ImaERtraumaRN

In our level II... ...experienced RNs get 6 weeks, new grads get 20 weeks or longer if they need it. The new grad orientation is based on ENA recommendations. New grads also have 5 hr weekly classes during the 20 week orientation specific to the ED. All RNs also get ACLS, TNCC, and ENPC.

Ouch. I think there are some assumptions being made in this thread that many times are just not true - at least in our ER. In our ER we do not have any control over when our patients get beds. Nobody sits around and waits to d/c patients to the floor right before leaving. In fact it is a real pain for us because we are trying to give/take report on patients while others are arriving at the same time. Our EMT's in the unit who help transport are also in report. It is false to assume that we are trying to "clean house" at shift change. When a bed becomes available for our patient we try to send them up for the very reasons that Taz has mentioned above, not to mention the fact that many times we have 5-6 critically ill patients, 2-3 which are rolling in by EMS and placed into beds that have not been assessed OR stabilized yet. At least when they come to the floor they have SOME sort of diagnosis and direction for care. Some are stepdown or ICU patients that have been waiting on beds for hours. Other more stable patients are put into the hallway to make room for the more critical patient when report cannot be given. We cannot refuse to take patients because we dont have enough beds or nurses. I cannot simply deny report on those patients, nor can I say a bed is not available because I am in report on another patient or passing meds. I try to give report to the floor before I leave NOT because I am trying to run out of the door at shift change, but because it is more important that my patient be ensured continuity of care. That means the person who stabilized and provided care to the patient all day should be reporting off and not someone who just took report 30 minutes ago who knows virtually nothing about the subtle changes that may be significant to the patients needs. With that being said I understand that transporting and giving/getting report at shift change is a problem. I try hard not to have to give report to the floor at shift change, and when I arrive with the patient on the floor I help move the patient, tuck them into bed, put them on telemetry, and many times get their first set of vitals before leaving them - having NEVER seen the primary nurse or CNA during that time. Many times the bed has not even been pulled back or the correct equipment in the room in anticipation of the patient when I called report a significant amount of time earlier. I dont feel the need to be greeted when I show up, but preparation in anticipation of my arrival would be wonderful. I know this is an age-old issue and has been discussed to death. There are challenges on both sides of the issue and not a lot of good answers to the problem. I try very hard to consider both sides of the issue and adapt as much as I can to ensure the best care to the patient. I just think it is important to consider what it is like to walk in each other's mocassins occasionally.

A friend of mine just went to critical care transport for the same reasons. One on one, or TWO on one pt. care, no primadonna docs. They *do* transport our crackheads and other mental health patients, but there arent as many as make it into our ED just for some "special pampering". He is loving the change and I am considering following his footsteps after a couple more years.

Once you have experienced first hand EVERY situation you can possibly encounter, THEN you feel completely comfortable. :lol2: Truly we all have questions and situations that arise that we just have never had to deal with. I have learned that "improv" is a good thing. A good nurse told me once that while in orientation to worry about my clincal practice because the paperwork and protocols for everything else were secondary and could be perfected later. She was right. Hopefully you are on a floor where you can ask questions even after you are out of orientation. Eventually you will be the one answering the questions for the next newby. Go easy on yourself!

While I know that the OP said that she is ashamed about this behavior, I just can't get over the fact that she just "tucked him back in" and left the room. I am quite certain that this would equate to negligence in any courtroom when considering what a "safe and prudent nurse would do". In fact, I think it goes beyond a med error or other unsafe act because she was aware the pt. was seizing and did nothing. It could very well be seen as criminal if this pt had died from injury or aspiration. If it was my family member and they had lasting effects from this negligent behavior I would have pursued it with the BON and beyond. That being said, what's done is done and now it's time to learn from the behavior, get to the root of what caused it to happen and move forward. Many new grad RNs "freeze" when faced with an emergent situation because even though they have learned about this very subject in school, they have never had to apply the skill in "real life". So, was the situation that she "froze", didnt know what to do, then was too embarrassed that she didnt know what to do that she didnt tell anyone else about the incident? I think it's plausable. Not an excuse, but plausable. I think that additional preceptorship is a good choice, but I also think that seeking out other learning opportunities is in order. Seek out every code, seizure and uncommon event on your unit and ask to watch, do or evaluate. While you are still orienting, tell your coworkers to come get you when someone is going bad - and ask what signs/symptoms they noticed. If you have a rapid response team ask to round with them for a shift, or spend a shift in the ED watching trauma or resusitations. Spend a day with respiratory therapy and working with vented patients. My belief is that if you emmerse yourself in the situations you most fear, that soon they will become much more manageable.

I say listen to your instructors, your mentors and your heart. If you are someone who adapts to an environment quickly, has good organizational skills and learns quickly then a specialty area might be the way to go. You will understand that every patient is a learning opportunity, and there may even be research/reading you will need to do on your own time (without prompting) in order to make your practice stronger. Many times I find myself going home and looking up something I ran into that day that I didnt know about. I was a new grad in the ED and the choice was the right one for me. I also had a very good orientation with 20 weeks of classes and preceptorship. On the other hand, if you had clinical instructors tell you that you need to work on organization, or you need more work in a specific med/surge area, then you may want to go for the foundations first. Our hospital will allow you to transfer w/in the first 6 months if your position is not a good fit. If you find yourself stressed out, burned out or overwhelmed transferring does not equal to failure. I would have been miserable in med/surge. It isnt for me and I know that. That doesn't mean that it isnt a great place for others. I had to follow my heart and commit to doing everything I could to ensure my own success. Good Luck!

I have NEVER heard of a preceptor telling a nurse to leave during a shift and ESPECIALLY without explanation. We can only learn from our mistakes if we are told what we did and are given the opportunity to correct ourselves the next time. :angryfire :angryfire :angryfire Regardless of whether or not you did something to make her upset, you are a professional (new grad or not) with a license and should be treated as such. You have spent a lot of time and energy getting into the program, graduating and passing boards and nursing is your career. You owe it to yourself to ensure that you get the best orientation and training wherever you work and you really have to demand that if you are getting less than you deserve. I would request a different preceptor and speak to your manager about the reasons why. If you are concerned about backlash have your manager simply relay that there was a personality conflict, otherwise I think the preceptor should be called out on her unprofessional behavior. Remember, you are going to be solely responsible for your actions after your orientation and that is the only opportunity you will have to REALLY learn the ropes before you are on your own. Good Luck!

Congrats on getting into Nursing school. It is quite the roller coaster ride but you sound dedicated and that is really what it takes. Safety is incorporated into your schooling and it becomes part of your practice as a student nurse, and should be part of your practice as a nurse as well. Needlesticks are not as common esp. with all the needleless devices out there becoming the norm. I work in the ED and have only seen a couple - one was on a needle a trauma pt. had in his pocket and the nurse was helping him undress. It was a learning experience for all of us, and luckily all her tests came back fine. So, if this is really what you want to do then relax and just go for it! Dont let others steer you off of your path. You will be so surprised at how fast the time goes.

Priorities are different in the ER, it takes more than a couple of days to learn the pace and to "get in the groove". Watch your preceptor and how he/she does things and in what order, but dont expect that you will have things down to a science after such a short time. Soon you will notice that you do things on auto pilot that used to take a great deal of thought, and be able to do things more quickly and efficiently. Be good to yourself and good luck!

This is an age-old problem. At our hospital we tried using faxed written reports but it seemed that something was lost in not giving a verbal report. Also, sometimes the paperwork was lost and that was a problem too. We recently went back to verbal reports and now deal with the "I'm not ready" issue. It would be nice if there was a rotating "admissions RN" that could be on call to take report in shifts, maybe a two hour block. This way the pt. could be accepted, admitted with a history done and then handed off to the recieving RN with all the info gathered by the admissions RN. Of course, that would be in a perfect world where there was plenty of staffing. My biggest issue is when there are beds closed up on the units but we are not allowed to close beds in the ER due to staffing. We are holding with pts in the hallways and EMS rolling in, but due to staffing issues we have beds closed upstairs. Oh well, what are you going to do???

nope...dont think this is crazy at all...I have a few I get attached to, but I really like not taking every one of them home with me. I think if I had to care for them day in and day out I would be emotionally drained.

Of course I like knowing I'm helping people on one of (for the most part) the sickest and probably worst days of their lives. For all that I complain about the "whiners" and the "whiner's familes" I really like providing care to those who genuinely need it. And, truth be told, there is NOTHING like standing in the trauma bay with your gown and gloves on when you have a serious trauma 5 mins. out and guessing what it will be and anticipating the plan of care...except when they roll them in. PURE adrenaline...

Appendicitis can be misdiagnosed as UTI - it depends on how the symptoms present. We do not do abdominal ultrasounds on every pt - especially if the urinalysis comes back positive and there is no other evidence of appendicitis -which I dont have much to go on as far as that is concerned. There may have been additional labwork however the article that was posted above states "No single sign, symptom, or diagnostic test accurately confirms the diagnosis of appendiceal inflammation in all cases". A kidney infection or even PID can cause elevated WBCs, high fever and severe abd. pain. Of course, I dont have the labs or assessment info to evaluate what the MD was thinking. In our ED we always assess for rebound tenderness - although this is absent in many depending on the location of the appendix in the abdominal cavity. And any time symptoms increase in severity the pt should return to the ED. I think part of the problem lies in that many EDs do unnecessary testing that costs the pt. a great deal of money when the diagnosis could have been made based on more inexpensive diagnostic criteria.

One step further - Decorticate means you are still protecting your core, which is a GOOD thing, therefore decorticate is the BETTER of the two.

Me too! Hope she is feeling better today!

Hi there! When someone comes into the ED with a complaint we generally try to do the least invasive and cost effective tests first so that we can rule out something simple without a huge cost to the patient, use of resources in our ED and taking a large amount of time. In your sisters case (I assume) a Urinalysis was done and a UTI was indicated and she was treated for that. At that point unless there was further indication of infection somewhere else we would stop there. As someone said Appendicitis can present in different ways. Many times it isnt easy to diagnose - and can be misdiagnosed especially if there is another infection present, even with a nasty appendicitis like your sister's. I am sorry she had to go through so much pain and her appendicitis was missed at the ED. Unfortunately, medicine is just not always an exact science.

I think the fact that you are wanting to anticipate what is expected of you, and what to expect is a good sign that you will be an asset to your ED. I see techs and nurses who stand around and talk when we are in the middle of a post-CPR, a respiratory arrest and a hot MI two minutes out. I also pay attention to the ones who aren't standing around and who are working alongside of us and I try to make a point to appreciate them when it's all said and done. It can be a thankless job sometimes, but it can also be very rewarding. Make sure you dont let anyone else put you in an unsafe situation - get their butts in gear when things get tough and dont be afraid to ask for help. At the same time, when you have downtime (maybe not often), I always really appreciate it when our tech/EMTs come and ask if they can do anything for me. Even if the answer is no, it is good to know they are available. On the flip side I try to help get vitals, etc. when I have a little downtime as well. The size of the degree doesn't matter - we are first and foremost a team. Anticipate pt. needs - sometimes they just need to vent. I dont advocate or expect anyone to spend hours talking to a pt. - especially when we are slammed- but a couple of minutes to get an extra blanket or ice water is appreciated. Remember that you are helping them on what is probably the worst day of their life (at least in their eyes). As someone else said, watch what happens when certain pt. types come in. Learn to anticipate what your role will be and be in there to initiate the protocols that are within your scope (ECG, monitoring, removing clothing, setting up lines - if you are approved to do this). It will allow the RN to do the assessment and initiate protocols that are within his/her scope more efficiently. Hope this helps! Good luck with your new job!

Yes, our hospital is doing an aggressive study on managing glucose levels in the ICU. We use something called a Glucommander. It is a laptop that is kept at the bedside. You put in MD parameters for CBG and parameters for insulin drip calc. The Glucommander requires (and alarms) every hour, the nurse checks the CBG, enters the results into the Glucommander and the Glucommander calculates the adjusted insulin drip rates. The nurse is responsible for actually changing the drip rate. It is wonderful for real-time glucose control. When the sugar is managed for an amt of time specified by the MD, the nurse requests MD orders for basal SubQ insulin and sliding scale management. We use it in the ED for hyperglycemic pts and can D/C the drips after the sugar is managed. In the ICU it is used ongoing for pts who need glucose control.

When I was in school my classmates had to do a presentation every two weeks in our last semester. We had fun trying to outdo each other. One did a skit, another group did a jeopardy game on powerpoint. We did a video production of "what not to eat" on iron-deficiency anemia. We went to our local grocery store (with permission from the manager) and filmed a little story where one person had terrible eating habits and two others of us had to "intervene". We went around and pointed out healthy foods that helped prevent iron-deficiency anemia. It was SO fun to do and it was fun for everyone else to watch us make fools of ourselves as well. It also allowed us to keep to a specific time allowance and to keep audience attention. It took the heat off of us on "the day" as well since all we had to do is sit back and watch. We also gave some written handout info as well. You could film various teens giving facts or statistics about STDs at the beginning and make it in a "newscast" format. All can be done with a home video recorder... Just a thought...

I love watching chest tube placements. When the surgeon digs his fingers into the hole to spread the ribs, then put the chest tube in and ...whoosh! So cool to watch, and for all the pain it causes the pt. is suddenly much more comfortable and able to breathe again. Very cool. And cracking chests - that is something I've only seen once so far but amazing to watch. I DO NOT do "pudding" urine though...yuk. I try to wait to gag till I'm out of the room.

About two months ago we had a lady who came in with a maggot infestation of the lower leg - so infested the whole leg was pulsating and they were falling off - we found a few crawling in the hallway and had to call to have the room and hallway decontam. when she left. She refused to have the leg treated - she was there for another issue, so a social work and psych consult came along with her visit. I held it together but almost lost my lunch when a coworker who went off shift called back and said we all needed to check each other because he found a few "friends" when he took his shower upon arriving home. Yuuuuuuuuuuuuuk!!!!!

How about how to manage repeat visitors to the ED - chronic pain, etc. and treat more quickly/effectively? For that you will have to review current processes in your ED, pt populations and find ways to troubleshoot. Another issue could be security of medical staff in the ED - a biggie we are dealing with right now. Also, in our ED (assume it is similar everywhere) abdominal pain pts take up an enormous amt of time. You could focus on these pts, why they take so much time to treat, and how to manage the flow of these pts through the ED to dx. IMHO most major problems in the ED (this according to mgmt.) are surrounding surges (influx of people at certain times), treatment times and bed control, pain control, and pt. satisfaction scoring etc. Nurses at your specific ED might be able to provide more specific issues. Good luck!

Our uniform colors are hospital-wide. RN - Ceil blue or white Tech - tropical green (?) EMTs (ER only) - Hunter green Housekeeping - multicolored tops (hospital issued all the same) Lab - burgandy Echo - Red PT- purple Radiology - OR green Respiratory ther. - black Now, white in the ER is not the smartest color, but since it is hospital-wide we go with it. Most wear Ceil blue. We can wear a white top underneath either color. I have to say it is better for our pts who have mentioned it time and time again that they like the uniformity. We are "supposed" to tell them the colors - mainly RNs, EMT/Techs and lab in the ER so they will know who is who, but that doesnt always happen for obvious reasons.

Today we were going through the ENA's ED orientation manual and in the written material regarding trauma to the chest there was mention of the "dorf sign". Our RN IV (the president of our local ENA chapter) who was reviewing the material asked all our EDPs and they didnt know what this was. The closest thing they got to explaining it (a wild guess) was that it was when the chest hit the steering wheel and the "ford" symbol was imprinted backwards "dorf"...LOL. :chuckle :chuckle There seems to be no info on the internet regarding this and I can't believe that ENA would use this type of reference in its manuals although I know ENA has some "ENA specific" terminology sometimes. Does anyone know what this is?

I posted in another forum about this earlier. I thought I wanted to do Labor and Delivery when I went into school. I changed my mind several times - I always knew I didnt want to do med/surge and that I wanted to specialize. I actually chose where I wanted to go from my interviews/shadowing. I gave a list of several areas I was interested in to my recruiter. I got interviews in many of those areas, shadowed on the units with an RN and I chose the unit where I got the best "vibe". The nurses seemed friendly, I liked the unit, the director, and the other staff. It seemed a good fit and a place where I would learn the most, use the skills I liked the best adn I wouldn't get bored quickly. This happened to be the ED -which I had not considered seriously until during the last semester of school. And, btw, I Looooove it!!!