ernoc333

Thanks Morte.

Welcome to Nursing and Being Accountable. As a Nurse you aren't only Professionally Accountable for your Practice, but also accountable to the Conditions of your Workplace, the Behavior of your Coworkers, Safety and Ethical Issues. If you're not Management or Supervisory, your scope of Accountability in a case like this is to get in writing as requested, what you witnessed in the behavior of this person. Just be sure you tell the truth, are objective and are free of preconceived perceptions and influences by others in your write up. Write only what you saw, and this will ensure you're being fair and you can have a clear conscious knowing you were unbiased and truthful. Good luck!

That the EMTALA law has both Helped and Hurt people, and that parts of it need better clarification in order to prevent much of the abuse of the Emergency Medical System.

:eek:What a SCARY situation.

Right. Exactly my point. I'm so glad there are others who have the same observation. It does seem like it would be extremely difficult to stand up for the ideal principles all of the time. My fear is that given the current Legal Environment, we are eventually going to get into trouble for doing these common practices- it will get turned around on us. Ie: "If you knew I was misusing/abusing the Opiates, why did you continue to give them to me, you fed my addiction, ruined my life and caused me Pain and Suffering."

True....antibiotics for simple URI are detrimental, the doctors always explain this, but with patients' insistence, will write for antibiotics anyway. And most if not all of us Nurses will give it to the patients anyway as well. Sometimes I feel a little guilty about that, knowingly doing something for a patient that is detrimental due to if I dont I'll lose my job. Same as the Hypochondriac who has 60+ negative workups, X Rays, CT's...one day that patient will end up with a positive CT from all of the Radiation Exposure! It's like we hesitate to advocate the other way for the patient due to it's not the status quo, it's so much easier just to run a ton of the same diagnostics on the same patient over and over again.

You missed the whole point entirely. You are on a whole other tangent.

Yes exactly my concern. Thanks.

I was assessing a supine patient in the ER. The gurneys are such that the patient's eye level just happens to be at our crotch level. My patient said, "do you know that your pants are unzipped?" I looked down, sure enough.:imbar And I happened to be Commando that day due to working so much overtime, I had neglected my laundry duties and had no clean undewear. The patient must have had some view! I guess he saw how red my face had turned, because he said, "don't worry, I didn't see anything." So embarassing.:imbar

Under EMTALA, we're required to Triage, Provide a Medical Screening Examination and Stablize. Once a patient is deemed medically stable, we have fulfilled our EMTALA requirement. Although I know that doesn't end our obligation. What if after the Medical Sceening Exam it's determined that the patient is NOT SICK? Are we in terms of Civil and Ethical Practice basis required to provide care for them? Here's my real world example. A patient's chief complaint was Fever 98.9 degrees and Rhinitis for 30 minutes prior to arrival, no history, no medications, no other complaints, no other symptoms, no recent travel, no sick exposures. Just was worried that he or she was coming down with the Swine Flu that had been in the Media. The CDC recommends that we only do Viral Swabs for H1N1 if the patient is very symptomatic, very sick and will be admitted to the Hospital, we are not to do a swab on every single person who is concerned about H1N1. We get these presentations constantly, I believe due to the Media coverage of the Swine Flu. This is one doctor's regular approach: Viral Swab for Influenza, IV, IV fluids 1 Liter, Labs- CBC, Chem Panel and Urinalysis and Tylenol orally, then repeat vital signs per protocol (for him, it's every 15-30 minutes). Prescription home for Sudafed, Motrin and Tylenol. Another doctor sees this as a Not Sick patient, and will discharge this patient home with the recommendation of Tylenol and Ibuprofen if a Fever does start, and to see the Primary Doctor in a few days just for follow up. Which doctor's treatment is Right? I say doctor #2's treatment was more Ethical as the patient was Not Sick and hence, we should not treat someone who is Not Sick, that is part of our obligation. Although Doctor#1 would never be sued due to he covered every possible base imaginable, while doctor #2 could have complaints from people who didn't feel enough was done. Are we obliged to do, or should we do Diagnostics, Medications and Prescripations for Not Sick people? Is Legal Medical Practice, ie: what was done by doctor #1, where a doctor is so worried about a Lawsuit that his or her orders, even if not clinically indicated, will cover ever possible Legal Base, Right?

:banghead:It's frustrating when during Triage, a 23 year old will arrive with his mommy, and she won't let him answer questions. For example, Me to the patient: "Can you rate your Sore Throat Pain on a zero to ten scale?" Mommy: "Oh it's more than ten". Me to the patient, "Can I ask YOU to tell me what number YOU think it is?" Mommy: "I said it's more than a ten!" Patient: "No it's not that much, it's more like a 2." :banghead:It's also frustrating when the ER is extremely busy with many critical patients, many very sick arrivals, it never fails, nightly someone will drive up to the waiting area ramp, run out of their car, screaming for a Nurse to extricate their very sick friend or family member by gurney. I'm forced to temporarily abandon my Triage post to go to the car, where I find the "BLEEDING!" patient to actually be Chief Complaint: Stubbed Toe with very superficial abrasion, very slight oozing, requesting wheelchair or gurney extrication service. Then 12 people jump on me, shouting their history stories all at once. Then when I have them wait in the waiting room, as my Cardiac Chest Pain waiting patiently for me to finish the Extrication in Triage, needs the ONE available bed...these people become terribly irate and demand that their friend/family member is far sicker and should go back first. It's more frustrating when the Cardiac Chest Pain patient, who was there first and needs to go in first, feels bad for these people and says, "it's ok, I can wait, let them go first," and the Toe patient and their concerned significant others hear this. UGH. :banghead:It's frustrating that there's a HUGE Disparity in the Community about what Entails Sick versus Not Sick. Ie: Dire Medical Emergency versus Nothing Wrong. Some people will arrive to the ER with their Dire Medical Emergency as Rectal Bleeding for 2 days, unable to stand up without losing consciousness, and that IS a Dire Emergency. Some other people will arrive to the ER with their Dire Medical Emergency as Fever 98.9 and Itchy Throat for 1/2 hour prior to arrival, and that is NOT a Dire Medical Emergency. The frustrating part is that Not Sick people who consider their problem to be a Dire Medical Emergency expect the same Attention and Treatment as people who are Truly Sick with Dire Medical Emergencies. How did our Society ever get this Entitled and Selfish where someone who is totally WELL, YOUNG and HEALTHY expects to come before someone who is Criticaially Ill and Fighting for their Lives? I:banghead:t's frustrating that NOT SICK people misuse the ER so much, are the ones who complain the most, are more likely to Sue Healthcare Providers, and hence, we have to cater so much to the Not Sick patients, much to the Detriment of Truly Sick Patients. This all goes back to Selfishness and Entitlement. :banghead:It's frustrating to know that the patient who comes 1-3 times weekly to the ER with Chief Complaint Abdominal Pain, has had 60+ NEGATIVE Full Workups, all of which included IV, Labs, Urnialyses, Pan Cultures, Acute Abdominal X Rays with Chest X Ray, Abdominal CT with Contrast, Pelvic Exam, Pelvic Ultrasound, IV Pain Medications, etc...at our Hospital ER ALONE (not to mention the same patient is a regular at other surrounding hospitals, receiving Diagnostic Studies there too)....has been exposed to SO MUCH Radiation, that one of these days he or she WILL have a Positive Scan showing a new Malignancy from all of the Radiation Exposure (a CT scan has what, 1000 times the radiation as an Abdominal X Ray?). It's more frustrating when trying to advocate for the patient by asking for a Care Plan to minimize Teratogenic Exposure, only to be shot down.

All of these complaints would receive very very liberal IV Opiates, then a prescription to go. The typical Opiate order would be an initial moderate dose of say, Morphine 6mg IV or Fentanyl 50mcg IV, then titrate every 5 minutes as requested by patient. Doctors want the patients to go home in very little, ideally NO pain. The TMJ, Tattoo and the Blisters may get IM Shot, usually Morpiine 10mg IM, or some doctors (the one's who disagree with the liberal Opiates policy) give PO's in the ER, for example Vicodin 2 pills or Percocet 2 pills; then a prescription to go. The proponents of the policy believe and teach our staff that patients should not go home in pain, even if a relatively minor complaint, such as an invisible contusion, if the patient says the pain is 10/10, then we are to treat it as 10/10. The Hospital worries about bad federal ratings, complaints, lawsuits and potentially bad media that they believe will be caused by allowing someone to go home in any pain whatsoever. The quote cited most often is, "Pain is what the Patient feels it is"- I believe that quote is often used by JCAHO standards as well? To note, compared to other hospitals I have worked in, all of which have had much higher volume than this current, I have never given so many Opiates in my life! Also, this current hospital has a vast majority of patients who ask for Opiates and will cause big problems if they dont get them. At the other Hospitals where they're not routinely given in the same way, my patients with Lacerations, Blisters, superficial contusions, etc., never even asked EVER. So I believe our Hospital's current policy has CREATED the situation in which Liberal Opiates are EXPECTED. I want to know, how are the same complaints above treated in your hospitals? For example, an uncomplicated Cat Bite, Superficial Abrasions, etc...are they given Opiates like our patients are? Is my Hospital taking the Pain Managment too far, too free of any Critical Thinking, or is what we're doing the "Right" way, the way JCAHO, CMS, DEA and other agencies want us to do?

Really, really great advice. Thank you!

The ER Lead MD and Nursing Manager of our Department stated that we- MDs and RNs- are to give pain medicines in this way. The subject was reinforced at the last Department Meeting.

Thank you all for your replies. Yes, this is for real. I and a doctor have brought this up recently, and basically were put in our places. What really concerns me too is all of your surprised responses...it raises red flags that what we do at our facility isn't common practice and maybe really far from the norm. I have tried to bring up the subject of giving Opiates only for THERAPUTIC reasons, only to be squashed. Part of the problem is that our policy is to treat the Pain NUMBER. Of course, we rate EVERYONE'S pain on a 0 to 10 scale at arrival. So if a patient with a Paper Cut rates his or her pain 10/10 and they leave with no Pain Medications on Board and a 10/10 pain, regardless of what the patient looks like (talking on cell phone, eating potato chips, laughing), regardless if we did other non medication interventions, we are chart audited, reprimanded, etc. Whatever happened to Treating the Patient not the Number, and Approriate Treatment Interventions?