larhigh

Why couldn't you bolus the amiodarone? Briefly stop the dilt, flush the line and give the amiodarone 150mg, flush again, restart the dilt. Also, a second attempt at adenosine 12-18 mg to determine rythm would seem to have been indicated. If it was new onset a-fib or flutter, you could do a cardioversion attempt. I too would have been concerned about sepsis and sinus tach being a possible rythm, especially if she might have had pneumonia. Should have called a cardiologist for advice. I haven't worked ICU in more than 5 years but it seems like afterload reduction was indicated, possibly with a combination of dobutamine and nipride (what with the 92% on NRB). What did her xray look like? Did she have rales most of the way up? JVD?, etc, She needed a PA catheter. I wonder why they didn't want a central line?

If you work in an ED that has great patient access to the ICU, your ICU skills might not be up to par. I know a lot of ED nurses who have real trouble calculating constants for vasoactive drugs for example. Many ER nurses use a standard starting rate for each of their inotropes, etc. On the other, hand if you work in an ED where ICU patients are frequently held over, you should qualify as a critical care nurse. I think that JCAHO requires that patients who "are admitted" receive the same standard of care that they would receive in the area that they would be admitted to if a bed was available.

If you work in an ED that has great patient access to the ICU, your ICU skills might not be up to par. I know a lot of ED nurses who have real trouble calculating constants for vasoactive drugs for example. Many ER nurses use a standard starting rate for each of their inotropes, etc. On the other, hand if you work in an ED where ICU patients are frequently held over, you should qualify as a critical care nurse. I think that JCAHO requires that patients who "are admitted" receive the same standard of care that they would receive in the area that they would be admitted to if a bed was available.

1. What protocols do you use. i.e. Abd pain gets a line, labs, etc, We have a bunch of general protocols that are mostly related to the triage nurse ordering labs and x-rays. For example, for a patient who comes in with symptoms of ACS, the triage nurse orders the EKG, Labs, O2 as necessary, IV, etc. The one thing that we can't do in our protocols is order medications. So if the patient needs ntg. etc, we have to get the doctor to do that. 2. How invasive are your pain protocols. i.e. Can you give an isolated extremitiy injury i.e. obvious fx get narcotics in triage. (This is just a hypothetical example) We do not have a pain protocol as the nurses are not allowed to order medicaitons. However, for suspected fractures the nurse does order the xray, etc. 3. Does it make a difference in how fast patients can be seen, treated and released. Yes, if the diagnostic studies are started in triage, it speeds treatment time. 4. Do they empower you as a nurse or make you life harder They can make life easier for everyone. The only time it might make life harder is when triage is really busy; then, the time it takes to make the orders will slow the nurse down. 5. How often do the powers that be check to make sure your following protocols. It depends on how much time the powers have to do this. Our protocols are not mandatory--the word "may" is used a lot. 6. How often do your Doc's disagree or stray from the protocol They are always grateful that the nurse has started the ball rolling. 7. What are your thoughts on protocols? Pos, neg etc. I think they are great.

I think the scenario you describe could happen in any ER--it just depends on who was on duty. I agree with the previous comments that the ED is not the place for Inpatients to be sent for procedures since the ED is technically an Outpatient area. I also agree with the previous comments that the ED is the one hospital area that is not allowed to say "STOP" we are too busy, close the doors etc. The ED becomes the dumping ground for all types of patients and might have multiple emergencies going on at once and with questionable staffing levels on top of that. All that said, we do have to think about the patient and the availablity of needed services. If the ENT doctor was not able to find a facility other than the ED to take care of this patient, then the ED was the ONLY choice. Sorry about your experience, we aren't all grumpy!