1. A general and open disdain for psych patients.
So, psych patients can be very testing. A general ED course involves, presentation, needs medical clearance, needs 1-2 liters of fluid to lower a CPK, then patient holds a bed for 10 or more hours (I have heard cases of 24-48 hours) before placement can be found in a psychiatric facility. This is frustrating because you have a patient who literally does not need any medical attention at this point, but is holding a bed, reducing throughput, all the while, they need to be fed, blanketed, toileted, etc. etc., also reducing your tech availability because they are on 1:1 observation. You add to all of this, the patient may be acutely psychotic, delusional, manic, suffering hallucinations, combative, wandering in the halls, calling out loudly (disturbing other patients), etc. This is just a frustrating situation that, right or wrong, leads to a stigma associated with psych patients in the ED. Of course, they deserve proper, compassionate, evidence-based care, but you will inevitably hear venting from staff.
2. A nurse told me to discharge a patient AMA even though the patient told me she had changed her mind and would like to stay. I refused to discharge her, by the way. That did not go well, but I survived. (this I attribute to the bad nurse). In addition to this, there was a general rush to clear the beds, especially during busy times.
To this, that RN in question does not have the scope to disposition patients. Consult the physician. It'd be useless to D/C her though, she can walk right back to triage and check right back in if she so pleases. So, why not let her stay.
3. I was told that we do not address problems that weren't "what the patient came in for." I also attribute this to the bad nurse, because the charts suggest that we do in fact do that, or we are supposed to.
This is a complicated, entirely subjective discussion in and of itself. As someone else stated, if someone comes in for toothache, but oh, it turns out you're in SVT, we might need to take care of that. Then of course, we do not just give ibuprofen/antibiotics and discharge. In the same vein though, if you come in for "toothache," but your back is hurting (as it has 15+ years) and you just lost your script for pain meds, oh and I think my toenail is ingrown, do you guys cut those? And can I get sandwich and ginger ale too? This (to me) is the case of "Mm, no, you came here for a toothache. This is not your primary care provider, we cannot manage chronic pain here, our provider is not a podiatrist, and food is for admitted patients." This just taps on over-reliance on the ED, lack of access to primary care, access to insurance, etc. But we just can't treat all of the things all of the time, it's not what we're here for. Sometimes you just have to tell us what hurts the most and we'll go with that.
4. A disregard for all things not immediately life threatening. For example, a physician removed an unconscious patient's leg dressings, then just threw the bandages back on without tape saying, "Ok, that's done." When I addressed this problem with the nurse and asked if I could redress the wounds she said "No, we don't do that. The ICU will take care of it." But the ICU did not have a bed for the patient for the rest of the 12 hour shift.
There's a couple comments, I would make on this. First and foremost, hospital geography does not have to define care. Now, I can't imagine having the time or supplies to do any full on debridement, wet-to-dry, hypo-silver-aquagel-P90X wound dressing in the ED, but come on, there is nothing wrong with letting a student nurse (or doing it yourself) throw some kerlix and gauze on a leg. In this case, that nurse needs to get over him or herself. That legs going to take 30 seconds or a minute to do some basic first-aid on. What next, we don't put patients on the bed pan, ICU can take care of that. Good luck explaining why you transported a patient to the ICU in pile of stool. It's a matter of time and resource management. No, we don't always have time to get cups of water, find extra pillows, but I have seen on more than one occassion the "THIS IS THE ER, AIN'T NOBODY GOT TIME FOR THAT" mentality used to cop out of providing some basic care when it would have been perfectly possible to do.
***On a side note, I am noticing most of my issues have to do with one nurse whom I feel gave poor care. ***
5. In general, I heard a lot of "we don't do that." in response to my questions about interventions
See number 4, I think lol.
In summary, I think all of your internal frustration and confusion is most definitely temporary and "fixable," not to say that you are broken. Emergency nursing is most definitely 100% different from any other area. It takes a certain mindset, a certain focus, a really different model of care than the traditional "nursing model" that you might find in other areas. I think school puts you in a very med-surg, very Nightingale-esque mindset of nursing. You want to fix the whole person, body, mind and soul. Emergency medicine/nursing flips the entire healthcare dynamic upside down. When you go to a PCP with cough, congestion. They're going to say, "Okay this is most likely acute sinusitis, doesn't really need antibiotics, but I'm going to get a crap review on Yelp if I don't prescribe anything so, here's a script for penicillin, get well soon." So emergency medicine flips this, and says, "Okay SOB, cough, congestion. I need to rule out pneumonia, acute bronchitis, CHF exacerbation, etc." So run some basic labs, get a CXR, order a DuoNeb in the meantime. When that all comes back negative, okay you're not dying, here's a script for abx, discharge.
Anyway, all of that is to say, emergency nursing requires you to take everything you learned in school and adapt it, refine it, flip it upside down to look for acute signs and symptoms, changes, recognize and response to them. It will a good year there to do this, and then you'll continue doing that, learning and changing it, growing for the rest of your career.
I do not think an ill experience with one not-so-super preceptor defines you as a poor candidate for ER. If it's in your blood, go for it.