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There's two very important details that everyone is leaving out: 1 - The ER I'm from is divided into two areas of care. I don't know if many or most ER's are setup like ours, but we have a quickcare sectioned off from the rest of the ER. Esentially, it's a 12-bed area that's open from 0800 to 0100 and staffed by one or two mid-levels, depending on time of day, and 2-3 RN's and secretary. It's really like two ER's in one. People get infuriated when they have to wait, but quickcare CAN NOT see clients that are in need to true emergency care. If you have stable vitals and stubbed your toe and there is an open bed on quickcare, then yes...you will go back to a bed prior to the sicker patients. It was setup because people routinely have and always will use the ER as a PCP. However, it also encourages that BAD BAD behavior of skipping by the Dr. office in favor of the ER. Since it is QUICKcare, clients are really moved through there quickly. By definition, client should not require more than one resource (i.e., labs but not xray, xray but not labs, meds and neither xray or labs). People in the lobby who don't understand that get upset...understandable. Be mad at the people using the ER as a PCP...not me. 2 - it's pretty rare to hold admissions in the ER. Usually, the floors and ICU's are excellent about doing what they have to do to get clients moved. On the occassion that we do hold clients and they get nasty, I simply ask them: "what is different about being on the floor versus being here?" I explain that I am a RN, just like who would be watching over them upstairs, there is a physician here, UNlike upstairs. We will get a regular bed from upstairs to make them comfortable...any medication they need to recieve, I can give them. The ONLY thing that's different about here versus there is the setting. Different colored walls and a little less space. We can pull the curtain and turn the lights off and they can be just as comfortable in the ER as they are upstairs. Once that's explained, they usually see it my way because it's true. I don't like holding clients...it is frustrating for me, but it is more frustrating for them. Late, Trav

No worries! You're not a hypocrite. A lot of nurses have fear of going under the knife! That's perfectly normal.

I'm in triage now and this 20-ish y/o lady walks in, says "ya'ah'teh" (Navajo for hello) and shakes my hand. She lays a package of the large tissue/wrapping paper for making backgrounds on big bulletin boards down on the desk and says "this is to decorate your bulletin boards. I wanted to bring this to you and say thank you because you all have helped me so much here." I thanked her and before I could get her name, she turned around and walked out the door. It is an odd gift, but when you think about it, in a place where every hallway is lined wall-to-wall with bulletin boards and pictures and whatnot....probably one of the MOST thoughtful gifts someone could bring. Plus just the whole principle of the thought. Made my night!!

I was in a situation several years ago where I was convinced I had started an A-line on a young guy. He was ~18 y/o muscular, fit guy, in ER for intense abd pain and being a little....shall we say dramatic. Either way, tensing abd muscles, or rather tensing muscles all over. Elevated BP (2º pain or drama - I couldn't tell) and tensing all his muscles, he was able to produce a pulsating venous return. Mind you it wasn't very forceful, but it was certainly pulsating and it was certainly a vein (since I D/C'ed mine thinking I had hit artery)....another person stuck a different vein with same results. It's not something you'd routinely see, but it happens.

It's pretty unanimous nationwide that the court will require her to complete alcohol safety awareness program. That's a big part of the money-pit. I still maintain that the BON would MUCH rather make you jump through a few extra hoops so they can stick a couple hundred dollars in their pocket....

"PLENTY of nurses who DON'T choose to put their lives the lives of countless innocent individuals in harms way may be more deserving of a job than those with a history with the judicial system =( " I suppose no one on this forum has EVER picked up a cell phone while driving. Or did their makeup in the mirror going down the road (which my mom use to do ALL the time...and for all I know, still does)....or had an argument with the husband/wife or kids. Or drove while sleepy. All those things are a wanton disregard for human life on the road driving that big 2-ton missile.... On another note, I know and am friends with a man who has been a RN for ~10 yrs and has (as he told me after he was more than a little drunk) 3 or 4 convictions for assault, not one but TWO DUI's and has served some prison time for said convictions. Did he retain his license...yep. Has he ever been denied employment based on prior criminal record...nope. There are people out there FAR WORSE than the OP that maintain nursing licenses. If you can be convicted of narcotic diversion and prescription forgery AS A RN and still maintain your license, I'd say the OP's transgressions against our sensitivities here are rather slight.

Fact of the matter is, MOST sources will say 3 mL for large muscles, 2 mL for peds VL injections. But the fact of the matter is that there hasn't been much true research on what is an acceptable volume to administer IM. We give clindamycin 600mg IM frequently for dental complains in the ER. That's a 4 mL total volume...and if the person is very large and they request to, I have given 4mL injections several times. A lot of texts will say that "general consensus" is to limit volume to 3 mL in adults, 2 mL in children and if the patient is very small, 1 mL. You won't find much supportive, evidence-based practice proving or disproving that these are acceptable volumes, though.

I have been a traveler since March '11...and on one level HATE IT!! Houston, TX was SCARY because NONE of the docs there trusted any of the nurses...especially travelers. "Hey doc, this kid has a GCS of 7 after the meds you ordered....should we consider intubation because I think we might should consider it." Doc: "yeah ok....whatever you think." "Doc, this kid has a fever of 103.8, can I give him some Tylenol....say 15 mg/kg." Doc: "Well....let's do like 30....umm....45 mg/kg." SCARY!!! Here in lovely Kayenta, AZ, where the docs are 100% locums....are either 100% FOR the nurses or 100% against us. It blows my mind. Client is on LSB - log-roll client to assess spine. Client has tenderness so LSB needs to remain. Straps are D/C'ed and doc says "well, we might as well D/C the LSB without the straps on him." Me: "ok, so are you saying we should put the straps back on?" Doc: "well, the LSB won't do him any good if the straps aren't on." Me: "so are you trying to say that you want me to put the straps back on?" Doc: "he needs the LSB" me: "ok, so I guess you are saying that you want the straps on so I'll put the straps back on." PFT! PLEASE ******* The point to all of this is just saying that the hospital I came from was SO WONDERFUL and it was 100% because of the physicians. They were wonderful awesome people. They would come in and defend "my nurse" because a patient was acting out. It was AMAZING! These guys were absolutely the best doctors any nurse could ever hope to work for. After working with them a while, you could kind of gauge what kind of work-up would be ordered. They complemented us, occasionally asked for advice from us (despite them ALL being brilliant) and had respect for all of us as healthcare professionals. Their view was that "we are a team and a family and our common goal was caring for the client." I have yet to ever work with a more cohesive group of people. If we were wrong in what we did, we were respectfully informed and when we were right and worked well, we were told. "Good work guys...you all did exactly the right thing!" AMAZING physicians!! It's a very symbiotic relationship, which is not so easy to come by, as I've discovered.

If your patient was an adult, they were a WEENIE. The vastus lateralis and dorsal gluteal muscles on a normally sized adult can handle 3 mL (irritating med or not) with no trouble. If I remember correctly, 1.5 mL is max for deltoid. Peds is different. For pediatric patients, 2 mL is the max in the VL. If over age 2, then 2 mL in DG is ok, even though I never do it because I HATE giving DG injections. Don't even think about delt on little ones, unless it's a tetorifice vaccine. I give 3 mL doses ALL THE TIME in DG (and VL on patients that I can talk into it). P.S. what med did you give??

At our facility, the big push for Magnet status has been well underway for a couple years. The dear people in HR even made a position for our "Magnet status consultant". At any rate, I feel certain that this has something to do with what our hospital calls CAP (clinical achievement program). It's just another name for the same thing. What's really astounding is that for each advance in your CAP level, your pay rate increases by $1/hr. CAP I and II are such a piece of cake. It's more along the lines of sitting down and forming a very elegant, fancy resume with some staff education and community service. You also recieve a $0.50 to $1 /hr raise for any certifications (CEN, CCRN, CRRN, etc.) With that said, the difference in pay between ADN and BSN is a massive $0.30/hr. YEAH!! Totally the hottness! LOL. Then again, greater education isn't only for financial gain - it should be more for personal satisfaction. I don't know exactly how HR correlates experience with pay rates, though. I would imagine that it's somewhere around $0.50 / yr of experience. Maybe not that much. Having been a RN for 6.5 yrs, I definitely would like to make more money. However, it would REALLY irritate me to think that I had been working as a bedside RN since dirt was invented and making the same wages as someone who was fresh out of school. I absolutely support higher pay rate for greater experience. However, I think patient outcome needs to somehow be factored into that pay rate determination. I have worked with some absolutely BRILLIANT nurses who were very, very new and who were very, very ancient. I have also worked with some of the most rigid, stubborn "seasoned" nurses who rarely had any communication between the right and left braincell and the same of many newer nurses. Late, Trav

"For ever 1meq of hydrogen loss you generate 1meq" I thought matter is neither created, nor destroyed....seeeems like I remember something about that. Give me details on this...I'm curious.

Search for "Lasix IV" and "ototoxicity".

OCNRRN63: THAT was a total waste of 30 minutes of your time. Anyone with more than two braincells would instantly look right past that useless heap of judgement calls. EricaSAFJAF: The most challenging thing (hopefully) to deal with is going to be guilt. Second to that is going to be the court system. Each state and county/jurisdiction will differ greatly in how they deal with DUI offenders. In general, you will receive the minimal punishment if your BAC was After you have satisfied all of these requirements with the court, I would check your school student handbook to see if they require you to report any criminal charges directly to them. My guess is most likely not, but you need to check for sure. As far as the state BON, check the nurse practice acts to see. Most (if not all) BON's stipulate that you notify them immediately of any criminal conviction. Usually, a letter stating the facts (this location at this time, this officer arrested me, my BAC was this, I was cooperative with officers, have no prior criminal record....grievous mistake and feel guilty...court said to do this and I have complied with all court mandates, paid fines and me and the courts are groovy with eachother). KEEP EVERY SINGLE PIECE OF PAPERWORK YOU GET THROUGHOUT THIS WHOLE ORDEAL because EVERYONE is going to want a copy of EVERYTHING. It is a headache. But having a DWI on your record does NOT make you an unsafe nurse. This may be slightly different, since you are applying for NCLEX and aren't actually licensed, yet. But I'm sure the BON wouldn't mind pocketing a couple more hundred dollars to afford you a license. Rule #1 - do not lie about anything on the application...they will know and you will be permanently denied licensure. Occasionally, they will request a face-to-face meeting with you before they grant you a license. I doubt it will come to that. Most state BON's deal with this sort of thing similarly. They will want to make sure that you are complying with the court orders and that you are...well, basically...just sorry for your actions. ABOVE ALL ELSE....never forget that you aren't driving a car. Think of it as a 2-ton weapon and thank God that you nor anyone else was injured. Mull it over in your head for a few weeks and eventually....forgive yourself. It'll be ok. Late, Trav

I had just recently left an assignment in Houston where ANY febrile child would receive a 500mg suppository in triage "per protocol"...regardless of age or weight. The physicians would routinely give orders for the same. "Give the kid some Tylenol." "How much, doc...15mg/kg." "Eh...give them 30mg/kg...actually make it 45mg/kg." "Are you sure...that seems like a massive dose for a little immature liver." "Oh it's fine...a one-time dose won't hurt them." So, I never would. They were given 15mg/kg. Haven't seen a place since then that did this. Late, Trav

In your experiences... What is acceptable practice for a one-time dosage of acetaminophen? What is acceptable practice for q4hr administration? Have you ever seen a child that received a one-time hepatotoxic dose ( What about hepatotoxic doses received over multiple doses in a 1-2 day timeframe? Late, Trav

I've saw the same thing once. Ms. X came in repetitively, over and over and over again, but instead of just sticking to one identiy, she'd alternate between two of them. Finally, when someone caught onto what she was doing, they discovered she had racked up like $30,000 in unpaid ER bills (not even $5 paid) under her false identity. My absolute FAVORITE clients of all times were the narcotic seekers. It just gets really hilarious, sometimes. And I am only a LITTLE sorry to say that I am jaded because you start to noticed patterns after being in the ER for 5 or so years. Namely, if you are allergic to codeine, ibuprofen, naproxen, toradol, ultram, Darvocet, Nubain and you calmly tell me your pain scale is a "100/10" WITHOUT bones protruding from your body somewhere or AT LEAST some vital sign abnormal, all the while smiling and laughing and chit-chatting on the phone with your buddies while I'm trying to triage you....yep...I may have formed a label about you in my mind just now. ESPECIALLY if you ask me not to dilute the Dilaudid and "push it fast." ORR if you send me on a wild goose-chase to ask the doctor for a different prescription when you see the RX you are getting is for Ultram or Motrin and the doc looks up on the prescription monitoring website and sees that you have been to 5 ER's locally in the past week and have procured a narcotic prescription from each one of them. It's always a little bizarre to me how the ones who are the sickest are just glad to get the care and the ones who are there for trivial, piddly crap yell and scream and throw the biggest fits for having to wait or not getting the drug they want when they want it. There are actually "how-to" guides on the internet about how to fake a renal stone. Search for it in Yahoo and see for yourself. Mighty impressive. Of course, northeast TN/southwest VA is notorious for narcotic abuse, anyhow. Thankfully, in TN it is now completely illegal to doctor-shop and is completely at the practitioner's discretion to call the PD and have them arrested....seen it done a time or two and it is VERY liberating. Sorry....end rant. Love my job! Late, Trav

Theoretically, the BEST site for a PIV is in the forearm. Hand is contraindicated due to extravasation and very little soft tissue there. Wrist contraindicated due to high risk for compartment syndrome if infiltration. AC is actually contraindicated due to close proximity to brachial artery and high concentration of nerves. The BEST place for an IV is forearm and that's where I always stick if I have the option. And in a situation that is not emergent, smallest IV size that can actually accomplish the job you need. Now, with that said, being in ER, I have seen and myself started several lines in the upper arm (which doesn't make me as nervous) and shoulder and chest. ER nurses get pretty non-traditional in emergent or critical situations. But then again, infiltration is usually discovered and corrected within minutes as the staffing ratio is better in ER than on floor. Late, Trav

Yeah...documentation is one of the trickiest parts of nursing. But if all else fails, just plain english works great. I would have written it just like you did, Kiddo87. "Alert, but disoriented to person, place, time" works just fine.

Hi all. I am a travelor working in a remote location on part of the Navajo reservation. I have been an ER RN for over 5 yrs and "grew up" in a level 2 trauma center with 44 beds that rolled around 200-250 pts through per 24 hrs and WONDERFUL MD's who are all ER board certified. Here, the healthcare consists of the clinic and the attached 7-bed ER. The physicians are all supplied by a staffing agency (about half the RN's are agency). The turnover rate is high, but there are several MD's who continue coming back. One in particular is a new(er) MD and his residency was in pediatrics. Smart guy, knows what he's doing. I don't think he relies on his assessment skills and EVERYONE gets the million-dollar workup. Very much the "CYOA style". We have a lab that does most basic studies, x-ray (no CT scanner)...a crash cart, IV supplies, most emergency meds we'd need (except propofol....GO IHS!) We have chest tubes, central line kits, all the airway supplies (but no Glide-o-scope) There is no admission unit. All admits are transferred out. The point is that we can stabilize clients, but any extensive procedures or admission of any kind and they have to be flown out. Either way, this is the situation: 2 month old male - fever 103.4 at home per parents (rectal temp), Tylenol given @ 1830 by parents. At 2000, in triage, temp 98.1R, HR 172, RR 44 unlabored, SpO2 100% RA. Neonate acts appropriate, interactive with parents and staff, no N/V/D, drinks fluids, producing adequate wet diapers, no rash, no cough, no runny nose....nothing except the fever, which parents report child has had "on and off for 2 or 3 days". After IV with CBC,CMP (which were negative except a WBC 32.8). U/A cath ordered. Partially because infection control at this facility will not allow clean-catch bags and partially because MD requests caths on ALL uncircumcised males. 5Fr I&O cath attempted without success twice. Cath will advance just inside meatus and resistance met. After 2nd attempt, slight amount of bleeding. MD notified. MD is insisting on the necessity of a cath. Requests another nurse to attempt. At that point, after pulling the stopper out of 30cc syringe, capped luer lock, cleaning genital area well, and taping to clients perineum - ohh...and a 30mL fluid bolus, we have urine within 30 minutes. Now comes the real kicker. MD, after learning of client's WBC count and while we are still waiting on urine specimen, is preparing to perform a SUPRAPUBIC URINE COLLECTION. Yes....we are going to stab a needle through the abdomen of this 2-month old BLINDLY and hope we hit that small little bladder. And if we miss bladder and something goes horribly wrong...well at least we can stabilize client (maybe) and transport to another facility. Secondly, MD is also voicing intentions of doing a spinal tap on client. Like...WOAH...this man has actually gone to the bedside and spoken with parents about these procedures and obtained verbal consent. I was beginning to really fear for this child's life. Not due to my doubt of the physician, but that we are so ill-prepared to deal with neonatal emergencies. These are both very risky procedures and the nearest NICU is 2 hrs by ground, 1 1/2 hrs by air and the nearest NICU that would actually accept this client, should something go horribly wrong, is 5-hrs by ground and 2 hrs by air. So, at that point, I requested that MD please speak with transferring facility's pediatrician prior to doing these things. Or perhaps just allow transferring facility do these procedures if deemed necessary (it's a 1-2 hr transport time to closest facility). He agreed, however he already had the "Textbook of Pediatric Emergency Conditions" flipped open with "step 1,2,3" instructions on how to do the S/P urine collection. What ultimately happened? Pediatrician at transferring hospital thanked MD here for offering to do these procedures, but his recommendation was to D/C IV and discharge client home and to follow-up in 24hrs, as this was likely simply a viral illness. Child F/U today with clinic and was discharged home with dx: viral illness. I like the MD, he is polite and respectful of nurses, but I couldn't help to think that he was itching to do heart surgery in the bathroom. What should I do? Reminder: this is a federal facility. IHS....federal government. And travelers opinions are not regarded very highly in response to complaints or suggestions about things that need to be changed. Late, Trav

Agreed. As a 6 yr ER nurse, I wouldn't even consider taking a patient to a MS or tele floor with a core temp of 91ºF. Whether I had the order and accepting floor ready or not. Just isn't safe. A now, common-place practice of giving the floor nurses 8 patients every night is ridiculous even with stable sub-acute patients (which we know is a rarity). Late, Trav

The first thing I do in the ER with any MI is slap some combi-pads on them. STEMI's are notorious for inducing some wicked ventricular arrythmias. They go NSR c ST elevation → VF → ZAP! → NSR c ST elevation. What's especially creepy is when someone goes into VF and they continue to sit up in the bed and talk to you for a few seconds. VF isn't exactly conducive to cerebral perfusion. LOL. And yes, VT will 99% of the time decompensate to VF and then asystole. The majority of junctional rhythms I have seen have been accelerated junctional....which is something you can easily mistake for NSR if you don't look very closely at the ECG monitor. A 12-lead picks it up with no problems. The few truly junctional rhythms I've seen have been during codes, which quickly progress to agonal or asystole. I've also witnessed several clients in a-fib (with and without RVR) flip-flop with NSR or SB. Late, Trav