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.