RedSox33RN

Honestly, new fees won't stop a lot of these people. Many just don't pay because they don't have insurance. We have many frequent flyers who use EMS as a taxi service, and when they are told about Medicaid not paying for non-emergencies, many continue to use EMS for non-emergent reasons anyway. And for the non-emergent patients, isn't that why many ER's have Fast-Track now???

I see what you are saying, Rhia. In terms of what a pt comes in "saying" is a yeast infection, I would triage her a level 4, with my reasoning being that in our facility (not sure of others), she WILL be getting a pelvic and since they're doing the pelvic, they will be doing a GC/Chlam & wet prep, which constitutes one resource. I would also send this woman to fast-track (unless closed). Stuff like that is obviously harder to triage since you obviously can't SEE what is going on in your triage booth, and are basing it on subjective and objective info. Some providers in our ER may just do a quick pelvic and not send labs, but in fast track, they figure as long as they are down there they might as well culture it. I work triage for 7 hours of my 12 hour shift (long explanation, but I work 1p-1a, and work as second triage nurse until 8, then move to either ER or fast track. If a 2nd triage RN is not needed, I'll work as float in main ER with a pt assignment until needed in triage or fast track. It's a crazy way to work, but I love it!), so I've gotten pretty comfortable with what PA's and MD's are working and what I know each will "work up" and what they'll "treat & street". That said, I hardly ever triage anyone a Level 5. Usually only med refills (although must say I got BURNED a few weeks ago with one pt that came in looking for HTN meds. Turned out she actually had IVC papers taken out on her and it became a big mess!! Not that I knew, but still, I felt bad that Fast Track had to deal with that) and the FF that comes in with a recurrent complaint I know they won't work up, but even still I may make it a 4. And since we are more and more sending off urine to the lab, even the simple UTI sx gets a level 4 (no point-of-care for urine - except UPreg - in our ER, which really chaps me. It's just as easy for us to dip a urine as it is for the lab, and quicker results. It can always be sent off if needed) since we have to send to lab. Once I get to Level 3 and above, especially with c/p, it can get more tricky. I know MANY nurses that make ALL c/p a level 2, no matter what, even if it seems muscular or may be from a chronic cough. C/p and CVA sx are ones that you REALLY need the ESI "danger" vitals and a good hx. If there is ANY kind of cardiac hx, or hx of current drug/cocaine use, they're level 2, and if I don't have a bed, I start a cardiac work-up according to our protocols. If it's a guy that had been moving furniture and having c/p, can be reproduced, no health probs or hx, I'll still do an EKG and have the MD sign off on it (if no beds), but would feel comfortable making him a Level 3 if EKG is okay. Those ones are the most tricky, and especially with women. I "go with my gut" on a lot of the women with c/p in their 40's and 50's, especially when they say they have GERD and "some stomach upset". I've seen too many women having STEMI with vague sx like that. I'd love to know how others will triage c/p and CVA sx. I really dislike that our registration can even USE a term like CVA Symptoms when quick-registering before they come back to triage (this is if we're full, which is most of the time. If a bed is available, they go right back, don't get me wrong). I know they have to use something, but a lot of times I will end up changing that term so it doesn't look like the chronic migraine FF is sitting in the WR having a stroke! We are having EVERYONE who triages in our dept re-take the ESI course every 2 years, which I think is a good idea. I've worked some places that demand every c/p is a level 2, and some places that don't. It's good if we're all on the same page with that.

Like LilgirlRN, I've started IV's in many places besides arms, but we're not permitted by our state to start EJ's, though the paramedic students are permitted. It's really a skill I would like to have, and have been present for the insertion of more than I can count. It does seem silly not to let RN's be checked off on the skill.

This is SO true, and what I am struggling with right now. I really thought ER nursing would be for me, but find myself more "disenchanted" with it than ever (although it's only been 2 years for me). I'm looking now for a new area of nursing, hoping and praying that I will find my niche. I know I need to be able to spend more time with my patients and truly HELP them make lifestyle changes and follow their progess, which obviously not what the ER is about. Yes, helping people, of course, but after they're gone to the floor or out the door..........they're gone. I often wonder what happens to a lot of them, and this feeling and wanting to follow-up/follow-through, has become much more pronounced in the past few months.

I got yelled at by a surgeon once because I couldn't understand him. I work in the ER, and I was taking telephone orders for him because he couldn't get in to see the patient before he was admitted to the floor. He spoke VERY broken English, and with the heavy accent (not sure from where, but I was told he had only been in the US a year or so), he was just impossible to understand. I DID, however, understand the gist of his yelling when I kept asking him to repeat what he said, and I would TRY and repeat it back (incorrectly, as it was)! lol I finally said he would need to come write orders or fax them over. I was not taking any chance of a missing or incorrect order! That p'd him off to no end.

I feel your frustration! I lived in the Northeast all of my life, graduated NS in 2007, and probably sent out 150 applications in 2 states, and all I got was two PRN jobs in M/S and LTC, neither of which was the area I really wanted, ED. I had to relocate, leaving family and friends behind, which was tough. But I got into a great "ED school" in NC that was for new grads and RN's looking to get into the ED. It was 6 months long, combination of classroom and dept shifts the first 3 months, then with a preceptor for the last 3 months. It was very helpful and a great experience. I've since left that hospital and in a smaller ED (they had just opened a new ED the place I trained at, over 75 bed ED and not nearly enough RN's!) and as much as it pained me to move, I don't have any regrets. I hope you can figure out or find something soon!

Several of our docs are now documenting in their assessments and notes that they have educated the pt about use/abuse of the EMS system. I'm hoping that one day this will help fine or prosecute the ones that have demonstrated abuse of the system, showing that these people were informed of the correct use of EMS. One doc in particular recently got extremely irritated at a woman who came in via EMS with her 6m old r/t a diaper rash (if it could be called a rash. The area was slightly red, child interactive and smiling) x4 hours. The woman has a big hx of EMS abuse. I wish more of the docs would speak up, because coming from me ("You're JUST a nurse, not the DOCTOR!") doesn't seem to have much effect.

Wow! They didn't even identify your title or license?? I wouldn't like anyone caring for me or a family member where I didn't know what their title was (RN, LPN, NA, MD, DO, etc.). I would have taken it as a personal affront also.

In the 3 ED's I've been in, we've used Emstat, Meditech and now Ibex. Emstat was by far the best, though I'm getting to like Ibex. Meditech was AWFUL - we actually did paper-charting there, and had to manually put in meds and stuff into Meditech.

Roy's list nails it all! It depends on the docs that are on also. Some are very partial to Toradol, so I may give a ton of that IV and IM some days. Others always go straight to the "big guns" (ie. Dilaudid) and those days I feel like that is all I'm giving. Some docs prefer IV Phenergan and others are really frightened of it, so only want Zofran or Reglan. I've only been in the current ED I'm in for 6 months, but can already tell you when certain docs are on what they will prescribe. And yeah, IV NS is a biggie.

Good luck to you, momofthreeboys! I live and work in Nash county, and have a lot of friends that graduated from Duke, UNC and ECU. Those are some great programs, from what I've heard.

I went right into the ED after my graduation from nursing school. But I think the big difference was that they had a 6 month "ED school" which was fantastic, and we were with preceptors for all of that time, which also included classroom work and many different in-services and classes for Basic Arrhythmias, ACLS, PALS, etc. I have heard both sides of the "issue", whether an RN should get Med/Surg and ICU experience before the ER, or can go straight to the ER. I think it not only depends on the person and how motivated they are to learn, but also the quality and length of any preceptorship and "ED school" (if they have one) and the ER department itself. The ER I began in was not a trauma center, but because of where it was located and the lack of other hospitals around (and the size of the ED also - this one was 65 beds), we got everything from GSW and stab wounds to psych to MVA's to sore throats - you name it, we got it, and a lot of it! If we missed one GSW, unfortunately (or fortunately, depending on how one looks at it!), there was likely to be another before the shift was done. That's just how it was there. The only thing about that ED was Peds had a separate ED, so I never saw a pediatric pt unless it was a pregnant minor. That was a separate "ED school" which I did not do, but really wish I had. Peds is not separate where I am now, and I feel very ill-prepared for peds trauma or acute illness, still. How is the education dept where you are? Does the ED have a separate educator if it is separate? That person may be best to advise you on your career in the ED. I still consider myself a "new" nurse at 2 1/2 years in the ED. I still ask a LOT of questions and do a lot of reading. I'm glad I entered how I did though, and did not do M/S first. I have done some work per diem after I first licensed in M/S, and will agree with everyone that it is so totally different, that really almost nothing I learned or did on that M/S unit applied to the ED. In fact, every hospital ED I've worked at now (where I am now is the 3rd, and I don't want to move again!!) uses completely different software than the in-pt units. Why I don't know - maybe someone here knows why?? Maybe there just is no good software that can cover both ED and in-pt units or something? In any event, I think whether or not you go to the ICU for experience depends on you and how/what you want to learn, and your facility and their education dept and what they will do for you.

Our catheters have retractable sharps, but then we have a bedside container in each room. I miss those pre-filled flushes! It is a waste of time and resources to fill one for each IV start, to flush IVs, and then for meds if the pt has a saline lock.

Exactly. And the ED is available when it's convenient for them. They can go after work or on weekends when the Dr office is closed. It ticks me off that a good portion of these same people can think far enough ahead to make sure they don't run out of beer or cigarettes, but not when they see they have one b/p pill left. Or that gee whiz, I've had this abd pain on and off for 6 months, but in those 6 months, can't remember to call to set up with a PMD, or even CALL their PMD if they have one, because we all know it will take a couple days to get an appt. And I do like asking pt's that - "So you've had this pain for 6 months and have been here 5 times for it, but haven't called your PMD about it? Why?" Pt: "Because they couldn't get me in."

I understand your point there, M Boswell, which I guess is why most ED's have Fast-Track areas now. It wasn't long ago that these weren't even thought of. Those are definitely non-emergent pts. Like you, I don't mind them coming and being seen there - they know the wait may be longer, but I don't want them taking up my last bed in the Main ED. The big question is if they will pay or not..... It really chaps my rear to hear patients tell me they can't afford their b/p meds/diabetic meds/tylenol for fever or pain, then see the cigarettes (or smell it on them) in the Coach purse, $300 Blackberry with bluetooth in the ear, kids playing PSP in $100 sneakers, hair and nails professionally done....I know we've all seen it. And yes, I've discharged many in w/c and brought them to the parking lot and seen the spouse's luxury SUV with spinner rims and expensive tires. It is all THAT kind of stuff the makes me mad. If you can't afford to pay me, sell that stuff. I do like the idea of evaluating those pts seen in the ED on a frequent basis. I question whether a lot of ours, if time was taken to set them up with a PMD or clinic, would comply. I sometimes think we, because of our new and improved "committment to customer service" are part of the problem. Some docs will tell pts they are using the ED way too much, but most just treat-n-street, no matter how many times the pt comes in. I had one the other day that has been seen over 35 times in 2009 alone in our ED. When will it end??? We have to be part of the solution, and I do agree with the OP article. I'm not doubting the woman in the article was in pain, but if she was evaluated (and I'm sure she probably was), there was nothing wrong with giving her a list of free-clinics or PMD's accepting new patients.

We use the caddies also, though many times I just grab a 10cc flush (though we have to make our own - they haven't figured out yet that the pre-filled flushes are probably more cost and time-effective than grabbing a 10cc syringe, blunt needle and 15cc saline container!), j-loop and pre-packaged IV start kit. I always carry around a 16g, 18g, 2-20g and a 22g with me all day. We are not allowed to leave IV start stuff - mostly just the catheters - in pt rooms since only the trauma rooms have locking cabinets. It is sort of a pain in the butt, but whatever isn't nailed down does tend to walk away. I'd never heard of using an emesis basin. Most times I don't need a chux or washcloth for those that bleed a lot - a good amount of pressure above the catheter placement usually does the trick for me, but have had several "fool" me, and had to change my scrub bottoms for those that bled all down their arm and onto my leg!

I work in a busy ED (aren't they all??!! lol) and we have TV's in the rooms - without remotes, because those just get broken/lost/walk away. I can't tell you how many people I get that get on the call bell and ask me to stand there and change the channel for them (I will do this, if I'm not terribly busy, for the ones hooked up to the monitor and can't reach the TV and don't have a visitor with them). They actually will sit there and go "no, keep changing....wait! I think I like this show ...no keep going. Can you wait for the commercials to be done so I can see what's on this channel?" I would have NO PROBLEM saying "I'm busy, I'm not a TV guide, and I have no idea what stations are on what channel because I don't get a chance to watch TV or in the 6 months I've been here have had a chance to learn them. Besides, you're here because your b/p is out of control. Why don't you watch our hospital network channel on b/p and dietary/lifestyle changes?" If only management wouldn't write us up if we did that!! But I steadfastly REFUSE to sit there and be a channel-changer....I know we're all supposed to be about "customer service" now but I didn't go to school for all those years to do that, and I'll be darned if I'm wasting my NA's time, schooling and hard-working ethic for that either. They're just as busy!

I work in a fairly large ED, and anyone that is coming in with fever and one other flu sx is being tested. Until the result comes back (usually takes about 30-45 min, depending on how busy the lab is since we don't do bedside testing), we have to put the room on contact and droplet precautions. If it comes back at all pos (all positive results are then sent to state lab for H1N1 testing), we have to use our N95 respirators, and the room has to be totally disinfected before the next pt. I think I had two positive for A flu last week, but apparently is wasn't H1N1 after sent to state lab. We are also testing *most* people for flu that come in with r/o strep throat.

You are absolutely right!! I never thought of it this way, but it is so true...

Congratulations!! That is on my list within the next year or two.

Thank you so much for all the great replies. It has really just been eating at me, and I know it shouldn't, but we all know there is always the ONE pt that sticks with us for a while. I forgot to add in my OP that while talking privately with mom and step-dad, the subject of the father of the baby came up, and they asked me if I thought rape charges could be brought against him. I asked how old he was (in my state if the girl is a minor, it is considered consentual sex if the male is less than 4 years older, but I know there are loopholes to that too) and they stated he was 15. The step dad then said something to the effect of "I guess maybe we should have met him before we let her go out with him", to which the mother replied, "Well, I know he lives in such-n-such area with all those nice homes (or something like that) so I *thought* he would come from a nicer family than he obviously does." Again, I was FLOORED. Just astounded. It was all I could not to put my size 7 1/2 right up both of their butts! It never occured to me NOT to talk to my kids about sex and have an open line of communication with them about that, drugs, violence, etc. My whole "sex" talk involved my mom telling me to watch one particular episode of Eight Is Enough (I know, I'm dating myself here! Anyone remember that show??!) because one of the daughters was going through puberty. My mom said "watch this, because this is what you are going through..." When I became a mom, I vowed to never do that to my kids (to my mom's credit, that's how she was raised and it was nothing anyone talked about when I was growing up). When my daughter decided she wanted to go on the pill, she came to me and we made an appt with her MD. At the appt, the Dr. asked if she wanted me in the room while they talked, to which my daugher replied "My mom knows why I'm here and I would like her to stay." The Dr. was sort of surprised, but I told her my daughter and I had spoken at great length about it, and she knew that even on the pill, she promised me she would make her b/f wear a condom for ANY kind of sex. The Dr. said she had never had a teen tell her that before, and was glad to hear that she was well-informed. I do like the idea of that questionnaire. I think if anything, it will make them stop and think, which they tend not to do a lot of if they can help it. I did let my children participate in sex education in the schools, but went to the Parent NIght prior to it to know what was going to be taught. Honestly, it was stuff my kids knew by that point anyway. My boys knew all about menstruation long before the 5th grade, having seen tampons or pads advertised or in the house and asked what they were for. Not that they didn't giggle and do the "ewwww, gross!" thing, but they knew and never were embarrassed about asking. But if I remember correctly, they even stated at the Parent Night that the information they taught MUST be backed up at home with opportunity for the child to talk to the parent after taking the classes. Given the very few parents that showed up (probably only 5-10% of the parents), I'm sure all of that didn't happen with most of the kids. Thanks again for the replies. That pt did "hit home" again when I was triaging another pt yesterday, 21F, that said she "might" be preg "again". She wasn't, but having to triage her as a "G3, P2" for a 21F was sad and disturbing to me.

What a week this has been! I have had so many interesting patients - you know the ones that just stick with you? The other day mom brings in 13yo daughter b/c ongoing n/v for 3 weeks, states she thinks her daughter is pregnant. She was. It just broke my heart. I'm a mom of one teenage daughter and 3 teenage boys and right from an early age, have always been very open about sex, masturbation, birth control, abstinence, puberty - all of it. They can, and do, ask me whatever they want. I'm certainly not naive, and know I'm not the norm (my ex-h won't even say the word "member", nevermind talk to the kids about sex!), but what really chapped my rear about this pt and her family, was when mom and step-dad wanted to talk to me privately. They wanted to know if *I* knew what schools were teaching girls about sex and pregnancy. I was admittedly a bit confused, as I'm an ER RN, and know nothing about their school. I asked them if their daughter knew about sex and birth control, etc. I was just shocked to hear from them that they didn't know, because THEY had never talked to her about it because sex education is "EDUCATION", it needs to be taught IN THE SCHOOL and NOT at home, and because of all the "new teenage sex stuff", the school is "better equipped" to teach it. They were blaming the school and educators for their daughters pregnancy and even mentioned the "sue" word a couple times. UGH!! After a 10 minute conversation with this very nice, suburban, two-income, two-kids couple, I was just shaking my head at THEIR stupidity! I know we all get pt's every day that make us take pause and think "did that person REALLY think/do/say that???" but with all the access to EVERYTHING sexual -music, movies, internet, "sexting", drugs, you name it - I just cannot believe that they have never, ever, ever spoken to either of their kids about sex and expect the school to do it because "we pay our taxes for them to teach them what they need to know in the world". Whose to say if the girl wouldn't have gotten pregnant with or without parental teaching, but at least she would have had a fighting chance. Thanks for letting me vent! This has been bugging me all week.

I hope your interview went well! Good luck to you Sleepless! Let us know how your interview goes.

Our Urgent Care is attached to our main ED also, and we regularly get those that must be transferred (just a w/c ride away) to us. I wish we could do the same thing, but unfortunately, no downgrading in triage. We get a LOT of pt's that say the magic words "chest pain" and when I assess them, it's "oh, I really don't have c/p, just am nauseated and have a sore throat, and oh yeah, I need a refill on my Percocet". It makes it so difficult on triage nurses. Just this week I've had 3 pt's that came in Level 4, who are usually quickly d/c'd, that ended up being admitted for something severe, and more than twice that in Level 2 that were in and d/c'd within 20 minutes. One was almost admitted with GI bleed because of black diarrhea, guiac was negative though. It wasn't until pt told me she had taken Pepto-Bismol the night before that we called off the CT and admitting doc. That was something the pt hadn't told the triage RN, and obviously the pt was unaware the s/e of bismuth. We hear that a lot also - that pt's went to Urgent Care or Fast Track because they didn't want to wait for the regular ED, but they really do belong in the main ED.

I would not like having such a policy, but would follow it if we did. It does seem very time consuming to have to escort ALL pt's to their car (and what if they are waiting for the bus? Do you have to wait with them until the bus comes??). I know our facility just does not have enough RN's or tech's to do that. I am one to use a w/c for all pt's that have had narcotics or are a fall risk of any sort, but to use a w/c for a pt that came in for a small lac repair or got an RX for a sore throat seems like a waste of time and resources.