CNAtoMD

Symptomatic bradycardia has no role for nitrous. This patient is sick and sick as hell and likely to die no matter what you do. First step is pacing them while someone draws up atropine. The next person is hanging fluids and I am putting the PCA on hold to start compressions if needed while another RN is pulling dobutamine from the pyxis. Do not do anything to reduce their preload (i.e. nitro is a clean kill). The cardiologist needs to get here ASAP. Pressors, pacing, and fluids get them out of the ED. The ICU team can deal with the code in the cath lab after that.

You absolutely should have the following when contacting the on call physician. 1) a quick history "Mr. Jones was admitted with x" 2. the reason you are calling "Mr. Jones blood pressure or lab value is X" and 3) the chart open to answer my questions. If you have done that you really have done your job. Sure I don't work in a specialty that gets woken up in the middle of the night anymore but I did in residency. If you have done the above three 95% of the physicians won't yell at you. The other 5% will and nothing you can do will change that. Not calling because the physician will yell at you is not an option when it comes to patient care. It sucks but either you can report them or let "thick skin" prevail. My opinion is that they shouldn't be practicing medicine or maybe you should page them q10 min when they are on call and "update" them on the normal BP or normal lab values.

Not a nurse but feel that I feel I still can answer. First it is not your life, your family member, or your friend. It seems cold but this is business (just like any other business). Business stays at work and your family stays at home. If you sign up for a job in medicine you WILL see death, hurt and tragedy. Again this is not you, your family, or your friends. Patients will need you and you need to be there. The demanding patient still needs care whether you just got out of the room of a drug seeker or watched a 6 year old die. Really you need to distance yourself from what other people are going through. You are there to help and sometimes even after the best it will still not be good enough, you have to dust yourself off and get on to the next person/patient. I say this because that is really how 95% of your career should be. Yet we are still human and most of the population will never see what we all see. It really is OK to connect with a patient and really feel bad if something goes wrong or someone does not have a good outcome. It is also OK to cry at work and feel absolutely terrible. It is OK to tap someone in and say you cannot handle it. It really is ok to stay after a shift to talk to a patient or family member when you should have been home an hour ago. It is also OK to question yourself if you did everything possible or if you were good enough. Many of us signed up for this job to feel this way. If you sign up for a job in healthcare you signed up for seeing some awful things. You shouldn't break down at every case but you shouldn't suppress every feeling you have. The number one thing is finding outlet. This may be a spouse or family member.

I quoted you because you said you immediately thought PE and many have posed the idea of a d-dimer. My thoughts are that if you have been in the hospital you should never rule out PE by d-dimer. The research has shown that there is a false negative rate of 7-10% for high probability via wells criteria. In my opinion every hospitalized patient is high risk via Wells. Still for every chest pain starting in or out of hospital we cannot rule out every diagnoses by tests. Occasionally we have to use our brains. For every chest pain I see (3-4/day on my job) I cannot order a CT PE and CT aortic dissection for every single one. Sometimes I have to say that I don't think it is a PE or Dissection. Over the next 20 years I will be wrong. At some point someone will die from a PE or a Dissection and I will have missed it. I refuse to order a CT on every single chest pain that walks in the door to prevent that 1.

Also as an ER doc you know how many times my ears have been ringing PE or maybe could be, or I cannot say it is not PE? Probably 500 times. How many times have I picked up a PE between 3 years of residency and 2 years of being an attending? 15: 15 freaking times. I have CT'd or d-dimer'd 500 people to pick up 15 PE's. Thats crazy.

So take this same patient that had CP and was dyspneic on the floor and the resident hear's crackles in the lungs and gave 40IV lasix and they got better? Seems like problem would be solved and everyone would rejoice. Now lets say the same patient had CP and was dyspneic. Lasix didn't help and the patient coded and died and the autopsy shows PE. Pretty easy to diagnose huh? Diagnoses are really easy in retrospect. Now how many would have ordered a d-dimer? How many send this patient to CT? Also how many get a d-dimer that is negative and still send this patient to CT? You should all just send this patient to CT; forget the dimer if you really think PE. I run "rapid response" for one of the hospitals I work at. The D-dimer is the Houdini of medicine. Everyone thinks a negative D-dimer rules out PE; it does not. Again a negative D-dimer DOES NOT rule out PE. Read the research. If someone has been in the hospital >1 night a d-dimer means nothing, other than false hope. In hospitalized patients if you are concerned about PE a CT is the ONLY choice. If I have a patient that is dyspneic and I find another reason for the dyspnea I stop looking at PE. This will haunt me sooner or later as my CHF exacerbation, Asthma exacerbation, acute bronchitis, pulmonary hypertensive, anxiety hyperventilation, Sleep apnea, viral URI, pneumonia, drug seeker, pneumothorax, cystic fibrosis, pleural effusion, sarcoid, or COPD'er will eventually also have a PE. I can't get CT's on them all. It seems like this resident found another reason (or made it up) to explain the dyspnea and acted on it and it burned them. Seriously though we can't get a CT on every patient with dyspnea or chest pain so we pick our battles. Sometimes we are wrong.

First I'm glad you had a positive relationship with a physician, seems from many here they don't have that experience. Second do not buy them anything. Gifts for a physician can often turn cheesy and not needed. Being that this doctor personally walked over to the place you were applying to meant that you were a great help and a valuable asset to his or her practice and that is the best gift they could receive. You said it that they probably have everything or probably could buy it if they didn't (unless you buy them a beach house in Maui and, if you do, I am going to start walking over to more places for my co-worker's.) Overall what I have treasured most in my career are truly heartfelt thank you's. I have a small box of true thank you's from patients and co-workers that I have helped and that is soooo much better than a clock or the bottle of wine bought for me. If I were you I would send them a great thank you and as a bonus send a letter 6 months later showing what you were doing; that is a ton better than a gift. Congrats on the new position and having someone put their name on the line for you. That means you were a great asset and will do fantastic in your next step.

The age old fight x vs. y and is bound to incite an argument of the PA vs. NP. You are posting on a nurses forum so most likely everyone will tell you go the NP route. In reality as it stands now it does not really matter. They have almost the same practice rights. Now looking down the road NP's have a greater legislation behind them so maybe (or maybe not) they will have a greater responsibility down the road. As a practicing physician I would take an experienced PA over an unexperienced NP. Same I would take an experienced NP over an unexperienced PA. Straight out of school I am not sure it really matters. In the ER I work in both NP's and PA's staff the urgent care and I sign off on their charts. The freedom I let them have is irrelevant of their degree and more so how much I trust them to make the right decisions. If you want to work during school NP might be the way to go. I mean that you get your RN before your NP and could have the ability to work as a nurse while you pursue your NP. As a PA you might get a degree in Biology and very limited opportunities with that. In the long run the scope is about the same, at least as it is right now.

And so I contribute to the actual thread. One from my intern year. Fresh out of medical school about a week into residency and had a pretty sick septic patient that I really wasn't sure how to take care of yet. Pretty sure the nurses liked to screw with the new interns. They kept yelling "what should we do doc?". I asked them to put in a foley not knowing what to do' one patted me on the back and asked "how about we start with some fluids first?"

So what do you actually expect from nursing week? What type of gifts do you expect? Real question. I take back that many of the nurses complained about what we bought for nurses week, it was a select few. What got me so mad is that I am involved in 0 aspects of the nursing staff. I don't hire them, fire them, or pay them. I am merely an employed worker (with a small percentage of my pay based on what I bill) much like the nurses, techs, and clerks that I work with. I am not the nurses "boss" but I am the leader of the team when it comes down to patient care. Even though I am not the boss, nor in charge of their paycheck I still find that a good RN (same goes for the other ER staff) makes my job a ton easier. So it is not like I wrote off the expense of nurses week on the company. It was straight out of my paycheck. To complain about that is pretty ridiculous.

Sounds like I really got to ya with that anger. I was actually already set on medical school when I started working as a CNA. Seemed like a good job with decent pay for a college student, plus worked at the place my grandmother lived so got to spend time with her. That and med schools love it. Didn't mind working for RN's most of them I am still friends with. Anyways the EMR went down a month or two ago where I work. Had to go back to paper charting when one of the nurses grabbed me for an order one of the interns wrote. 1 L water, apparently the RN went up to him and they told the RN that tap water should just be fine.

Whoa whoa whoa. Talk about sweeping judgements. I never said nurses are drunks. I said the nurses called in to get drunk. Heck every year all my medical school friends take 4 days off and head to my cabin to get rip roaring drunk. It doesn't make us drunks nor does it make the RN's alcoholics for drinking one night. Also I am definitely not bitter nor do I have "anger management" issues. I love taking care of patients and love my job. Yea I am pretty fresh out of residency and have a ton of loans and it pisses me off to have the amount of loans I have but I can pay them. Also I get along with most of the nurses I work with. Heck when I applied for my current job out of residency I needed a letter of recommendation from an RN I worked with and about 15 signed a "committee" LOR for me. Also this whole thing about "spreading germs" is ********. Most colds don't need you to stay home. Throw a mask on and do your job. I did that several times throughout residency. Maybe it is the US medical training but my residency had the idea that if you called in you better be being seen by one of your colleges in the ED (I was an Emergency Medicine Resident). That may not be right but if one of your co-residents has to come in on their precious day off it better be legit and not for some party. Still now, as an attending, calling in has a huge burden on the department. It doesn't mean shutting down a couple rooms, it means someone has to come in or we shut down 14 rooms. My partners would fire me if I called in more than 1 time per year unless I had really good reason. This brings me to the entire point of my tirade. This thread is ridiculous. I have no doubt that occasionally doctors say dumb **** (If I swear does that mean I have anger issues?). It is just hilarious that a forum made of nurses who have 4 year degrees (and often 2 year degrees in the US) think they know soooo much more than doctors that did at minimum 3x's the training you did. What I am actually bitter about is the national consensus that nurses are "heroes" (I don't necessarily disagree with this but so is anyone that has to save lives.) Overall the average MD has a better work ethic than the average RN (see above about calling in.) Many nurses (whoa no "sweeping" judgments I said many not all) need a pat on their back and to be told how important they are just to do their damn job. The "hero" nurse gets up to take care of patients. Just watch your RN friends posts on Facebook this holiday season. They are "heroes" for working christmas. The doctor just signed up for it because they chose the profession and because we make more money we somehow aren't missing family like the nurse or tech is. Just look at "nurses week". I lurked this forum around that time and how many people cried about the "gifts" they got for that week. Personally the ED docs where I work all pitched in for catered lunches for 5 days straight. A few of the nurses ******* that we didn't get "low fat options" and next year I won't contribute. Apparently there is a "doctor's day" and I didn't even know that except I got a pen from administration. Again I don't need a pat on my back to do my job. Anyways I just got off the "whambulance" and I have an anger management session to get to. Discuss

Also over Halloween there was a big party hosted by one of the ED docs. I had to work that night and had to miss the party. Every single doc and resident showed up to work. Six, yes say it with me, six RN's and 4 PCA's called in that night. I know for certain 5 of the 6 RN's and all 4 PCA's that called in were at that party. Still not a single resident or physician missed work. It is hilarious how all the RNs care sooooo much about the patient. Lets face it Doctors cannot miss work and our work ethic won't let us call in. In 3 years of residency I never once called in and was physically told I had to go home twice after showing up. Yet RN's care soooo much about the patient that they will call in to go get drunk. I guess I showed up to get my money because that is all I wanted. Pathetic.

What ignorance. Go through 4 years of college and 4 years of medical school to be 300K in debt and work for another 3-5 years at just above minimum wage. Yea totally in it for the "money". Sure some physicians are in it for the money and those are often very bitter physicians who didn't realize how much time they had to put in before they made a dime. Yea I am out of residency and make a damn good living but I worked for it (and am paying for it). Sorry if you want to make the big bucks do the schooling. Also just because I make more then you does not mean I don't care, I know crazy idea!. Just the last night I had an RN ask "really you want to give 4 of morphine to that old lady!?" Yea the one screaming in pain I sure do. An hour later still no pain med given. Finally had to physically walk the RN to get the damn morphine and give it to the poor patient. Thats just one example of an RN sitting around playing candy crush so I am sure that means all nurses do it. Also talk about a freaking scam. A 2 year degree to get an RN and make more than teachers, firefighters, and serviceman. That is the definition of "in it for the money". Don't forget the CRNA's trying to find the easiest way to make a buck.

Very common. Where I did residency I needed 15 central lines to be "signed off" to do them solo. I was supervised by a senior until I hit them which I did probably 6 months into intern year. Still we had a rule that as interns someone supervised so after I hit 15 a senior would sit in the room. I rarely was supervised by an attending. After intern year as long as I had hit my 15 I could put in a CVL solo or supervise an intern. I always documented "Dr. Attending was available and the supervising physician for the procedure." If I documented "Dr. Attending was present for the procedure" I feel like that would be wrong. Obviously available ranged from holding my hand to sleeping in the call room. Still this is common place. Most places have a credentialing committee. Like I said my institution credentialed at 15 CVL's so if we hit that we were essentially signed off. Still when I was signed off it was essentially up to the Attending how confident they were. If they wanted to be right beside me they could but if they wanted to sleep could do that also.