ERERER

Sitting here with the flu, yuck. debating on whether or not to call in sick. what is wrong with nurses that we give work notes to hangnails, but don't take time off for ourselves if we're sick? how do you decide when to stay home? i have not called in sick for many years, and dread doing it today but due to fever/cough etc don't think i have a choice....... and, i bet that i caught this bug from another nurse!!

so, how did you do? mind sharing some tips for the rest of us? how has the exam changed, where is it's focus, etc. thanks!

30+ years as RN, 20+ in all kinds of ER's..... used to be CEN, but unfortunately let it expire, so have to retest. Have heard that they changed the content last summer, anyone noticed??? also, wonder why Laura G-VonFrolio has not updated her tapes, i really enjoy her but they are really old. Has anyone else tried "http://www.mo-media.com/cen/" that a previous poster suggested? just wondering, never heard of it before.... guess i'll have to crack open the old books, learn the actual NAMES for what we see: LeFort fractures, etc. Hope to hear from those of you who have taken the test in the last couple of months as to whether or not they made it more real life

well, I'm still in the ER, at my advanced age and bad feet every day I ask myself how much longer can i maintain this? There are only 12 hour shifts, new grads counted as full staff (not their fault), corporate mentality (right now you have some empty beds, send a nurse home!), not to mention all the other crap. but, i have a hard time picturing myself leaving....... how did you do it?

after handing the syringe to the doc to give, he changed it to IM and we haven't had that problem anymore. are you giving it for a high INR from Coumadin? we generally use FFP too if there is a critical need

we are trying to deal with this among ourselves. I do not like to "write someone up" or blah blah blah to management unless it is something we can't handle ourselves. This particular nurse has been taken "outside" and talked with, given direct orders, given report from triage, etc. Whatever intervention we have tried has only made the situation worse. Is there a better way to divvie up the ER than assign rooms?

In our ER we are assigned a group of rooms for the shift. Patients placed in those rooms from triage or EMS are "our" patients. If we are getting "slammed", everyone else usually pitches in to help out..... Lately we are having trouble with one nurse who focuses in on one or two patients (out of 4 or 5) and ignores the others, assuming someone else will pick up the slack (IV, labs, meds, etc). She does not even acknowledge that there are pts in those rooms (how can you walk past one of your rooms, see a pt lying there, and not know it?). It is getting worse. My question is aren't you legally responsible for your assignment? is triage placing a pt in one of your rooms considered a "hand-off" by JCAHO? Can anyone give me some constructive suggestions on how to deal with this escalating situation???

you cannot transfer a patient to another facility if you have the ability to care for them. this does not mean bedspace, it means specialties (burns, neuro, etc). i've been doing this a long time. you would never find a physician to accept an established pt just due to "bed problems". THAT would be an emtala violation. Emtala addresses inappropriate transfers, started out as an "anti-dumping" legislation to prevent sending self-pays to other facilities. For example: we send out all our OB's because we do not offer, or have OB physicians on staff. This would be even if the entire hospital was empty. the closest facility that offers OB and has bed space is obligated to take the pt, insurance or not. THAT is emtala in a nutshell. Someone above said it "emtala ends when the pt leaves the ER". It does not cover in house patients at all. If the powers to be think that the pt would be safest in the ER, then that's where they go, like it or not. The patient still has their admitting orders, physicians, etc the same. The only way the ER doc gets involved is if the pt codes. Which would be the same if the patient was upstairs.

+++++++++++ I have researched Emtala quite a bit for some problems we were having. No where did it address this issue. The patient is not "dumped" on the ER. They keep their same doctor and their same orders. The ER doctor is not involved. It is similar to sending a M/S patient to the ICU. I really do not understand how you think this is an Emtala violation. If it is, please send me the references, because we sure need to know this if it's true.

I do not understand why this would be an emtala violation. When the patient comes down to the ER, they continue under the care of their admitting physician along with their orders. The ER doc does not get involved in their care. If we need an order, we call the attending. Why is this different than say going from tele to ICU?

I can see both sides of this problem. I am currently working in a dinky non=teaching REDNECK hospital. If a patient goes bad, ICU is full, there have been a couple of occasions where they were brought back to the ER. SIDE1: where is the safest place for the patient? SIDE 2: in the ER we take care of non-stable pts before they go to ICU. frequently the load is quite heavy. the initial care of these patients is high: starting drips, intubating, stabilizing, etc. In the ICU, the nurses have their set limit of patients. In the ER there is NO set limit. The other night i actually had an ICU nurse say to me after hearing report "sounds like that patient is too unstable to come up here". huh? then can i send my other 5 patients to you?

hey... i've been a nurse since the dinosaur age. This is what i carry in my pocket: "Emergency and Critical Care Pocket Guide, ACLS version" by Informed.(Paula Derr). i'm pretty sure you can get in from Amazon too. Just remember, there is no way you can keep all that stuff in your head. It is in your best interest to look stuff up (see the post about the Dilantin overdose)

so what is the answer? as professionals we should have input on how we conduct our profession. I personally resent all these "like it or leave it" memos that come down from above. i don't think that admin has a clue as to what is actually going on with patients. The mid level managers report to admin what they think they want to hear, not what actually is happening, to save their own hides. Do any of you have free access to the CEO/CNO?

Do staff nurses in your facility have any input in policy making, clinical decisions, etc? In our hospital there is upper management, who get their information on problems on the units from managers. I have read of some hospitals using shared governance to solve problems and make policy. Here staff nurses are not even included in committees that discuss clinical issues and problems, and managers are not relaying accurate information. How involved are staff nurses at your hospital in committee work, clinical issues? We are professionals, after all, and should have a say in how we conduct our profession.

always, always, have your own policy. your employer will tell you that "you are covered" by theirs. smile and say thanks. then get your own. more than once, when a hospital has been sued they have turned around and blamed the nurse, then sued her to recover $$$. they do not have your best interest in mind. they have the corporation's best interest in mind. malpractice ins. is not expensive: i have a big policy for $116 per year. access to a lawyer, even if just to run something by. coverage if i give advice to a neighbor or stop to help on a highway. your hospital employer does not want suing parties to know that there are "deep pockets": more than one insurance carrier to go after, therefore a more agressive case. DO NOT LEAVE YOUR HOUSE WITHOUT MALPRACTICE INSURANCE!!!!

In our ER, PT, PTT, INR are part of the cardiac panel (lab tests ordered on all chest pains, SOB's, etc). We draw them on all pts presenting with these symptoms, they are not individually ordered.

I have been an RN for 30+ years, still learn something new each shift, still go and look things up. Still read journals and scan the internet. The best thing to remember is you are never alone. I have never been angry at a new (or old) nurse for asking a question. I HAVE been angry when they don't. I don't have all the answers, but I do know where we can look it up together. If I remember right, I thought that the REAL nursing school started after i graduated. Good advice above. If you cannot afford a nursing journal, ask around if anyone else gets them, and if you could borrow. Each thing that makes you stop and think, research it a little.... write down the important stuff. You can't keep everything in your head! Even doctors carry cheat sheets. Know the basics: the meds that you give most often, the "gut" signs that someone is doing poorly or "just doesn't look right". Those kind of observations by a nurse have saved many lives. You may not have the scientific words to describe it, but you do have the words to describe what you are seeing. Keep working and keep learning!

Here's a cheer for working in a small ER.... I hear the same crap that you do while giving report to a hospital that I am transferring a pt. too. Little does that snippy nurse know that I have 30+ years of critical care exp, teach, and keep up with what's new. I have worked in teaching, magnet, trauma, etc centers and you know what? I think it takes more "smarts" to work in a small non-specialized hospital. We don't have the luxury of lots of other nurses to bounce things off of, residents and interns to hover over our pts, round the clock clinical coordinators (we're lucky to have a house supv). Only one doc, and hope he knows his stuff. many's a day that the nurse diagnoses the pt from her "gut feeling". In my opinion, it is MUCH harder to work in these small ER's, and it seems like the sickest patients come in private vehicles.

i feel your pain. i have been a nurse for 32 years and have weathered through every different "innovation" of patient care. this past 10 years have frightened me the most, though. alot of the nurses i watch now are merely technicians. patient "care" has fallen by the wayside and it seems as if we are taking care of computers and charts more than the actual flesh. i spoke with a nurse the other night who went to school because "nowhere else i could make 50,000 + with a 2 year degree". the same night i worked with a Filipino recruit from a "nurse mill" who had no interest in anything but racking up a paycheck. I love ER nursing and will not give it up. I worry about my family and if they have to be admitted to a hospital, someone (probably me) will be sitting at their bedside to protect them. whatever happened to the love of learning? i learn something new every shift. i read journals, read the internet, talk with doctors, research unfamiliar drugs and symptoms. then i read about a nurse who gives 8 grams of Dilantin and kills a patient. i am sickened by what has happened to nursing. I worked with a nurse the other night who got his RN because he lost his job as an engineer, and it only took a year or so to get his RN and make comparable money. no interest whatsoever in anything "care" wise, just punch in and punch out and not get written up. something's gotta give.

I first thought that i would skip over this thread, but maybe need to vent??? ++all the SIDS babies and their moms ++6 month old girl who was RAPED by her step dad.... ended up with a colostomy and cystectomy after incredible surgeries ++putting the dead 2 week old in mom's arms to say goodbye after her drunk stupid husband rolled the car on second thought, i am going to stop. this is too much.

i could send you an attachment that has the article (and a picture) of the doc. just need your email, not sure of the "protocol" involved on this forum of exchanging email addresses

Just a thought, but with "ER Nurses Week" coming up (oct 8-14) how about everybody sending a copy of this editorial to their local newspaper??? the doc that wrote it said feel free to distribute......

After circling the drain with compassion fatigue, I stumbled upon this article that was published in the ACEP: read it and tell me you don't feel proud! Guest Editorial ACEP News September 2006 By David F. Baehren, M.D. For a generation or two, we have lamented the loss of role models in society. As parents and individuals, we naturally seek out others we would like to emulate. Sadly, a serious search through the popular culture leaves us empty-handed and empty-hearted. Thanks to a long list of legal and moral shenanigans, many entertainers, politicians, and athletes long since abdicated this momentous position of responsibility. We usually look afar for heroes and role models, and in doing so overlook a group of professionals who live and work in our midst: nurses. And not just any kind of nurse: the emergency nurse. There are plenty of people involved in emergency care, and no emergency department could function without all of these people working as a team. But it is the emergency nurse who shoulders the weight of patient care. Without these modern-day heroes, individually and collectively we would be in quite a pinch. This unique breed of men and women are the lock stitch in the fabric of our health care safety net. Their job is a physical, emotional, and intellectual challenge. Who helped the paramedics lift the last 300-pound patient who came in? Who took the verbal lashing from the curmudgeon giving admitting orders over the phone? Who came to tell you that the guy you ordered the nitro drip for is taking Viagra? The emergency nurse has the thankless job of sitting in triage while both the long and the short buses unload at once. With limited information, they usually send the patient in the right direction while having to fend off some narcissistic clown with a zit on his butt. They absorb the penetrating stares from weary lobby dwellers and channel all that negative energy to some secret place they only tell you about when you go to triage school. Other kinds of nurses serve key roles in health care and attend to their patients admirably. However, few function under the gun like emergency nurses do. It is the emergency nurse who cares for the critical heart failure patient until the intensive care unit is "ready" to accept the patient. The productivity of the emergency nurse expands gracefully to accommodate the endless flow of patients while the rest of the hospital "can't take report." Many of our patients arrive "unwashed." It is the emergency nurse who delivers them "washed and folded." To prepare for admission a patient with a hip fracture who lay in stool for a day requires an immense amount of care--and caring. Few nurses outside of the emergency department deal with patients who are as cantankerous, uncooperative, and violent. These nurses must deal with patients who are in their worst physical and emotional state. We all know it is a stressful time for patients and family, and we all know who the wheelbarrow is that the shovel dumps into. For the most part, the nurses expect some of this and carry on in good humor. There are times, however, when the patience of a saint is required. In fact, I believe that when emergency nurses go to heaven, they get in the fast lane, flash their hospital ID, and get the thumbs-up at the gate. They earn this privilege after being sworn at, demeaned, spit on, threatened, and sometimes kicked, choked, grabbed, or slugged. After this, they go on to the next patient as if they had just stopped to smell a gardenia for a moment. Great strength of character is required for sustained work in our field. The emergency department is a loud, chaotic, and stressful environment. To hold up under these conditions is no small feat. To care for the deathly ill, comfort suffering children, and give solace to those who grieve their dead takes discipline, stamina, and tenderness. To sit with and console the family of a teenager who just died in an accident takes the strength of 10 men. Every day emergency nurses do what we are all called to do but find so arduous in practice. That is: to love our neighbors as ourselves. They care for those whom society renders invisible. Emergency nurses do what the man who changed the world 2,000 years ago did. They look squarely in the eye and hold the hand of those most couldn't bear to touch. They wash stinky feet, clean excrement, and smell breath that would give most people nightmares. And they do it with grace. So, here's to the emergency nurse. Shake the hand of a hero before your next shift. Dr. BAEHREN lives in Ottawa Hills, Ohio, and practices emergency medicine. ER-Nurses-Read-This.pdf

we just went through JCAHO, yuck. glad that's over....if for no other reason now admin might not have the excuse to delay things "until after joint".. anyway, seems as though JCAHO wants med reconciliation forms filled out on ALL ed patients, not just admissions as we had been doing. can you imagine filling out all that on someone who just wants an rx for an earache or a couple of stitches??? especially when we are so busy?????? The ENA has addressed this with JCAHO and on their website is a copy of the letter that was sent, cosigned by the ED Docs groups, etc. they can't be serious, can they?????

a couple more: we mixed our hyperal solutions in the med room ourselves. dirty old place... remember doing cardiac outputs in the icu by injecting ice water.... cardiac patients were not allowed ice water or cold beverages, could not get out of bed for a week. uninsured patients were put in a ward.... 6 beds heaven forbid you go home with the narcotic keys in your pocket. scultetous binders? i was a pro at that! pts got backrubs, hs snacks, and fresh drawsheets/pillowcases at bedtime. we had to kneel in front of the supv if it appeared our skirt was too short so that she could measure how many inches above the knee it was we had bottles of concentrated KCl so that we could mix our IV solutions (oh man, JCAHO would have a seizure!)