brainkandy87

Funny/sad story.. We had one of our regular homeless come in quite a lot recently (a lot even for him), for stuff like back pain, knee pain, a fall, etc. It was so excessive, I wanted to explode. One day, I see he had arrived once again by EMS, to our main trauma room. I laughed and couldn't believe he was taking up our trauma room. And then I walked in and saw a man who was having a STEMI and AAA rupture. Every once in a while you have to get put in your place. Even though they use and abuse you, every now and then they actually are sick, so you must always treat them as such.

In T-system, we have an entire page that we can pull up to put in an infinite amount of information about EMS and their report, ranging from IV site and meds given to detailed information about a 12 lead. I rarely do anything more than the IV site, blood draw, and meds, but it is nice to have in case you have a very critical pt brought in by EMS to have the PTA picture on your charting.

Level 3, 20 bed main ER, 10 bed fast track. We have a nurse-patient ratio of 4:1. Typically we have 1-2 float nurses/medics (3 on a fully staffed midshift) and 1 am tech, 1 mid tech, 1 pm tech, along with a free charge nurse. If needed, we have lab techs available to come draw blood (and they have to be present for t&s and codes). If we are extremely busy, we can call a code purple, which means that the floors have to come transport their own admits and radiology transports all of the pts for scans and films.

The patient dictating to me their course of care and what I'm going to do. Sorry, no. You are in my bed, in my room, under my care. You are here because you need me to take care of you. Emphasis on the need me part. I don't need you bossing me around. You do, however, need me fixing whatever is wrong with you.

On Monday, Krispy Kreme gave us donuts all day! That rocked the casbah, to say the least. Today we had catering from all around town and had the "Scrubby" awards. In the words of Nurse Jackie.. only the overworked and underpaid have a week devoted to them. However, I quite enjoy it. :)

This is an endlessly discussed topic. My opinion is that it depends on the new grad. A motivated, teachable new grad can succeed anywhere, just like a lazy, hard-headed new grad can fail anywhere.

This whole situation just blows my brains out. Does your facility not let RN's do EJ's and/or US PIV's independently (our ER docs "check" us off on skills such as EJ, US, etc)? I love my ER docs and the great procedures they do, but I'd never want a doc to put in a PIV over a nurse. How often do they do PIV's compared to us? But I do know every facility is different with policy concerning RN's and EJ's. I think you might've avoided a lot of the yelling had you not trendelenburg'd her until he was walking in the door (it doesn't take that long for those veins to distend once the head is dropped) and you would've had a lot less worry about her BP. Anyway, it happens. Docs get mad and yell, even the nice ones. No matter how many years you do this, you'll always end up doing something that makes you feel stupid. We are just human. :)

This. A simple way to explain it to someone who's not having a life threatening emergency is that we are here to make them feel better and their PCP is there to cure them.

Erowid This is a site really meant for people who do drugs, but I think it's a terrific resource for education about drugs. Personally, I think people who do drugs are a far more reliable source on the effects of drugs than most other sources available to us.

Actually, let me correct what I said.. they are 1200 ml/hr. I had to grab one to double check it. For some reason I had it halved in my brain. My bad! Anywho.. 600.. 1200.. my thoughts on 24 gauges on adults remain the same.

24g angiocaths, that is.

Our angiocaths state 600 ml/hr on the packaging.

Sure, there are definitely varying degrees of trauma and yes, pretty much anything you can do in an 18 you can do in a 20 (however, I don't think a 22 should be put in any trauma pt, I don't care how negligible of a different the flow rate is). Everyone has their own way of doing things. Nursing is a very objective profession, yet it is even more subjective, IMO. I worked with a CRNI that wouldn't put anything bigger than a 24g in an adult and wouldn't put it anywhere other than the hand. She provided evidence and research for what she was doing, but there are a lot of variables and intangibles that come into play in nursing that research can't cover. Is the evidence there that says putting a 24g in an adult with no issues with venous access is acceptable? Sure. A 24g angiocath can hold 600 ml/hr. However, I think the majority of nurses with any experience at all would find it laughable that a nurse is putting in a 24g IV into an adult that is not a difficult stick. We just naturally "know" that's not the IV that should be placed. Anyway, to each his (or her) own, I guess. I'll stick with my trusty 18's. They haven't failed me yet. :)

Maybe the 15 minute wait was due to shuffling. We have hall beds in our ER that get used when we are totally full (as was the case tonight). However, I'd rather have a pt hang out in triage/waiting room for 10 minutes while I move someone non-emergent from a room to a hall bed instead of putting an emergent pt in a hall bed immediately. My rationale is that it's much more unsafe to put an emergent pt in the hall where you don't have a monitor or supplies. I'll hold that pt for ten minutes while I shuffle a non-emergent out. Who knows, maybe that was the case. Like I said.. lots of variables we don't know.

I think Stargazer said it best: triage is an extremely subjective area. One man's emergency is another man's, well, non-emergency. There's a lot of variables we don't know.. the experience of both nurses, the other patients in the waiting room, what was going on in the ER at the time, your father's presentation, and so on. Don't take it as the ER not taking your father's complaint seriously. Fifteen minutes is not a long wait at all and at a high level ER, this would actually be considered a short wait time. Sometimes when you're the patient or with a patient, it's hard to step back and look at the big picture of the ER. Yes, you might be worried and yes, it might be an urgent problem that should be addressed by the ER, but as always, emergent complaints take priority. Hope your Dad is ok though.

Well if you want to look at the numbers, you can put 600 ml/hr through a 24g. Does that mean we put 24g's in every pt that isn't going to be getting rapid infusion? Nope. Hell, most ER nurses would slap someone for putting in a 24g IV on any adult. Do 22g IV's serve a purpose? Absolutely. They're great for peds and LOL's that just need something to push meds. Personally, I have a standard of care that is consistent for everyone, trauma or not, that they always get an 18-20g IV. I don't mess around putting 22g's in people because "it hurts less." A needle is a needle. Now, considering we are talking trauma patients, yes, everyone gets an 18g IV. Heck, TNCC teaches you to put in two large bore IV's on trauma pts. You can never, ever go wrong with an 18g IV. I'm more of the thought that I'd rather overprepare than underprepare. If you overprepare, you have your crap ready when it hits the fan. If you underprepare, you end up screwed every time. By putting in an 18g IV on EVERY trauma pt, I don't have to worry about needing a bigger IV if and when someone takes a sudden turn for the worse. I've been in that situation where I didn't plan ahead and put a 22g in someone. Guess what? I screwed myself.

I use the term "throwing" loosely. Absolutely if you don't see a vein you can access in a couple of attempts, it's IO time. I'm not implying you should stick and stick and stick. IO is definitely a viable option if you need an immediate line and don't have anything else that can be easily accessed.

You page the MD and get your co-workers to help you. I don't care what they are doing. If someone is circling the drain, you go grab someone. If they feel inconvenienced, too bad. That patient's life is priority. I doubt they were all doing something more important than that. Never, EVER feel bad about pulling other nurses in to help when you've got a critical patient that's going down. You're absolutely right, you don't want people dying on your watch. First of all, my priority would be getting a second line in her, an 18g at the very least. 22g angiocaths are for babies. I've never seen an adult that couldn't get at least a 20g somewhere in their body. You go for an EJ or use ultrasound to find a vein (this is why all ER nurses should be trained to use US). If nothing else, throw a 20g in their foot until a central line can be placed by the MD. When that pt crashes and all you have is a 22g, you're going to have one gigantic mess. In your situation, I would've called RT to assess (and draw an ABG if not already done) and worked on getting a large bore IV in her while you had another nurse find the MD to come assess.

You should buy this and always have it on you. Learn to read EKG's and telemetry. There's a plethora of books/guides out there for EKG's. You absolutely must must MUST know your cardiac rhythms in ER. Download Medscape and Epocrates for your phone. If you don't have a smartphone, get one. Those two apps, both free, will make your life a lot easier. Watch how good nurses do things. If you don't understand what they're doing ask them. Never stop asking questions.

If all you are is an adrenaline junkie (or as they are known in the ER: trauma junkies), don't even bother trying to be an ER nurse. The best ER nurses I know all share common traits and their best traits aren't their addiction to trauma. Yes, they all love the crazy traumas and jumping in head first. However, what sets these ER nurses apart from the rest of the trauma junkies is that they love to use their brain. They love to learn and apply what they've learned. They love to be presented with a riddle of a patient and use reasoning, whether it's deductive or inductive, to solve that riddle. It's nice to have a trauma junkie who isn't afraid to jump in head first, but it's better to have someone who thinks about how deep the water is before jumping in head first. If you can be more than just a trauma junkie, absolutely go for it. It's an incredible experience every day.

I started in ER with only BLS and ACLS and I did okay, but I learned as much as I could from other nurses. So by the time TNCC rolled around, I already knew most of what was covered, e.g. spinal cord injuries and precuations, shock, et al. I used to think you should work in the ER for about six months before taking TNCC, but my opinion of that has changed greatly. I honestly think TNCC should be something that is obtained as soon as possible in the ER, as I see a LOT of inexperienced nurses not doing basic things like c-collar for a neck injury or not adequately monitoring pressures for a pt in shock or not infusing fluids as they should be on trauma pts or putting in 22g IV's (I took over an SCI pt the other day that had a 24g IV only) or blah blah. I have just grown to be anal, because I've seen some nurses do things that just scare the crap out of me and I don't want patients dying or having poor outcomes because we didn't do things the right way. Anywho, sorry to deviate from the original topic. Hope you join the ER crew! It's always a fun place to work.

I love T-system. Welcome to the ER. Always remember to stop and take a breath. If you don't breathe, you'll drown. It's a stupid analogy, but it's true. As far as triage needing to be done right away... that's a big negative, in my opinion. Getting the patient stabilized is priority, not charting. That's not to say you should put off charting for hours, I'm just saying that when you get an EMS pt that is kind of a mess (especially when you're slammed in other rooms), that triage screen can wait until you've got your line, blood, etc. You are definitely right in wanting to get your basic stuff done to get things cooking before trying to chart. Being a charge nurse in step down for 6.5 years will definitely be valuable experience for the ER. Hope you enjoy it!

Is this homework? And I strongly suggest a drug handbook or an app such as Medscape or Epocrates that allows you to look up drugs including administration, pharmacology, et al. You won't always have AN.com handy to ask what's what. In a nutshell: benadryl IV does the same stuff benadryl PO does, except much faster. It can be used for anything from an allergic reaction to anxiety to abdominal pain. It should be diluted and never be pushed any other way than slow (25 mg/min max).

We share a similar story. I hated floor nursing... seeing the same patients for several nights in a row, doing a lot of repetitive tasks, etc. However, seeing that variety of cardiac patients and learning to read tele as a necessity of my job.. so invaluable. I work with a lot of very good ER nurses who have never worked anything but ER and they struggle with tele. As boring as I find floor nursing, I'm a much better ER nurse because of it.

I ask them: What's your pain, 0-10? Zero is no pain at all, ten is you're about to die. If they say "twelve" or something that's not 0-10, I tell them I need a number 0-10. I can be such a richardhead sometimes. *shrug*