Rules for the ER (long)

[EDValerieRN]

The Emergency Room

1. The world of ER does not revolve around you. There are sick people here, and you aren't one of them.

2. Our definition of sick is not your definition of sick. If a member of the ER staff says that someone is sick, it means that they are in the process of DYING. They have had a massive stroke, are bleeding out, having a heart attack, or shot. We don't consider a tooth injury sick. Painful, yes. Sick, no.

2. At any given time, one nurse has four patients. One doctor has up to 15. There is a law (similar to Murphy's) in the ER. If you have four patients:

• One of them will be sick (see #2 for definition)
• One of them will be whining constantly
• One of them will be homeless
• and one of them will be the delightful patient.
• Don't be the whiner. Please.

3. Physicians and nurses are not waiters. We are not customer service representatives. This is not McDonalds, and you very well may NOT have it your way. Our job is to save your life, or at least make you feel better. If you want a pillow, two blankets, the lights dimmed, and the TV on channel 14, go to the Ramada.

4. If you have one of the three, go to your own doctor in the morning:

• A cold
• The flu
• A stomach virus

5. If your child has a fever, you had better give him tylenol before coming in. Do NOT let the fever remain high just so I will believe the child has a fever. Do you want your child to have a seizure? Do you?

6. We have priorities. We understand that you have been waiting for two hours in the waiting room. If you don't want to wait, make an appointment with a doctor. The little old lady that just walked in looking OK to you is probably having a massive heart attack. That's why she goes first.

7. Do not ask us how long it will be. We don't know. I don't know what's coming through my door 30 seconds from now... so I surely don't know when you'll be getting a room upstairs.

8. We are not for primary care. Get a family doctor, and go see them.

9. If you have diabetes and do not control it, you are committing slow suicide.

10. We know how many times you've been to an ER. We can usually tell if you are faking it on the first 5 seconds of talking to you. Do not lie to us. If you lie about one thing, we will assume you are lying about everything. You don't want that.

11. If you are well enough to complain about the wait, you are well enough to go home.

12. If your mother is a patient and we ask her a question, let her answer it.

13. If you see someone pushing a big cart down the hall at full speed and you hear bells going off.... do not ask for a cup of coffee. Someone is dying, you inconsiderate %#@^. In the ER, bells don't ring for nothing. Sit down, shut up, and let us work.

14. If you have any sort of stomach pain and you ask for something to eat, you are not that sick.

15. If you can complain about the blood pressure cuff being too tight, or the IV needle hurting, you are not in that much pain.

16. If you want to get something, be nice. I will go out of my way to tick off rude people.

17. Do not talk badly about the other members of staff I work with. The doctor that you hate? I work with him every day, and I know that he knows what he is doing. I trust him a lot more than I trust you. I am not here to be your friend, and neither is he. I will tell him what you said, and we will laugh about it. If you want a buddy, go somewhere else.

18. Every time I ask you a question, I learn more about what is wrong with you. I don't care if I ask you what day it is four different times. Each time I ask, it is for a reason. Just answer the questions, regardless of if you have answered them before.

19. Do not utter the words "It's in my chart." I don't have your chart, and I don't have the time to call and get it. Just tell me.

20. Do not bring your entire posse with you. One person at the bedside is all you need. It is really difficult to get around seven people in the event that you are really sick.

[snowfreeze, BSN, RN]

Sick people are grouchy cuz they are sick, student nurses are living in some kind of "ideal perfect nursing world" with limited sleep and lots of stress. Real nurses vent among themselves and get on with their work.

If you as a patient have what seems like a grouchy nurse, maybe that nurse has worked a third or fourth 12 or 16 hour shift, has not seen their children for 4 days and is hungry and has to pee. We are humans too, believe it or not! Oh yeh and so far this has not been designated as a 5 star resort.

[TazziRN, RN]

Sugar9486 said:

we're just going to have to deal with people coming to the ER because the person doesn't have insurance or doesn't have a PCP.

Not having insurance does not mean one can't have a PCP. ER bills for a pain that's been going on for three months are MUCH MUCH larger than one for a visit to a PCP as a self-pay pt. And I have complete sympathy for someone in pain at 2 in the morning, but not if that pain has been going on for the aforementioned three months, sorry.

For those of you who say that each person considers their problem an emergency, I will never forget the horribly busy night when the staff was tied up with a code, and the clerk and LVN dealt with the rest of the ER. One irate man whose child was there with a cough (a COUGH, of all things, in the middle of the freakin' night!) stood in the doorway and told the LVN that we "should stop working on a dead man and take care of the living." This is all too common. Yes, when you are sick or in pain you want to be tended to as soon as possible, but I will NOT tend you at the expense of the trauma that just came in the back door. Pain is an urgent/emergent problem, but pain does not kill. Illness does not kill at the snap of the fingers. Traumas do. Your abdominal pain may very well be appendicitis and you may very well end up in the OR in two hours, but right now I need to deal with the drowning victim that is spewing up blood and trying really hard to die. Someone on here said something about imagining being the pt ourselves. I say to you: imagine that YOUR loved one is the trauma/code that the staff is working on feverishly. Would you like it if your loved one were abandoned for the lady across the hall demanding a blanket or a pain pill?

[caroladybelle, BSN, RN]

Sugar9486 said:

If you live in an area with no urgent care centers where are the people who don't have a PCP or don't have insurance suppose to go. People go to the ER because they need help, not because they want to make the nurses mad because that nurse doesn't think that they are ill enough to be in the ER. I totally argree with rosieseattle. The ER is a place for people from all walks of life. Just because the nurses feel that the nonemergent case should wait does not mean that all people agree with them. If we lived in a society where health care was free and no one needed to pay for it, then yes there would be less people in the ER day in and day out, but until that happens (Which doesn't look like it's going to happen any time soon) we're just going to have to deal with people coming to the ER because the person doesn't have insurance or doesn't have a PCP.

And yet many of those coming through that door presenting with the most benign issues have insurance/medicare or medicaid. Which means that their health care is subsidized.

And who is responsible for getting a PCP. Well, let's see that takes a little effort on the part of the individual, to take the initiative to find one when you are healthy....much like the initiative required to go to school, keep a job, plan your family and manage a budget.

Nothing is "free"....it all costs something to someone. When a repeater that has had social services REPEATEDLY get them free meds, safe housing, and a regular counseling session courtesy of the local underfunded clinic and we have detoxed them on our penny, and they return in less than 96 hours because they just couldn't "handle" things, one realizes the answer is not a free ride. I have seen dozens of people that "let" their free scripts run out, sell them on the street (at the corner of the hospital, - Philly) , and miss all those appointments because they "overslept".

Health care is like many things in life. While there are poor sad cases everywhere, there are many people that have to have healthcare spoonfed to them and still will spit it out. We only value what we have to work to maintain, and too few people are willing to "work" for their health...to pay out the bills for its maintance and do the footwork to find that MD BEFORE they get sick. Or go to the local charity clinic or have the MD/NP that will take payment plans (and I have done this for myself, uninsured and recovering from major illness). Is it embarassing?....yes, but you can do it.

Yes, there are some hard cases in the ER...the tourist, the suddenly terribly ill and the areas without many MDs. But there are many many more that just haven't planned well, or won't take their meds (and can afford them), or have been hurting for days but it was just too "inconvenient" to go during the week.

But then what do I know..I've only worked as a nurse for 13 years, and had to get healthcare as an uninsured twenty something.

[jonear2, RN]

Once upon a time many moon (7 months) ago I was a student nurse who took the FLorence Nightengale pledge to be selfless and loving and caring and whatever else it said. Then one day I became licensed and still I was hopeful and wide eyed. But I started working in a teaching hospital, the county funded teaching hospital and I have learned one thing if nothing else... ready...enabling patients to depend on others IS NOT helping them. Somewhere along the way responsibility for one's own actions fell by the wayside. I used to be embarrassed to give patients DC orders that said "stop smoking crack" now I am blunt about it. You will die if you continue to do this. That does not mean I or any of the other posters are heartless witches who dont know what its like to be in the patient's shoes.

I had a patient 3 days ago who said "Move my leg 3 inches to the right."

***?

No ma'am. You go ahead and try. (pt was 626 lbs)

Stop calling nurses who come home from their hell shift mean because they vent about their patients. I would like to think that even old Florence god rest her soul, came home at the end of the day after wiping dying soldier's brows and said "dude, that one soldier on the third rag pallet from the right, he was a total a-hole. Ive seen bigger bullet wounds on mosquitoes." You know why? Cause Flo was just as tired as the rest of us. Didnt make her a bad person? Nope just a tired nurse.

Sorry if this is rambling...just got off a 14 hour shift.

[Sugar9486]

i hope that all of you who have criticized every word I have said will one day be in my shoes... until then, good luck and keep helping people.. I guess thats all any of us can do....

[CoolhandHutch, MSN, RN]

Okay, now that we've heard from the "high and mighty" crowd who CLEARLY don't "get it".....can we continue please? The last few pages have been a royal buzz kill...

[veegeern, BSN, RN]

canoehead said:

If you come to the ER, and get brought right back, and two nurses descend on your loved one, don't repeat "aren't you going to get her a blanket?" five times. We won't be stopping the EKG, IV, moniters etc and tucking her in gently. It may be your priority but not ours.

And when I'm trying to get your loved one's Sat above 69%, my priority will not be the bath he hasn't taken or the breakfast that he didn't eat! Patient admitted for possible lap chole had an acute MI at on my last shift.

Seriously, you can adjust the context on these just a bit, and they'd fit perfectly on the floor where I work. I'm so glad that you ER nurses like what you do, because I don't want to walk in your shoes!!

[jonear2, RN]

ok here goes, this works for the floor as well as ED:

Do not tell me that the "other nurse" always gives you ativan, phenergan, benadryl, and dilaudid together, even if she did, I wont.

Please do not play possum on me. You will experience a sternal rub soon after if you do.

If I find crack hidden in the dressing of your dialysis port I get to keep it.

No I will not give you a "hit" of whatever it is I am giving your roommate.

If I find your significant other in bed, under the covers with you, sticking her tongue down your throat, I will document this behavior on my pain assessment as "complimentary therapy" and decide not to search trhough naked limbs to find your IV to give your morphine.

Do not lie and tell me you had a grand mal seizure a few minutes ago if you are on telemetry- I can tell if you were moving around.

[Altra, BSN, RN]

I also figured it would come to this ... someone would say, "that's just MEAN."

You have no idea ... you probably think it's the rare exception - the person who does not need to be in the ER and is impossibly demanding.

It is not the rare exception - it is the norm. Every single day, every single hour, mixed in the with truly sick.

Many people are intolerant of symptoms - aches & pains, dizziness, nausea, diarrhea, & 50 other myriad symptoms of random viruses & upsets that we all encounter now & then. But for what I'm now convinced is a significant number of people it is intolerable that "I DON'T FEEL WELL" and it is equally intolerable to have to take some responsibility to feel better -- i.e., take appropriate OTC meds, call a PCP and be willing to wait a day to be seen because there is no medical reason why you must be seen sooner.

No, no ... "I MUST BE MADE TO FEEL BETTER NOW." I'm dizzy, my back hurts, my foot hurts, my neck hurts, my belly hurts, I vomited twice ... and on and on and on.

And some of you tell me that I must consider this to be an emergency just as much as my patient in the next room who is a shade of gray normally seen only when I catch Casablanca on TBS.

Please.

[S.T.A.C.E.Y, LPN]

Sugar9486 said:

If we lived in a society where health care was free and no one needed to pay for it, then yes there would be less people in the ER day in and day out,

I'm sorry, I know one of the previous posters said to get onto the rules, but I just read this post and had to say something. I live in a country where Health Care is free (Canada), and that is definitely not true. Several years ago it was not uncommon to have ER wait times upwards of 8hrs, at all times of the day. Why? Because everyone went straight to the ER for their coughs, flu, prescription renewals, broken fingernails, headaches, etc. For many of the complaints that ER nurses have listed on previous pages. Many of these people did NOT need to be there. How do I know that? When SARS hit the city of Toronto, people finally realized that the ER is not somewhere you wanted to be unless you needed to be. The wait times in Toronto Emergency Rooms dropped.....to almost nothing in some places. Why? Because people who had problems that were not emergencies, took care of it via more appropriate routes. People who still had legitimate reasons to be in the ER, were still there, and were actually able to get the care required. The Toronto Newspaper actually published a big article on the front page showing an empty ER room, and asking the question "Where did all the patients go?". It was brought to the attention of the public that clearly many people who had previously been going to the ER did not need to be there. Sadly, only a few short years later, people have forgotten the true meaning of ER, and wait times are back up there. Providing free health care to the public does not result in people going to more appropriate places to be seen. Blunt public education about what types of things to go to the ER for was actually what changed people's thinking.

To all the ER nurses out there: I've loved reading through this thread, and understand that this is just a vent. Hopefully, more of you will have more rules to post ?

From my own clinical experience in the ER:

1. Do not interrupt the triage nurse (who is with someone else) to ask if you'll be seen by a doctor soon (when the waiting room is clearly full), then get exasperated when you're told it could be several hours. Especially when your chief complaint is that you were feeling *seasick* earlier today. You are now on land!

[andhow5, BSN, RN]

Treat us with respect and we'll treat you the same.

Do not chase me into another patient's room to complain about the wait. If you do, you WILL found yourself bounced out very quickly and *gasp* very UNPLEASANTLY.

Do not follow me into the bathroom. I am allowed to use the restroom whether you seem to think so or not. Do not follow me into the nutrition room - I have to get a cracker (with peanut butter), or a soda into my stomach to get my blood sugar up, or I will puke on you and pass out at your feet since I don't get a lunch OR a break.

No, you do not need to hold a family reunion in your treatment room. Two visitors at a time please, and you can switch off and on as needed.

No, you do not need to be standing in the hallway staring into the trauma or code bay. Return to your rooms and stay there. If you need anything, please use the call light which I have placed within easy reach of you AND your visitors.

Having family members/friends standing in the doorway, jingling change in their pockets, huffing and puffing, and coming to the desk and screaming you've been here too long and have someplace to be WILL NOT GET YOU SEEN ANY SOONER. And if you need to be somewhere else, by all means, GO. If you were emergent or even truly urgent, you would have already been seen.

Don't try to manipulate the staff members by attempting to turn us against each other - we're family, and have each other's backs.

Don't climb down to sit on the floor and start screaming that you fell and hurt yourself and point to the "injured" part of your body. I had you pegged the minute you walked in the door, and was watching from the other side of the curtain - and everything observed was charted (and an incident report was filed)!

If you do try to scam on a fake "injured" part, at least point to an area that is reddened, indented, bruised, bleeding, or has palpable crepitus. Make it interesting enough to get some attention.

Telling me to "look it all up" will GUARANTEE you that I will piss you off by repeatedly ask the questions ad nauseum until I get an answer. If you do not answer me, you will only experience my preventative health care lecture that includes a portion on actively participating in your health care by insuring your providers get timely, updated information with EACH visit (and you would have more fun watching paint dry than hear me talk).

If you threaten your nurse in any way, shape, or form - make sure you've thought it out and have the cahones to carry it through. Because you will find yourself hog-tied in 4-point restraints, in a spit mask, and under constant observation by a roomful of people that can appear out of thin air, within a split second. The more you scream about "suing" and "unfair", the longer you'll be restrained.

Just because your nurse IS a nurse does not mean they have given up their civil rights. You can and WILL be removed from the premises (if medically screened and cleared), sent to jail, and/or sued.

If you come in convinced you're dying, yet refuse IV, tests, medicines we order, but demand a specific script; you're NOT going to get anything.

Just because we are not able to give you advice over the phone is no reason to scream obscenities. Gee, if we had x-ray vision and could see you over the phone, we'd quit and start our own practice...

No, we can NOT call in refills for you, we're an ER, not a clinic.

No, we won't be doing the tests that your doctor "wanted done", because you will be seen by an ER physician who will determine what she thinks is necessary (and besides, the doctor you named died 10 years ago).

And how exactly are we supposed to tell you WHO cut your illicit drugs, and with WHAT? And how are we supposed to tell you that this "side effect" is going to last without that information?

Don't lie to me (I can smell a lie a mile away). If you're here for pain control, tell me and I'll do my best. If you invent a wildly spectacular tale about chasing Bigfoot through the forest and tripping over Thumper after looking up and seeing a UFO that was being piloted by a zebra and small panda bear, and then fall off a 30-foot cliff and hurt your great left toe as a result of the surprise... Well, first I'll try to convince you to publish your story (might go on the best seller list) and then I'll tell you that the doctor only authorized Tylenol for pain.

If you had that pain that "No one can ever figure out what's wrong and I've been to every specialist in every major city and I've just seen my own doctor again today", means we will NOT be able to help you. Follow up with the pain specialist as we have instructed the last 30 times you've been here.

I don't care "Who you know".

"Do I know who you are?" Yes, I know who you are; you are my patient. I wouldn't care if you turned out to be the leader of the free world. You will get treated appropriately, without special treatment. Everybody was created equal.

"I'm a nurse". Good for you! If you say that in passing, then I will gladly talk shop with you; just don't say it in passing TOO loudly, or we'll be tempted to beg you to throw on a set of scrubs, and ask you to PLEASE come down here to work with us (once we get you feeling better) as we are horribly short-handed.

"I'm a nurse". Good for you! If you say that as a threat, you'd better be all up on your nursing scope of practice, protocols, and certifications - because I will be all over you. You think throwing those 3 little words around will get you preferential treatment? Uh-huh...

[LeahJet, ASN, RN]

~dinner, movie, and a lady partsl exam are not the makings of a hot date.

~oh, and if you are lame enough to come to the er with any type of pelvic discomfort or discharge.....plu-ezze...have the common courtesy to wash down there. the person you are sleeping with has it bad enough...do we all have to suffer??

~it's bad karma to c/o ob problems just to get a "free" ultrasound.

~if you are a sniveling immature 20 or 30 something that insists on mama holding your hand....don't get upset when i ask your sexual history.

~don't ask me (in front of your husband) if your std could have been caught from a toilet seat.

can you tell who had the ob rooms the other night?