pererau

I'm not living in Washington anymore, so I can't guarantee that anything I say applies anymore, but I didn't know anything about the residency program at Franciscan when I was applying for jobs. I just applied and when they interviewed me, they put me in a residency. For Legacy, I filled out a huge packet of information and got it back to them... turns out I was 2 days past the deadline and would have to wait 3 months. For Providence, I worked there as a CNA and I know at the time they didn't hire new grads into the ER, but they did have residency programs for other floors. I have heard that since then, they have had a few new grad residents in the ER, but I don't know any details on it. I loved the residency at Franciscan, as the didactic was detailed and specifically tailored to the ER. I learned more in those 3 months than in the whole of nursing school. That was a couple years ago, though, and I don't know what it is like now. I still have lots of friends over there, so if you want to email me at pererau at gmail then I'll try to connect you to someone who at least can give you some details.

My Davis and my Gahart both say 1 minute, and I've never had a problem with that speed. Has anybody else?

Why not? 1 D 2 D - I really hate this type of question, because in the real world we would be doing D and B at the same time, and I could see a pretty reasonable argument for either, but in the end, absent standing orders, the RN does not have the authority to start a normal saline bolus, and typed and crossed blood is always safer for the patient than o neg. 3 B 4 D 5 A - wild guess here.

The total care was the idea of the (at the time) new nursing bigwig who wanted to achieve magnet status and decided that the best way to do it was to fake staff to patient ratio numbers by firing LPNs and CNAs and using only RNs. It ended up working out well for me (a CNA at the time) as it pushed me to apply to the ER, where I fell in love and have called my home ever since, but I feel bad for the nurses on the floor as they now have to do the butt wiping and bed changing in addition to the critical thinking skills that they are getting paid big bucks for (don't get me wrong - nurses aren't above wiping a few butts, but when you go to school to be educated to assess and implement procedures and become knowledgable on meds and the like, it is a waste of money to have the nurse doing menial tasks that can be done by anyone). I also feel bad for the patients who instead of having several team members available to help them have one overworked nurse who comes by when possible. That is why when I graduated from nursing school, I didn't even apply to St. Pete's. (That and they don't have an ER residency program and my eyes were fixed on the ER prize) Overall it is a good hospital, and I think that eventually the thinking will come around and the stupid nursedoeseverything policy will change.

If it is the rush of the hospital you are looking for, you may be disappointed, because most hospitals around here are doing away with LPNs in favor of RNs. That said, Group Health hires a lot of LPNs for their clinics and urgent care centers. Good luck.

I am very seriously considering a move to California. I've tried to research the subject of how best to get a license in CA, and in fact, I've already paid to have Nursys verify my license. My concern is that I have read at various places that it is better to wait until you are actually in CA and get a temp license because if you submit the application packet, and then go to CA before it is approved there is no way except to start over. So my question is this: Should I just go ahead and send in my application packet so that I get a CA license, or should I wait until I have a sure thing and stop by Sacramento to pick the license up? And if I do submit the application from my current state and then get an offer for a job, what are the steps to get a license at that point? I know this theme has been posted to death, but I'm still a little confused, so any help would be appreciated.

I worked there several years ago as a CNA. I was on the TCU (transitional care unit) side, and I don't know if anything has changed in the past few years, but for a nursing home, I found it to be nice. That said, I'm certainly not a nursing home fan, so I would never want to work there again, but I have had experience in three different nursing homes either as a CNA or RN student, and MJCC is the best of the three.

I got my CNA training many years ago at the Puget Sound Healthcare Center in Olympia and it was free. Also, I was employed as a CNA while working at the Providence Health System and going to nursing school and they helped me with a reasonable chunk of the cost. I'm not sure about anywhere else.

I am considering a job offer in Sacramento at Mercy General Hospital in the ER. This offer is somewhat coming out of the blue, and I need some help with anyone who lives in Sacramento. Is there anything about the MGH ER that I need to know before I run blindly into it? The hospital itself seems to be in a fairly nice neighborhood, but it seems expensive. Where are the best places in Sacramento to live to be safe (two young children) and fairly quiet? Some important things for us: we don't want an ancient house, we want sidewalks in the neighborhood. Near a mall would be great. Near Costco even greater. We don't want to go too far from the Hospital. Preferably somewhere that we can find a 3 bedroom house to rent in the 12-1600 range. What kind of heat is it in the summer? It is hard to tell based on the humidity graphs we have found. If anybody has any suggestions or ideas for getting by in Sacramento, please get back to me ASAP, as I will probably accept this offer baring anything unforeseen. The other thing I need help with is what I need to do ahead of time if I am going to get a walk-through Cali license. I have already paid the money for the national licensure web page to verify my current license, but what else needs to be done prior to heading down there?

The headache comes because Morphine produces vasodilation. This is why we give Morphine for chest pain patients. The vasodilation is great to reduce constriction due to angina, but it causes headaches due to the vasodilation. These are usually transitory in my experience.

Try the Franciscan Health System (Tacoma area), the Providence Health System (Everett and Olympia) or the Legacy Health System (Vancouver and Portland area). All three have residency programs.

I graduated in late 2007 and it took less than a month to find a good ER residency position. I don't buy the BS that you have to do floor nursing before going to the ER, but don't try to go into the ER except through a good residency program. I think trying to work on the floor would have ripped my soul clean out of my body.

Do you feel better now? Having worked the floor and ER as a CNA and now the ER as an RN, I have seen both sides of the picture, and I agree with you in principle, though I wouldn't take it quite so far. Working in the ER is worlds different than the floor and, I have to say, considerably more difficult. Honestly, ER nurses should be making more money, but unions will never allow that. With that said, from the other side of the coin, the floor nurses are not just sitting around smoking cigars and playing poker. One thing that a lot of ER nurses don't realize is that the floor nurses have 4, 5, or 6 (or even more at night) patients, many of whom are the crazies that we sent their way an hour ago, and while they don't have as much hands-on drama, they do have a load of paperwork and red tape hoops to jump through that makes their jobs pure misery. They want to know about the CT results and bedsores, because they have 3 double-sided forms to fill out for every little problem so that the hospital can get reimbursed/accredited/not sued. I've come to terms with the fact that there will never be the perfect transfer. Every time I take a patient up to the floor, either they find something that I didn't do, or I sit and wait in the room for 10 minutes only to find that the assignment was changed or the nurse didn't think to get an IV pole or a tele unit, or they tried to put my female in with a male roommate or some stupid business that keeps me away from my other patients in the ER. One day I'm going to take a patient to the floor and the nurse will be right there ready to go with all the supplies needed and magically I will have had time to do all the I&Os and skin assessments and fall risk scores and I will have detailed information about all the labs and radiology reports and will be able to quote, from the top of my head, the patient's meds and allergies and last 10 blood pressures. Until that day comes, we just do the best we can and try to remember that although we are busy with some of the people that even Jerry Springer wont accept, they are busy with the paperwork and guidelines created by even crazier people in the joint commission.

One thing that I have found is important in starting IVs is confidence. It is kind of a vicious circle, because when you miss, your confidence goes down, and when your confidence goes down, you are more likely to miss. You have to trick yourself into thinking you are going to get it, because I've found that when I go in with no confidence, I create a self-fulfilling prophecy.

You are a patient advocate. That means that it is your responsibility to advocate for the well-being of the patient. This means ensuring the patients get the proper treatments and medications and respect. The patient will sometimes have you believe that this means that you are to get them more dilaudid, inapropriate radiology tests, and the like. Don't fall for that trap. Advocating for the patient sometimes means pleading with the doc for more meds, but sometimes it means teaching the patient that the drugs they want are not appropriate for their condition, or explaining why an MRI isn't appropriate for a sore throat. Also, remember that advocating for patients also means advocating for patients that are still in the waiting room. If you fall for the idea that you have to do everything that your patient wants, then you are delaying the care of the patients that are yet to be seen. What I do: I try to respect everyone and make sure that they are comfortable, but I do not let them order me around, and I do not bend the golden rule of the ER (sickest goes first) on the whim of a patient. Good luck

Given that information, it sounds like she was very poorly treated. I still think that the ER is not the place to get the treatment that she needs, but courtesy should not be a foreign language to healthcare providers. I hope that you will understand my defensiveness given the number of times I have seen people get the exact treatment that they need and then proceed to complain about being mistreated when I know for a fact that they were not mistreated at all.

I understand the need to avoid assumptions, and believe me, those who work with me know that I am one of the most caring nurses that they work around - even with frequent fliers and druggies. But that is not the point of this post. It is about caring in giving respect for the people who present themselves for treatment, and if the staff at the ER that your daughter went to did not give respect, then shame on them. But to say that we have a moral responsibility to treat everything is not correct. We have a moral responsibility to care about people, and caring about people often involves sending them to the appropriate channels for care. The emergency department is not the place for your daughter and her chronic conditions. If I were the nurse taking care of her, I would explain it to her, give her community resources and hold her hand, but the end outcome would be the same - she does not have an emergency and should be treated by someone who specializes in following long term or chronic conditions that are not emergencies - a PCP or orthopedic doctor. The example is a person walking into a psych unit with a gunshot wound. You would do ABC and then get them out of there where they can be properly cared for. It sounds harsh, but it really is caring for someone to not try to do chronic care in an ER. Help the person find ways to treat the pain or discomfort, ensure that there is no medical emergency, and get them out of there where they can be properly cared for. Again, if the staff was rude to your daughter, then shame on them, but it sounds to me, just based on what you are saying, that they looked into her condition and treated her accordingly. It isn't that her symptoms can't cause problems - it is that they are not emergencies, and in trying to get care in the ER, she is getting care from doctors who do not have the expertise or infrastructure needed to properly follow her conditions. I know that there are plenty of specialists around who will work with those who do not have insurance to try to find ways to reduce rates and get workarounds for expensive treatments. I used to work as an LPN at a pulmonologist's office and we would regularly give large discounts to uninsured who paid with cash. Call around and find out who is willing to work on similar deals with your daughter. It sounds like she is having symptomatic stress reactions, and if that is the case, perhaps it would be better for her to come home for a little while to get herself back on her feet and sort her life out a little and then try again. It's not a failure to do that, in fact it is showing strength to accept that sometimes you need a little support. Earlier you asked what good it would do for her when she is trying to learn to be on her own. She needs to have a soul search to determine which is more important: feeling like she can do it herself when it sounds like, at this moment at least, she can't, and in so doing endangering her mental and physical well-being, or returning home to get things sorted out, and in so doing suffering some short-term disappointment. When all is said and done, however, the ER really is not the place for her, and the more it becomes so, the less available it will be for its true calling: emergencies.

And in a small town, you may have to be flexible like that. I seriously doubt there are too many real emergencies in a town that size, anyway, so it is not necessarily taking the docs and nurses away from the emergencies like it does in most bigger ERs.

If I walked into your psych unit and asked told you that I had just been shot in the arm and blood was dripping everywhere, what would you do?

I understand what you are saying about what the law mandates and that is my problem - mandates only inspire people to look at numbers. It also inspires acuities based on staffing and not on acuity. How does the law define acuity, anyway? What acuity is a patient who has chest pain that is responding well to NTG? What if the 18 hour labs come back positive? Does the acuity change? What about the post-appy patient who is healing well, but then starts to show signs of infectin? What about the patient who you can't find anything wrong, but they get a little sundowners and lean on the call light? What about the TIA patient who is at risk for CVA but show no neuro deficit but requires hourly neuro checks? Who determines what staffing level each of these require? What is the formula? You'll get your staffing ratio with some magic number for some formula-driven acuity level, and the management will see it even more as a numbers game and stick even more coldly to the minimum staffing ratio. Mandates are not the answer.

"They did just look at numbers. That was what the staffing grid was based on." And that is exactly the problem. You are concerned that they only looked at numbers. That will only get worse when the law only requires them to look at the numbers. I agree that something needs to be done when nurses are being abused, but that something is not unfunded mandates from above.

Without having been there, I can't say for sure, but a couple of points: 1. If there was no reason to do a pregancy test, then the doc made the right call: go to the dollar store and get a kit. Both of my wife's pregancies were diagnosed with dollar store kits. The only reason to do a pregnancy test in the ER is if they are going to give certain drugs or if they are going to do an x-ray, which brings me to 2. With knees, the ottowa rules are pretty acurate in determining the need for an x-ray exam. If she did not meet the criteria, then it really is a waste of your money and the hospital's resources to get her knees looked at by x-ray exam. If there is concern about internal knee derangement, then what she needs is a sonogram or an MRI, neither of which should ever be done in the ER except in those extremely rare circumstances where the limb is in true jeopardy if it is not done immediately. In your daughter's case, the injury is over 2 months old, so this obviously does not apply. 3. I'm not sure what you were referring to with the "fungus in the ear" part, but if ear pain is a chronic issue for her, then it is not an emergency condition unless something has changed dramatically. I don't want to be condescending to your daughter - like I said, I wasn't there - but from what you wrote, it really does sound like she got the proper course of action: an assessment with determination of no emergenent condition. The gold standard medication for such a condition is ibuprofen or naproxen as these will relieve pain and reduce inflammation. Otherwise there is very little that an emergency deparment can do. Speaking as someone who needed medical attention at a time when I had no insurance and little money, I understand the difficulty that she is facing, but honestly and frankly, what she needs is a primary care doctor, or even better, an orthopod to follow her and get her on some various treatments to help alleviate the pain. An emergency doctor is expert in assessing for emergencies, not in treating non-emergent pain. In the meantime, rest, ice, compression, and elevation along with NSAIDS is the key.

Does anything know about the Kaiser Hospital in San Diego? I have a phone interview tomorrow with the nurse recruiter and I really don't know anything beyond what she has told me. Based on what I know, it seems like a good place with great benefits, but I've heard some mixed reviews of Kaiser in general in the past. I have experience in the ER. If you don't recommend Kaiser, then what hospitals in the San Diego/Oceanside area do you recommend for good ERs with computer charting? I don't need a fast-paced or even a big ER - I like the chance to get to talk to my patients a little bit, and I'm a little less of an adrenaline junkie than many ER nurses. I'm also the sole earner in my family, so I need to find a place where I can rent a 3-bedroom house for a reasonable price. For that matter, we are not limiting ourselves to San Diego, it just seems like that is the best weather, whcih is our primary reason for moving. I've also heard there is great weather in the San Luis Obispo and Santa Cruz areas. We are less interested in LA because it is too big for us, and we don't want the hot summers of the central valley. The big thing we are looking for is a pretty flat temperature curve (not so much difference between winter and summer temps) and reasonable cost of living vs. salary. A nearby university that offers RN-BSN is a plus, but if I have to sacrifice that, I can do it online.

I did clinical rotations there in my nursing program, and besides the free soup in the break room, I hated everything about it. It was dirty and old, and patients did not seem very well cared for. The medication carts weren't always locked and the smell was intense. The one ray of light for me was one particular resident who liked to do puzzles and was fun to talk to. Good luck.

Oh poo! One more step closer to unionization. The nursing will really go in the toilet. " Mandates Minimum, specific RN-to-patient staffing ratios based on acuity and not by numbers Whistle blower protection for RNs who report unsafe hospital conditions or for refusing unsafe patient care assignments Legal recognition of the right of the RN to act as an advocate for their patients rather then for the economic interest of their hospital employer" I like the idea of safe patient ratios, but mandates - especially unfunded mandates that require laying a lot of money out - are rarely effective as desired and often have very unintended consequences. In this case, a lot of hospitals which are already facing sharply declining income would have to severely cut back in other important areas to address this mandate. Perhaps instead a carrot could be held out for facilities that take steps to ensure safe ratios. Some day, I'm going to have to have somebody explain to me how refusing an "unsafe assignment" actually helps patient safety. You feel that 5 patients is too much for you, so you refuse. The result is that someone else has to pick up your slack and take those patients or the patients do not get care at all. Besides, who determines which assignments are unsafe? In my experience, the ones who would take advantage of this are the ones who will complain over anything not going exactly according to what they wanted. Maybe it is just because I'm an ER nurse and we don't get the cushy rules that floor nurses get - in the ER anything and everything comes at you and you don't have the luxury of saying no. Finally, who determines where the line is between what the patient needs and what the bottom line of the hospital is? Again, the nurses who would take advantage of this are the whiny ones who aren't willing to flex as the situation requires. Don't get me wrong, I think that patients will have better outcomes and less errors if there is a lower ratio, and I think that nurses shouldn't be walked over by management, and patient safety should not be endangered to save a buck; but remember that healthcare is very expensive and administrations are facing smaller profits and higher costs. How about instead of unfunded government mandates and unionization, someone put together a website where nurses can indicate what the staffing ratios are at their facility as well as any patient safety concerns that they see - you know, kind of a hospital compare site, except this one would actually mean something. If we were able to see ahead of time what hospitals are good to the nurses and make efforts toward patient safety, then the market would work itself out. We would all flock to the hospitals that are good and leave the ones that are bad. If the bad ones want to stay solvent, they would have no choice but to improve. This is how the free market system works. The government mandate system works by loopholes. The hospitals look for what they can do to technically comply without actually making improvements, and without the ability to be flexible in applying safe practices to the idiosyncrasies of each particular hospital or unit. How about telling the California Nurses Association to get back in California and ruin hospitals there instead of trying to infest Arizona with their poison.