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KeeperMom

KeeperMom

ED
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KeeperMom has 10 years experience and specializes in ED.

KeeperMom's Latest Activity

  1. KeeperMom

    Is earwax removal an emergency?

    Minimal at BEST. Society is very "me, me, me" and would rather someone else fix his/her problem than even attempt self-help. How many times have we heard a patient's c/c and asked him if he tried anything OTC before coming? How many times is that answer, "Well, I don't like to take anything." SMH. What exactly are you expecting us to do? Healing interpretive dance? Laying of hands? Sacrifice a goat?
  2. We tell our new grads that it takes a year to feel comfortable with the patient load and charting. It takes three years to be fully competent and five years to be proficient and considered "seasoned." As long as I've been coaching new hires, I find this to be fairly true. There are exceptions to every rule but the ER is not like any other department in the hospital and has its own set of challenges in a consistently changing environment. It also depends on the type of ER. If it is a L1, it may take months or years longer to become proficient at everything that might roll through the doors. In a non-trauma ER, you might never see some really sick-as-stink patients that a larger facility might encounter. I had one new hire that came from a much smaller ED and she had never once seen a heart alert in her two years at the other facility. While she has cared for a cardiac patient and shipped that patient to us, she never had to do X, Y, and Z before getting that pt up to the cath lab.
  3. KeeperMom

    Bedside Handoff

    This pretty much what we do. I give the very basics at the BS and give a real report at the desk. I usually give a very brief re-cap of the pt's c/c, what we have done thus far and what we are waiting on. I think this kills two birds with one stone - gives the pt some reassurance that I have listened and a list of things that I have done for him so he can't say, "she didn't do anything for me."
  4. KeeperMom

    Way too close....way too personal

    I had a pretty sick patient today and was in the room pretty much the entire shift. The patient and his wife were very nice but the wife just grated on my nerves ALL day. First of all, she popped her gum constantly and I cannot stand mouth noises; crunching ice, smacking, slurping....drives me nucking futs!!! Annnnddd.... she was all up in my personal space and I couldn't escape! I even had my visitor chairs on the other side of where I was working but she wanted to be on *my* side until I finally had to create a boundary with an IV pump, infuser, and Bair hugger machine cords. Secondly, she told me how to do my job all day long. Y'all know how much we LOVE that. Lastly, she kept asking me so many personal questions. It was so off-putting to me that I started making up stuff! I don't mind people making conversation about my badge reel or something like that but this woman was asking me so pretty personal questions I was just at all comfortable talking about. Asking me about my kids, my marriage, etc. And I had a high school student shadowing me for two hours this morning and she felt that it was her duty to educate him since she was a retired principal and everything. I couldn't teach this poor kid anything medical today because of her. I felt so bad for that kid. I've been a nurse a while and can usually deflect some of the more personal type questions pretty easily but this was just WAY too invasive and caught me way off guard. She even commented about my engagement ring and then asked what my husband did for a living "to afford that." How do y'all handle these types of people? I didn't want to be rude but it got to the point that I was dreading going in the room. I'm starting to think that I'm going to have to come up with an alter ego just for work! I felt so violated!!!
  5. KeeperMom

    Clinical placement in ED

    Just to be clear.... are you talking about a full / respiratory arrest or are you talking about a trauma? We always allow students into codes and welcome them and put them to work doing compressions. Performing compressions on a human is vastly different than compression the CPR dummy. Level 1 traumas are another story. The rooms just cannot accommodate too many extra people in a L1 and it can just get way to chaotic. If you are being told that you can't go into a code, I disagree with that. Call me insensitive but it's not like you are gonna kill 'em. I think codes are an excellent opportunity to teach and experience a lot at one time.
  6. KeeperMom

    Experienced NP seeking Derm Job

    I'm a new grad NP and most places around here will pay you the topped out RN salary while in training and until your credentials come through. I think that is around $30/hr here (we have notoriously low RN pay around here). Most orientation is about 6-8 weeks depending on the specialty. I think $25/hr for an experienced NP for 6 months is just not acceptable to me. If I did have experience, but not in dermatology, I *might* take it for six weeks but definitely not 6 months.
  7. KeeperMom

    How much do NPs in the Southeast really make?

    From what I've seen, it varies quite a bit from state to state even in the South. In north and south Alabama, an NP in a larger facility makes around $40/hr but might make more in a clinic. In central Alabama, the hourly rate is slightly higher. That yearly salary is still a good bit above the median income for the state. I've heard of higher acuity positions in parts of the state that get as high as $65/hr. Of course, there might also be a night shift differential in a facility, too.
  8. KeeperMom

    Pain Management in Long Bone Fractures

    We don't see protocols as something in place when things are handled poorly at all. Our ER utilizes nurse-driven protocols that our ED docs have agreed to sign if the nurse initiates the set of orders appropriately. It saves significant time and the patients see that we are getting things started before the MD/NP ever enters the room. We have protocols for CP, abdominal pain (upper and lower), asthma, suspected volume depletion, hip fractures, extremity fracture, diabetic complications, etc. I think we probably have about 20 or so. Most do not include meds but a few do. None include pain meds, however, Our hip fracture protocol does include a battery of labs, X-rays, foley, EKG, etc. We have been using these for over 10 years and we tweak them from time to time but they work really well for us.
  9. KeeperMom

    Pain Management in Long Bone Fractures

    In the ER, I don't really think a protocol would necessarily work, so to speak. Every patient is different and even if you have two identical femur fractures, you could have two very different patients and scenarios. For pain control, we use Morphine, Fentanyl, ketamine, and that one that starts with a D. We also throw in some zofran or other anti-emetic. It all depends on the physician, MOI, and presentation. In my opinion, we grossly under medicate these injuries and very few of our docs like to dole out a lot of meds. I also don't think a protocol would even fly with our docs. They ALL have their own ideas of what works and what doesn't. I'm not saying attempting a pain protocol isn't a good idea but I just think there are so many variables that factor into what I would decide to order. I will be interested in seeing what other folks answer.
  10. KeeperMom

    If the shoe fits

    Every foot is different so it is really hard to give you one solid answer. For me, however, it is ALL about the socks. I wear Balega or SwiftWick socks. I wear running shoes with inserts for my high arches. I also have wide feet so not just any shoe works for me. I highly recommend going to a running store and have them watch you walk and fir you from there. You may be surprised what they put you in. I used to wear Danskos too but once they changed how they were made, they aren't so great anymore. Running shoes is what works best for me.
  11. KeeperMom

    Should I leave ER?

    I'd say you need to talk to a supervisor and ask for a 'peer' review to see where you stand in the department. If they feel like your skills are lacking to care for the critical patients, then you have to ask for more responsibilities with sicker patients. Maybe ask for him/her to set you up with a coach of sorts to pull you into the sicker patient rooms and guide you through the process. If you aren't showing initiative, you will be overlooked in most ERs as a newer employee.
  12. KeeperMom

    VISITOR POLICY

    Our policy is two visitors per patient. We just have stickers that are issued at our front desk and the desk staff is supposed to call back to the pod and ask when the visitors can go back. Most of the time, the desk folks know to give at least 20 minutes for us to get the patient off the EMS stretcher and at least initially checked in and settled before sending a visitor back. There are exceptions, of course, like when we have a patient that has AMS, etc. We can also put notes in our message column of our patient track / software to communicate "NO family" or "send family," or the like. We also have a badge entry door into the main part of the ED but that can be dodged if we don't catch the visitors right away. From the desk, we can push a button to release the doors but when it is crowded, we miss people. When we have patients that are close to end of life, we can accommodate more people but those patients are generally in a larger room anyway. We are so fortunate to have a Family Rep that helps the docs and nurses herd the masses. We have several small waiting rooms within the department where we can place extra visitors too. We also don't allow young kids in the back but we are an adult ER. Kids are just too much liability in the back and aren't usually very well behaved either. I know there are times when that is the only option but when 15 people show up, there really is no need for the littlest kids to be in the ER. We had one patient who was basically there for a broken wrist and about 25 people showed up to the ER with about 8 kids in tow. It is great for someone to be that loved and cared for but it was totally overwhelming to the staff to have to manage that crowd and they took up about half of the waiting room with an already crowded lobby of REALLY sick people. Our security is also pretty responsive when we have people dodge the doors or congregate in the halls, etc. They are a great help when too many people start showing up. If they don't want to leave, security can escort them out to the lobby. Our hospital policy actually reads that visitors that are disruptive to patient care can be removed but we, luckily, don't have to enforce that too much. So, while we have the two visitor rule, we don't post this anywhere because visitors will then say "I have a right to go back there..." when really they don't. Oh.... in our initial intake of the patient we do try to tell them of or policy and ask if he/she wants to designate a support person. Sometimes, the patients help police the policy but there are times we have to enforce it too. My go-to line is, "I now you all want to visit Joe but our rooms are so small and we do have a two person visitor policy. You are welcome to swap out visitor stickers in the lobby so you can all have time to visit." It does help that we have two chairs in each room and folks don't like to stand for too long. What I cannot stand is when the visitors hover around both sides of the bed. I'm like, "how am I supposed to tend to your patient from way back here?" I try to put the chairs on the side of the room where the family can sit and say something like, "y'all can have a seat in one of those red chairs..." in my stickiest Southern drawl. People kill me. I know they want to BE with the patient but you gotta let us do our jobs.
  13. KeeperMom

    My Tips on Passing the AANP Exam

    Thank you for this info. I took the ANCC adult-gero exam in March and didn't pass. I am almost out of the 90 day waiting period to re-take. I am debating on whether or not to take the ANCC exam again since I am somewhat familiar with their format and some of the content. There is a Barkley review in a few weeks nearby that I was planning to take but I'm still sort of up in the air about it all. Do you have a link for the practice exams? I also agree 100% about not waiting too long to take the exam. I did wait too long d/t some family things - good things but it took me away from studying, etc. I'm about to get really serious and more focused on re-directing my studies and dedicating some time to the exam in the next few weeks. I have got to get it DONE!!
  14. KeeperMom

    Triage times (under 3 minutes)

    In addition to acuity, we prioritize our elderly patients. Anyone over 75 gets a * in their column and we try to get those pts back as quickly as possible and even faster if they are a higher acuity. I'm pretty good at the triage thing and can typically triage a straightforward patient in 5 mins or less. Of course, if the patient has a lot going on and needs some additional questions / history and/or an EKG, it might take a minute or two longer. We used to have an NP in triage and that took slightly longer with each patient which caused a few complaints but we did get more done with them out there because they could order labs, imaging, etc. We get the chief complaint, med and surgical history, LMP, allergies, tetanus status, we ask about malignant hyperthermia, ht. and weight, fall assessment, vitals and name of PMD. Luckily, we can pull info from previous visits regarding allergies, home meds, PMH and surgical history which has saved us a boat ton of time!
  15. KeeperMom

    Feel stupid

    Keep your reports short and to the point. I tell my new orientees to stick with an SBAR approach and start from the top... Situation - what brought the pt to the ED to start with.... "Mr. PDQ is a 77 pt of Dr. XYZ that came by ambulance from home with a c/c of right flank and RLQ abdominal pain for the past 4 days getting worse last night. He c/o of N/V but denies any diarrhea." Background - "He has a history of..... and is allergic to.... "His belly was soft and tender in the RLQ to palpation and he did vomit twice before we gave him 4 & 4 that we gave through an 18ga in his right forearm and sent him to cat scan where they showed him to have a kidney stone..." "He also got a liter of fluids and we hung some ABX that is currently running on a pump so I'll need to swap one out when I get there." You get the point. I don't review a ton of labs unless they are pertinent to the patient's diagnosis / problem. We have floor nurses that will ask about your entire assessment and I just don't give that. I politely say something to the effect that she should do her own assessment. If the patient is here for a respiratory problem I will say, "He had rales in the lower right and diminished bilaterally" or whatever and then give a re-assessment after a breathing treatment so the receiving nurse can have a baseline to compare. That IS important. Doing a head-to-toe assessment for the floor nurse is not. Same for a nearo patient. I got written up by the floor one time for not treating a pt's blood sugar that was 212. The patient's K+ was about 2.2 and she had a small bowel obstruction and was headed to the OR later that afternoon. I purposely didn't treat that sugar because #1 I was treating that hypoK+; #2 that's probably the patient's normal glucose and #3 the patient was NPO for the surgery so I was pretty ok with that 212 sugar. Oh, and let's not forget that the floor isn't always on the ball getting to the room to see the patient nor check a sugar so I didn't want to treat that 212 not knowing how long it would be before anyone came around to check back on her. I'd rather have a 220 sugar than one in the 20s. I didn't accept that write up but wrote my own response to that instead. I think the floor was pissed because I called five time in a 45 minute period to give report and no one came to the phone so I took the pt up to give bedside report. By the way, you mentioned holding for ten minutes. I NEVER hold for longer than 5. That's my limit. Our charting system timestamps everything and it cannot be adjusted. I drop my "Report called to...." template in there and it time stamps me. It also time stamps the last time that field was accessed so it will show my five minutes of waiting. Our unofficial policy is to just give a BS report if you've called three times and no one answers. I wouldn't sweat that blood sugar really. We get flack all the time about not treating but I just say that we were treating the patient's acute problems and got 'em stable for ya. If the pt is there for a prolonged period of time you should treat it but it isn't always possible when you are actually treating bigger problems.
  16. KeeperMom

    How long you push emergency drugs during codes

    You push 'em as quickly as your can.....they ain't getting any deader. But I'm also wondering why you would give etomidate or sux during a code. In my world a code is epi, bicarb, atropine, more epi.
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