to us) We also request that verbal consent is acceptable to start to treat but that mom or dad needs to come in to actually sign for the discharge papers and obtain instructions. EMTALA only requires that a medical screening exam is completed, not that care needs to be provided in a non life threatening situation. We will triage the patient, obtaining a medical history including medications and allergies and vital signs along with a presenting complaint. If the patient is deemed non-urgent then they will not be brought back until parental consent is obtained. I have had patients admit that their parents were unaware they were at the ER as they were doing something they weren't supposed to or somewhere they shouldn't have been. Also, non-custodial family members may not want the parent to know that the child was hurt while in their care. We do not want to facilitate any deception.

I received my original nursing degree from Middlesex and went to Rutgers as an RN to get my Bachelors in Nursing, graduating from that program in 2003. My classes were mostly on-line and when I needed to meet on campus, they were in the evening. I worked in my clinicals around my work schedule. I was working full-time at the hospital at the time doing 12 hour shifts and didn't have a problem with completing my coursework. I graduated with High Honors and was invited to join Sigma Theta Tau. I am currently attending Rutgers for my Master's and will be graduating next Spring. I still work full-time and don't have a problem keeping up. I think that as long as you are able to prioritize, you shouldn't have a problem. Of course, I don't have much of a social life during times when school is in session, but you have to have a trade-off. Hope this helps. Jen

I would LOVE, LOVE, LOVE to have a 3:1 ratio with techs who have the same? and medics or EMTs? Seriously? We start out the shift with a section that has 5:1 ratio. We start the morning with 5 nurses. so that's a max of 25 patients which includes a mix of physical rooms and hallways. This doesn't include our fast track which opens at 9am and has capacity for 6 stretchers, 2 recliners and 6 chairs. It is staffed with 1 nurse until 1pm when a second nurse comes in. At 11am 2 nurses comes in to do additional hallways and provide a second triage nurse. We have techs..normally if we are staffed properly, we have 3 for the whole shebang. They need to stock all of the rooms and assist with vitals, lab draws, EKGs etc. As another posted stated, if a 1:1 suicidal patient arrives, they pull one of the 3 off the floor to sit with them and we are down to 2. No medics or EMTs in the ER. I've gone up to 6 acute patients in my present job, but honestly have worked in other ER's where I had up to 8. Again, as previous posters stated, depends upon the acuity and the charge person. If they really understand what is going on in your section, you get a break, but if they "pull to full" and have no clue, then your rooms fill up and you're screwed. If I were you, I would be thrilled to have gotten away with such great staffing numbers for so long. Even with your increase in ratio, you are still better off with your support staff than most of us I believe.

I agree with all of the comments. I work in a community hospital that is always overcrowded. We have a 5:1 ratio..sometimes more depending on the day. We always have hallway patients. We always run out of pillows and blankets. I do the best that I can for my patients each and every day. I split my time between patients based on their acuity and I gladly explain that to those who complain. I'm not rude to people, but I find that most patients do not even recognize what is happening in the rest of the ER. Their main focus is themselves. When I explain that I was not ignoring them or surfing the internet, that I had a legitimate patient related issue that I was attending to that was more acute than theirs, most people stop and think and do understand. There are those few who don't care no matter what. I had a man with gout in his toe who wanted me to interrupt a pediatric code to get a physician to see him. His response when I explained that they were working to save a child's life? "You mean everyone is in that room?". I told him and his wife they were more than welcome to ask the child's parents if they could borrow one of the doctors to see his painful toe. The child arrested and died. I don't think the selfish patient cared one way or the other. It's a shame. But, I am able to stay sane and functional despite all of our issues (short staffing, overcrowding, rude patients, verbal abuse, no breaks, etc). I perform my nursing duties based upon what is best for the patient. I am not stopping from applying oxygen to a COPDer with sats in the 80's to get her a blanket "because she's cold" and I politely explain why I am doing it. I'd rather she was alive and cold than dead and cold. I don't take verbal abuse to heart. People are angry, in pain, sick, upset, etc. It's really not personal. I don't react to this type of behavior. I remain professional and get my job done. 90% of the time, I got apologies by the end of the encounter "I'm sorry if I was rude to you earlier". Even the drunks end up apologizing. I'm not interested in the drama. If there isn't a pillow, I'll roll you up a draw sheet for the back of your neck. If there's no blankets, I give you extra sheets or cover you with your jacket. I may not have exactly what you want, but I'm honest and do my best to provide something in the interim. People just ultimately want to know that someone is listening to them. I tend to keep families out of the room when a patient comes by ambulance for the first 20-30 minutes so I can get my work done in peace...start the IV, cardiac monitor, EKG, straight cath if necessary. This way, when the families are brought back, the patient is semi-stable, comfortable and I don't need to climb over top of them to get my work done or explain to 3 people what I'm doing. I gladly give them a concise update of what's been done when they get there. The best advice I can give is to keep focused on what you are doing for your patients, giving the best care possible and don't let anything deter you from that focus. You have the experience and education to know what is necessary to save lives and nothing should get in the way of you accomplishing that. Hang in there!

We call report to floor on all patients. No fax report. Med/surg admissions go into a transport tracking system via phone. The transport dept sends someone to transport the patient to the floor. Telemetry admissions are taken to the floor by an ER tech only. Our ER techs must complete a basic dysrhythmia course. ICU/CCU admission are transported by ER nurse (and ER tech, respiratory, etc) Any patient receiving blood transfusion at time of transfer must be accompanied by a nurse.

The following study appeared in the Annals of Emergency Medicine: The Role of Oral Ondansetron in Children With Vomiting as a Result of Acute Gastritis/Gastroenteritis Who Have Failed Oral Rehydration Therapy: A Randomized Controlled Trial . Annals of Emergency Medicine , Volume 52 , Issue 1 , Pages 22 - 29.e6G . Roslund , T . Hepps , K . McQuillen In subjects with acute gastritis/acute gastroenteritis and mild to moderate dehydration who failed initial oral rehydration therapy, the proportion of children who received intravenous hydration was smaller in the ondansetron group than in the placebo group. As a result, the recommendation was to give Zofran ODT and slowly rehydrate with po fluids. You should show this to your pediatrician who clearly needs to read up on the most-up-to-date studies and recommendations. Evidence based practice!!!!

traumasrus and altra: my reaction to the IV contrast was in response to this particular case being discussed. There is no question that in cases of critical emergencies such as ruling out of AAA, arrangements can be made to perform this study. However, in this particular case I am assuming that the patient was having a CT of the chest to rule out a PE. This isn't specifically stated but I assume this based on the fact that the patient was in resp distress and being admitted with a working diagnosis of pneumonia and CT of chest ordered. I am guessing however. I would have to believe (hopefully) that if they believed this patient to have a AAA they would not have transferred to the PCU until results obtained as surgical intervention may be warranted. My issue with contrast in this particular case is that the benefit should outweight the risk with a dialysis patient. To rule out PE in my hospital...a nuclear VQ scan can be performed in place of a CT with contrast for those with kidney dysfunction or contrast allergies. There is no reason to put a patient at risk when there are alternative studies available.

Wait a minute..because I think I'm missing something here. Aside from the whole Cipro thing...is anyone else wondering why a dialysis patient was getting IV contrast injection? Isn't this raising any red flags? I've seen patients with renal insuffiency mistakenly get IV contrast and then end up on dialysis as a result of this blowing out what remaining kidney function is left. Doesn't anyone think that this could have contributed to the patient's declining function? It would appear that the patient coded after the CT scan if I am reading correctly. Aside from that...a septic patient with a WBC count of 26 in resp distress on arrival with multiple co-existing medical problems is a sick person to begin with.

re: the room being ready...granted there are some good apples that call me back..I already know who they are so when they tell me something they are usually pretty true to their word and I believe them. However, I've been burnt far too many times to mention. When they tell me the room isn't clean, I call the housekeeping supervisor on his pocket cell phone and tell him the room number. He is dispatched to the room to verify the information. I have had him standing in a clean room calling me from the room telling me "I'm looking at a clean bed". Then I call the nursing supervisor. I don't bother calling the floor over and over. Our policy is first call if there are no takers, the floor has 15 minutes to call back. If they don't we call them back and if still no takers the patient goes up without a verbal report. Haven't had to do it too often but we do. Then we get a frantic call from someone looking for report. Our hospital admissions dept employs a beeper system to assign beds to us. The bed is not assigned until it is confirmed clean by housekeeping through the computer system. So if we are getting a bed then it is highly unlikely that it is dirty. I call the nursing supervisor quite often when I get no report takers on the floor. Reason being is that I have to move this patient because I have a 3 hour wait in the waiting room. If I don't call the supervisor then she comes down and starts asking why WE haven't sent the patient "she's had a bed for 45 minutes!". Yeah we know. Many of my co-workers aren't as persistant as I am because they don't want to deal with the aggravation. Problem is that it backs up the waiting room even more.

Tex, played "stuck out in triage" for my co-worker who was stuck out in the box (triage) yesterday. There was a 15 minute period yesterday morning where there was no one signed in to be seen (shocking as that is) and the 2 of us were laughing so hard I actually had to wipe tears from eyes. Thanks for giving us a well-earned moment of humor in an otherwise humorless day. Keep em comin

I started my college education in a psycho-social rehabilitation program as psych was always an interesting field to me. Unfortunately, after about a year I found that the starting salaries once I graduated would be equal to or less than what I was already making in an office job. I decided, at another student's suggestion, to transfer into nursing. This way, I would be able to work in pysch, but as a nurse making a higher salary. That was exactly what I did. After about 2 years, I started to feel as if I was going to lose my clinical skills and really wanted to work in the hospital so I interviewed at local hospitals and was easily accepted onto a med/surg floor. Although I was not given numerous choices of floors I would be working on, I was given an adequate orientation to the floor and ended up transferring and working on several different floors and earning my telemetry certification through the hospital. I presently work in the ER and love it. However, I still have a soft spot for psych and currently work every other weekend at an inpatient pysch facility (where I've been working per diem for the last 4 years). I have actually found that this experience has been helpful to me in the ER because you routinely have to deal with pysch patients, substance abusers, alcoholics, etc and knowing how to effectively deal with this population is an asset and saves you a lot of aggravation. My advice to you would be to take the job in psych and continue to look for a hospital job if that 's where you really want to be. You can always stay on at the facility per diem. The experience you get learning how to relate with people and diffuse volatile situations will only better serve you later on. Just my Good luck.