NO50FRANNY

I am keenly following this thread and dying to know how you went. Will be starting my path to American license soon. Fingers crossed for you ?

My stoooopid triage shift yesterday..... (people usually cry if I'm at triage) oooh, and everyone wanted to play my least favourite game, kick the triage nurse. Someone rolled away the big rock from the cave and all those intellectually challenged, lonely and downright sooky patients ran really fast to my ER. 1) "Strong personality" nurse in charge of acute (sociopath) sends the co-ordinator to have a word with me about assigning a CAT 5 (2hrs) to a F/F intoxicated patient. "He was hypotensive at 90" tut tut. That's why I went to great pains to include in his comments, and assessment that he has a history of postural hypotension, 90 is good for him. Pt self discharges 1.5 hours later. 2) Oh please, oh please, no more man flu. Well, even just young person flu. Not only do you not need to be in my Emergency Department, you don't even need to see a doctor. I can't be sympathetic, I'm sorry, but there really is no excuse, go away from my sick, immunocompromised patients. 3) Young man and his girlfriend both state they have central tenderness when I palpate their c-spines post a VERY low speed MVA. They think they will get seen quicker by saying this.... Enjoy your rigid collars suckers! And the extra 3 hours you will be here waiting for CT, hahahaha. Oh and the punitive radiation. I intensely dislike liars. 4) It was also the day of symptoms present for a very short period of time, here are a few triages word for word: "30 mins urinary symptoms", "1/24 generalised abdo pain, now resolved", "2 x vomits this am". For god's sake people, could you not have just waited a bit to see if you got better? And why oh why did you call an ambulance. 5) 25 year old male, dressed in athletic type gear, "I think I have a flu / chest infection". Oh ok, what symptoms have you been having? "Well, when I played tennis this morning I was really tired by the 4th set". I'm not kidding. 6) 27 year old male, a little bit posh- "I've had this rash for a few days" May I have a look? "That's not a rash mate that's ringworm". Pt "I, do not have ringworm", "Yes, you do, I can tell you which cream to get at the pharmacy". "I don't have ringworm, I want to see a doctor". No worries, enjoy the wait. Is at the desk 15 minutes later asking what the hold up is and when will he be seen. 7) Morbidly obese, 19 years old with mum doing ALL the talking. After an elaborate explanation I have deduced that she was swinging on a swing in a children's playground and it collapsed under her 130 odd kilos injuring her ankle. "My daughter has a very high tolerance for pain". Yeah, ok, not real bright though huh?. Stooopid.

It really comes down to basics for me on this one, too easy. I love looking after sick people and making them feel better. I dislike not being able to look after sick people properly, sometimes not having the time to make them feel better, and all the elements that conspire to cause this which are usually- a) people who aren't sick, b) people in very high places who won't staff / resource us appropriately.

Having time to chat with our patients is a luxury most Emergency nurses are rarely afforded. I was Fast Track boss today with my hopelessly hungover and partied out colleague on a very civilised Boxing day morning shift. My Registrar asked me to remove a bellovac drain for a lady 2/52 post L) mastectomy as the breast clinic is closed over Christmas. This lovely, softly spoken lady started with apologising for "taking up an emergency bed". I started our interaction with "not at all, you must be dying to get this drain out" and it was as if I had opened a little door for her to tell me how she was feeling. She explained that she felt "brutalised" and had been totally unprepared for her emotional response to her surgery. She went on to tell me that she was having trouble staying positive, felt that she should just be thankful that the cancer was gone, that she was tearful and her mood was low. I said "but you're grieving, it's going to take some time, this is a huge operation and you are allowed to feel sad about this". It was as if I had turned on a light, she hadn't thought of it this way. I asked her if she drank, then told her to buy herself a bottle of champagne and park herself on the couch with a good movie and revel in a little pity party. We talked about gardening (she looked like a gardner) and I suggested seed raising while she was recovering, I made fun of myself, made her laugh. After the drain was removed I walked her to the door and slipped a few dressings in her bag, she said "you were just the morale boost I needed, thankyou". What a pleasure!. I love that every now and then we get to make someone feel better, not just clinical all the time. I felt truly validated today after looking after this lady.Tell me about your favourite Christmas patients!

We have a young guy who will let his calcium levels drop so low that he gets obvious carpal / generalised tetany. We suspect he just doesn't take his medication then comes in when he's in trouble. He has a port and will generally refuse a cannula. He has been visiting a little too often, and the concern is that he will die by misadventure if this continues. One of my most senior physicians was working in resus the other night when I triaged him and interestingly has not met him before. This is how she handled the situation. PT-"I'm not having an IV put in, I have a port." DOC-"I'm not waiting for someone to access that, I'm putting one in now sweetheart because I don't want your heart to stop, please give me your arm". PT- "I'm in so much pain, can you please give me some fentanyl? I don't want to wait for the blood tests it could take forever" DOC- "I'm going to run a blood gas, which takes 90 seconds, then give you some calcium, your pain should ease almost instantly, I will not be giving you fentanyl". She later went in, called him on his behaviour, and offered him some help. She showed the utmost compassion, and explained that her biggest concern was that one day he would die trying / that we wouldn't be able to correct it in time before he arrested. Haven't seen him since.

Oh, I almost forgot. Rigid C-spine collars on any patient over 85. Just, don't. I will take it off.

Honestly the list of things that irritate me on a daily, if not hourly basis are endless.... here are but a few. - I too, DESPISE the carry on with regard to insertion of an IV. It's 10 seconds of your life. I understand your apprehension if you have been butchered before, but it was not me. These days I say "you have two choices, I will do it for you now and I am very, very good at it, you will be my 28th today. Or, you can wait for the junior doctor to come and have a go". -I want to know why people think that saying they are "dizzy" changes anything when they clearly are not. -I want to ask a patient who has been investigated up the wazoo for their mild, non-specific belly pain thinks we can possibly do for them at 2am on a Sunday. -Sleazy, needy, useless, smelly, multiply diseased, personality challenged men who come to see the pretty nurses and be waited on. -General practitioners who send patients who are clearly DYING by private transport to languish while waiting to be triaged and treated but send a UTI in an ambulance. I will never, ever, understand this. -Chief complaint- "Cramping lower abdo pain and PV bleeding, last menstruation 4/52 ago". Given narcotics by paramedics, 22yrs old, with mum saying "oh, but it's never been this bad before." Yep sweetheart, you have your period, again. -"My blood pressure is 160/90, I've checked it at least 6 times today". Please, stop taking your blood pressure, have a wine and watch a movie. -Self righteous piffle that the occasional nurse feels the need to verbalise about patients rights and so on. My colleagues are largely very ethical and caring people and when you make comments like "the patient has a right to compassionate and unbiased care" it makes me VERY cranky. Especially after he has punched a half dozen of us while trying to provide him with said care. Keep it to yourself, no-one likes you. You look after him. -Lastly- a shout out to one of our new interns. Mate, you walked all the way from bed 15 to interrupt me, while I was on the phone, to ask me to do vital signs on a patient you have been assessing for 15 minutes. When I asked you very politely if you would mind doing it as it is plainly obvious we are getting slammed you were not clever or wise enough to smile and say yes. In fact, in a round about way you said no. You, are going to have a tough 8 weeks.

It was a rough day.

On my last day of work in my oncology ward many, many years ago one of the greatest pranks ever executed occurred. I was in charge of the shift and when I walked into the handover room and saw the board I couldn't believe it. On our bedlist of 25 patients, every single painful, demanding. difficult and well known patient that we had periodically cared for over my four years was there. The night staff had stuffed the beds with pillows, loaded up urinary catheter bags with tea, attached O2 to pillows and so on, to created the illusion that there were actually patients in the beds. They had done some pretty elaborate stuff and deadpanned a whole 45 minute handover with their admission details. Myself and my second in charge actually had a break BEFORE facing the shift and worked out a game plan. It was only after I went to check the 2nd patient, and 3rd that I realised. We only had 11 patients in the ward. Never forgotten it.

I have an answer for you but I don't know how helpful it will be. In our department we kill them with kindness. Food is not something we will often dish out regardless, but when being snarled at with the ever so common "she hasn't eaten since yesterday, and we've been here for hours!" (that's our fault of course) most of my colleagues and I will respond as sweet as pie... "Oh, I know how frustrating that is, I will check with the doctor for you and I'm sure we have some snack packs in the fridge but if it is going to impede or delay treatment we need to be very careful." We once had a patient who called an ambulance and was transported from an engagement party, a well-to-do insulin dependant diabetic. The hospital was close to the party and he figured we would give him some insulin so he could go back and party. After being sat in our corridor with our Saturday night friends for an hour he found his own way home. People disgust me. The best advice I can give is to be as nice and accommodating as possible within reason, it's hard to do, but wasting your energy on it is even harder. I had a patient at triage present saying "I just need a dressing for my leg". I looked at it, she did indeed need a dressing, nothing more. She was rude, dismissive etc. I just gave it to her, wasn't worth the effort of triaging, arguing and so on, the end result would have been the same. I behaved like an ATM though, emotionless. For me, I feel like if I deny undeserving patients my good energy, I save it for the ones who do. They may get a lunch pack, or see a doctor for the pimple they've had for two years, but they didn't get my good stuff, I save that for the sick people. Knowing that gets me through. For the record, I have a little fight every now and then, just to make myself feel better, the rest of the time I let it go and think about all the time I've saved. Nonsense presentations drive me up the wall and I also have trouble after many years, I just vent to my colleagues, and keep my small victories.

Can relate- I kid you not, we had a resus patient just yesterday who had some sort of catastrophic cerebral event at home. Our senior physician was deciding whether to intubate prior to CT given that we suspected heroic measures would be futile. Senior Doc, a man I have worked with for many years, after being asked what drugs he would like for RSI, says, "I think I'd just like some sux Franny..." We recently changed our primary induction agent to rocuronium but I usually ask. "No worries doctor, I can organise that for you". The patient's son was looking at us oddly but I didn't realise why until hours later. I think they should use roc just because it sounds cooler, also, it appears it would save some confusion.

A few years ago, early evening, I discharged myself from my hospital in the city following an umbilical hernia repair that morning. I was adamant that my pain could be managed at home with oral analgesia and was determined to be at my mothers' place and not burden the ward with my presence any longer than absolutely necessary. The charge nurse tried to talk me out of it, but I did it anyway - mum dutifully drove me the 3 hours back to her place. It was a very foolish thing to do and around 2am I was battling. At the time, I was an oncology nurse and had no idea how I was about to be perceived by the staff at the regional hospital ER. I knew I needed narcotics, so mum took me to the local hospital. I was lucky my physiological signs reflected the pain I was in and I'm fairly certain if I didn't have a surgical wound I wouldn't have been given anything. It was only many years later, after becoming an ER nurse and dealing with rubbish for 7 years that I understand the appalling attitude I was subjected to, I won't go into it but it wasn't pleasant. At the time I didn't realise that all the things I was saying made everything worse. I was from out of town, I told them that pethidine IM had worked really well post op, I told them that I had taken tylenol, digesic and tramadol and nothing had worked... I was distressed because I had put up with the pain for so long and it would have looked like I had an enabling mother. She was getting angry because the nurses were ignoring me- I needed a pan, I couldn't get off the trolley, I was crying and my bladder was full (after 2 stat bags of saline). Possibly the most humiliating experience of my life. I filled that pan... I know my fellow ER nurses reading this are cringeing.... What makes me so sad, is that I know why ER nurses can become unkind, why so often I hear stories like the OP. The malingerers and non-genuine patients, crippled, understaffed, overcrowded and overrun Emergency departments, tiresome complaints that are truly non-urgent, flagrant abuse of EMERGENCY services. People complaining to you about how long they've waited with a minor complaint not seconds after you and your team have given up resuscitating someone. It upsets me that genuine patients become the victims and I agree that there is absolutely no excuse for rudeness and poor attitude, but sledging ER nurses isn't going to fix it. I've watched some of the most caring and devoted nurses lose their cool with patients on occasion and assigning blame doesn't get us anywhere. You did well not to lose your cool, I didn't lose mine completely thanks to some IV MS04 but I've never forgotten that night. Give appropriate feedback to the facility, and vent on AN- I wish I had. Hope your hubby is ok :)

I can imagine it is difficult for a lot of nurses to get their "foot in the door" and I know nurses are always knocking the door down to get a job in my department. I would say apply even if you don't have all the qualifications expected to any advertised position. I applied for an ER position when I was still a new grad, and was so excited, emergency nursing was my goal, but I had only worked as an agency nurse for six months, mostly in aged care facilities (not exactly what they were looking for). I was new to applying for nursing jobs and didn't realise they wanted someone who had a couple of years' experience. I answered all the selection criteria in the position profile and was offered an interview based upon my experience mostly in unrelated employment. Although I didn't get the position, the powers that be met and liked me, and offered me part time work on one of their medical / surgical wards to "train me up" with a view to moving to the ER after six months. I didn't take them up on the offer as I was offered a full time position elsewhere but fast forward 10 years working in Haematology / Oncology, I was routinely (once or twice a week, night shift) working casual / agency shifts in the ER in my citys' level 1 trauma centre. After a month or so, various charge nurses encouraged me to apply for a position. They knew how I worked and felt that I would be a good fit. Took the plunge and six years on, best decision I could have made. I guess the point I am making is advertise yourself. If the managers and other long term staff have worked with you it helps get your foot in the door. I couldn't even read a monitor and they hounded me for weeks before I applied. Get to know them so they remember you, could help down the track- Maybe just ask the senior staff the best way to approach it. Best of luck.

My favourite "shocking" pardon the pun.... Very sick looking 40 yr old gentleman walks up to the triage desk, sweating profusely, white as a ghost. "I feel like I am going to pass out". Patient is breathless, "do you have any significant medical history sir?" "I had an unexplained VF arrest about six months ago". Patient then promptly collapses. Yep, VF arrest, zapped and got him back, again. EEEK. Triage= Collapse, CPR in progress....

I too love reflecting on how things used to be and I've watched the steady deterioration of holistic nursing care and the subsequent role of "nursing" becoming a rapid, task orientated one, a push for maximum efficiency / turnover and minimal contact with patients. Gone are the days of having time to move beyond clinical duties and maybe read to the blind elderly man, provide valuable and empowering education or chat with your colleagues. I am saddened that the powers that be will never appreciate the value of nurses having TIME to actually LOOK AFTER people. The patient who feels as if they were well cared for does not go home anxious, is well educated about discharge/preventative care and does not need to be re-admitted because they were pushed out the door. Injury and illness prevention will be a thing of the past as there is no short term vote winning financial benefit, already in my neck of the woods, vital community sexual health clinics and other services are being dismembered. Having the time to genuinely care for a sick person of course can't be quantified and these days it seems to only be about numbers and of course, money. Believe it or not, with the new "physician frontloading" system in my ER, a written nursing assessment has become almost obsolete. I would say that about 60% of the time the intern sees the patient the minute they arrive, so a "nursing assessment" has become "refer to medical officer notes". I believe nursing workload will increase at the expense of autonomous practice as our litigation focussed / instant gratification / entitled society demands specialist input for minor issues. We will not be able to assess a wound and select an appropriate dressing, we will follow a strict pathway for everything right down to how to wash someone with appropriate boxes to tick. I think nursing judgement will all but be removed from day to day patient care. Fortunately, I also believe that those of us who love nursing will perhaps figure out a way to bring things full circle. Hmmm, now I will try and think of something more positive to write!