JennyAS

VENT Why are some ED docs so averse to actually writing orders? I understand it's the ED, and they get spoiled by how much ED nurses are willing to do without a doctor's order (lines, labs, fluids, etc), but if you tell me to give Dilaudid, I'm gonna need an order for it. And if I come to you 15 minutes later and again ask you to please put the order in, don't get angry. It's your job. Yes, you need to order that foley, as insignificant as it may seem, because when the patient gets a UTI 3 days later, I'm not going to lose my license over it. And yes, you need to order all those NS boluses, because there's no other way for me to document their intake. And yes, you have to place an order for some stupid Tylenol, because the almighty Pyxis won't let me pull it out until you do. And no, I won't place a verbal order, because you are a resident whom I barely know, let alone trust. And also, I have enough sh*t to do. What kills me is that it takes them 10 seconds to place an order electronically, while that same order may take me 30 minutes to actually complete. woo! love to vent.

There is no hospital policy written to detail the exact step-by-step process they want us to use to prime an arterial line. I just wanted to get a poll as to how nurses around the board tend to prime their art lines.

I just moved from one level I trauma center to another in a different state. Of course I expected a lot of things to be done differently, but I think my new hospital may be setting up arterial lines incorrectly. At my old hospital, we would place the NS bag into the pressure bag, invert it, and pressurize it so that all the air was pushed out of the bag AND the chamber. At my new hospital, they seem to simply prime the NS bag just as they would for a regular PIV infusion, meaning they leave air in the chamber and don't get all the air out of the bag. I was told by someone that they do it this way so that they can tell if it's dripping... but you don't NEED to tell if an arterial line is dripping. If it's working correctly, then you'll see it flush the line. Am I wrong about this? It concerns me because in one trauma I was working, the arterial line chamber actually emptied somehow, which put the pt at big risk for an embolus if someone flushed the line. I'm new here and don't want to make waves, but I think a policy change might be needed. What do you guys think?

When we give Toradol IM, we offer a dose of 60 mg/2 mL. I agree that 2mL of fluid is too much to inject into a small muscle mass like the deltoid. I usually only use the deltoid for Tetorifice IM (0.5mL) and anything less than 1mL.

Yay, I passed the CEN today! I have about a year of ER experience, and I started out as a new grad. I know they recommend 2 years of experience, but I was eager to have it under my belt. I studied for about 3 months. My biggest studying tool was the practice exams in the "CEN Review Manual" by the ENA. I was getting 75-80% on each of those tests, and I ended up with a 91% on the actual exam. They were pretty similar to the actual test, but I think the actual test was more straightforward. I also took the 50-question practice exam on the CEN website, and got an 80%. It was also very similar to the actual test. If you're a member of the ENA, then you can go to http://www.ena.org/Pages/default.aspx and access all the old Journals of Emergency Nursing under "Publications." Each journal has 5 CEN practice questions. I ended up making another practice exam by compiling them all. I'm pretty sure they choose the hardest questions to put in the journal, because that exam ended up being pretty tough. Good review though. I used the "Emergency Nursing Core Curriculum" by the ENA for review. It's not super comprehensive, but it covers all the main topics. I also found the Jeff Solheim CEN review modules here: https://www2170.ssldomain.com/mededseminars/store/index.php?prodid=316. I found these pretty late, so I only had time to watch the topics that I needed the most help on, but they were GREAT. I wish I had come across them sooner. He's a great teacher, makes things really easy to understand and remember. I would've liked to watch the whole course. So good luck to everyone who's studying!! It feels great to have it done and over with.

To the loudly snoring ETOHer found in an Auto Repair Shop: "Maybe she needs her air filter changed." To the drug seeker throwing out his best pseudo-seizure: "Sir, that's not a seizure. Stop shaking." Response by pt: Immediately sits straight up and says, "I'm fine... sometimes that happens." From security guard to combative ETOHer being introduced to his very first Foley: "Just relax and enjoy it!" Triage nurse note: "Pt presents with L wrist pain, fell while off-road unicycling." Charge nurse to triage nurse: "I think that 'member suture removal' needs to be upgraded to a level 1." I think this could turn into a good thread. :wink2:

Patients and/or family members who are CNAs and think they know more than the nurses and doctors combined. Case in point: Lady, you've received Demerol 50 mg and Dilaudid 2 mg IV for a freaking abscess. No you can't have more narcs. Don't tell me "you have to go by weight." You weigh 170lbs! You've had enough. You can't figure out how you got an abscess? You work as a CNA in a nursing home, and apparently you're an expert on narcotic pain relief. So how have you not heard about MRSA? Don't tell my critical care tech that she can't use nail polish remover pads to remove that old tape gunk from your skin because she's "not trained to do it." She was trying to do you a favor because apparently you aren't capable of washing it off yourself. And she's trained to do a lot more than you could imagine. Please don't tell me how to flush your line. Let's compare how much experience we each have working with IVs. If you're such an expert, please go home, start your own IV, prescribe your own narcs, and I&D that abscess yourself. Because we're tired of dealing with you.

Look LOL, you came in c/o dizziness, sweating, and "pressure in your stomach" that suddenly resolved when EMS arrived at your house. You better believe you're being admitted for a cardiac workup, even though we're all convinced you had an anxiety attack. If you know you aren't sick then why did you call the ambulance? Did you just say it's better to call an ambulance because then you don't have to wait in the waiting room? That's not something you want to admit to the ER staff and paramedics. You said yourself that you live alone, you are perfectly capable of repositioning yourself in bed (I watched you do it), so why are you on the call bell telling me to readjust the 8 blankets I have given you so your feet don't get cold? No you can't have an Ambien at 4AM to help you sleep. No we are not purposely trying to starve you, make you uncomfortable, and prevent you from sleeping, so please don't throw tantrums over the call bell like you are 5 years old. Whining and whimpering every time any staff member enters your room will not earn you sympathy points. Yes I know you are hungry so I made sure to get you a turkey sandwich because I know they won't bring breakfast trays for another 2 hours - and the admission team has graciously decided not to make you NPO. Oh, you MIGHT eat half of it but you'd rather have soup? Well tough luck, lady, this isn't the Hilton and our caf is closed. Oh, and you're welcome. Oh look, you actually got a bed upstairs in 4 hours - this is RECORD timing, but yes we have made you wait entirely too long. You haven't stopped complaining about how much your legs hurt and how you can't use them (remember when you slid yourself up in the stretcher with no difficulty?), so when a team of nurses says we're going to slide you from the stretcher to the bed, please don't yell at us that you could do it better yourself.

I started out in the ED as a new grad 7 months ago, and I absolutely love it. But my 2 cents, on top of what everyone else has already said, is that we have our doctors immediately available 24/7. As a new grad, sometimes it's hard to decide whether you need to call the MD in the middle of the night. In the ED, it's nice to be able to ask for a different pain med right after reassessing the pts pain or to ask if you can give that toradol IM instead of IV. In addition, I think ER nurses are definitely more at risk for burning out. Like ILoveTheBeach said, we get a lot of drug addicts and people with toe pain x 1 year who have this sense of entitlement and want to be treated like they are in a hotel - these guys are soul suckers, as we say. Unless you have good coping skills and a great relationship with your coworkers, this could make you very unhappy with your job. Fortunately, I know I can leave those pts and come vent to my coworkers whenever I need to. On that same note - in our hospital I've noticed the ER nurses are much more tightly knit than floor nurses in general. This might be because, on a daily basis, ER nurses have to rely on eachother to pick up our slack when we get that LOL with a GI bleed and a pressure in the 70s and our other 3 pts are screaming for pain meds. I think on the floors, since things tend to be much more scheduled, this type of problem doesn't happen as often. Also, on nights, we do a lot of potluck meals that we can all graze on because it really is hard to sit down and have a full 30 minute break (can't say that all EDs do that, but it sure is nice).

I actually did share the site with the nurse, but he was uninterested. haha. Gram stain neg.

I'm a new nurse, have been working in the ER for 5 months now (and loving it!). Last night I offered to take a pt up to the floor for another nurse. Dx: viral meningitis (strange to already have that dx in the ER, aren't you supposed to wait till cultures come back?). Anyway, MD was confident it was viral. On the floor I am greeted by a nurse and tech wearing droplet precaution masks; both are looking at me like I'm crazy. I say, "hey guys, it's viral." "Yeah, that's droplet precautions." "I'm pretty sure it's standard." "No, he should be wearing a mask." I told them CDC recommends standard (http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation2007_appendixA.pdf) but they told me they had a sheet somewhere saying it was droplet because if the patient sneezes they can transmit the virus. When I came back down to the ER everyone agreed it's standard... but these floor nurses make me question it. So my question is: viral meningitis - standard or droplet? Another source: http://info.med.yale.edu/ynhh/infection/dislist/intro.html. But maybe there's new research out? On another note - I had one of those nights where one patient was screaming bloody murder at me for touching the tape around her IV and wouldn't let me do anything unless a doctor ok'd it (lady, I know what phlebitis looks like, I don't need an MD to tell me), and another ask if a doctor could put in her IV bc I missed the first try... I guess it was just one of those nights. I'm still developing my thick skin

But what happens when you've filled all your rooms with sprained ankles and abdominal pains, and you have a respiratory distress or STEMI come in? Do you leave critical rooms open in case that happens?

Good point, Crocuta... I've actually done lots of research: I forgot to mention that I shadowed at the Level I for 12 hours, and plan to shadow at the Level III soon. I loved the Level I, especially because of the teamwork. I actually had a resident pull me aside to teach me what was going on in a CT scan. Love the management - they have an open door policy and will even suit up and work if the ED gets overloaded. And all the nurses I talked to loved the place. Also, the Level I is opening a new trauma center in Nov 09, and it's going to be AMAZING... One major difference though is that the Level I has a bad reputation in this city... from what I'm hearing they hate the wait times and there are bad stories about nurses - but I've been to the Level I as a patient a few times and haven't had a bad experience. Honestly, what patient doesn't complain about ED wait times... but then again, when I shadowed there were people waiting for over 20 hours... so I don't know what to think about that. The Level III has a better rep. As far as orientation programs go, they are practically identical since they are both Shands hospitals. 4-6 month orientations, with 12 weeks of didactic classes and at least 16 weeks of a preceptorship. The orientations are based on the ENA orientation. Pay and benefits are also exactly the same. Same Nurse:Pt ratios (1:4-5), Level I has 32 beds, Level III has 22. Both see about 130 pts a day.

I am about to graduate nursing school in June. I've been offered a job at a level III ED, and I'm #1 on the waiting list at a Level I ED. I had my heart set on the Level I, so I was pretty disappointed about getting wait listed... but after talking to friends I thought it might be better to start out at a Level III instead of jumping into the chaos at a Level I. So what do you think? If somehow I got offered a position at the level I, which should I choose? Should I start out slow at the Level III, or take my chances at the Level I? And there's no chance that I might lose the Level III position if I wait to accept - both ED's are under the same company (Shands in Florida) so I have until March 14 to make my decision. Either way - I'm going to be an ED Nurse, and that's really what's important! Sooooo excited!

I'm about to graduate from UF's Accelerated BSN program, and I want to start working in an ED. Can anyone tell me what it's like to work at the ED at Shands UF? I've heard some bad things... but I'd like to get more opinions. Thanks!