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.

[mmutk, BSN, RN, EMT-I]

Cyndi13 said:

Wow. I've wanted to work in the ER/ED for twenty years. I start ADN (RN) classes this fall. Felt like I was finally realizing my dream.

After reading this, I'm reconsidering. I never want to by this cynical towards a patient. Of course, I live in a small town, not a big city. Maybe things are just that much different there?

But WOW...

Well the ED might not be the best place for you then, because it's not all candy canes, friendly nursing school instructors, and kisses in the ED. The PACU might be better off for you. There is still allot of quick turn over there and the patient's are allot more thankful and less likely to assault you in the PACU. You can also use ACLS and PALS there as well, and a MD is not too far behind if you need them quickly (like the ED). Being a medic I figured you could handle the ED's rough patient population and the cynical effects they expose the nurses too, but certainly I don't fault you if you can't. Or even consider the OR, the patient's always have a smile on thier face in the OR and the nurses in turn do too.

Good luck in what ever you do when you graduate from nursing school.

[Cyndi13]

Thanks, mmuck! I'll have to keep your suggestions in mind. I can certainly handle the patients of the ER, my comment was directed to those that were threatening to "pay back" (so to speak) patients whose behavior they didn't like... I wouldn't expect sunshine, candycanes, and kisses in any department, lest I be quickly disillusioned! lol!

Glad you didn't take it as personally as others did. If it didn't apply to the reader, then they shouldn't take it personally

A friend of mine works in PACU and keeps telling me I'd love it, so I'll have to look into that a bit more :)

[justerrn, BSN, RN]

God bless you for having the wisdom and understanding. We have to laugh due to the large amount of sad and bad that we see. Anyone who has ever coded a small child and lost them and then had to walk into another room and be verbally abused by an impatient patient gets this thread. All our patients recieve respect..no matter how badlly you treat us. But dont expect our careers to last long. We won't stop fighting to save lives everyday..we will stop nursing due to the disrespect and ugliness of those who demand resort treatment.

santhony44 said:

I'm not an ER nurse and never have been, but I've been a nurse longer than some of the posters on this thread have been alive.

Venting and "black humor" are a couple of the things that allow nurses to deal with their frustrations and be able to continue on giving patients the care they need.

Don't ever think that a nurse who may come across as cynical or jaded can't be compassionate or can't have his or her heart broken over patients.

Friends of ours recently got a call that their beautiful, vibrant, healthy 20-year-old daughter had been taken to the ER near her college town several hours away. They drove to the hospital, knowing only that her rommate had found her unresponsive and called 911.

Her dad told me that he should have known what was happening when they walked into the ER and the ER staff- doctors and nurses both- were crying.

They had lost her. Their beautiful 20-year-old had died of a medical problem no one ever knew she had.

The ER staff had worked for hours to save her. She arrested in the ambulance; at one point she had a heartbeat but never regained consciousness. She got many units of blood (she had an internal bleed but the autopsy report is still pending).

That ER staff did everything humanly possible to save this girl, and it wasn't enough. I wasn't there to know what they did, but I know enough about nurses, doctors, and emergency rooms to know that they didn't quit until they had to. Then they cried, for her, her family, and themselves. Then they sent their condolences and apologies that they couldn't have done more.

They were "there for" this family in the only way that mattered. The family will never doubt that if she could have been saved, she would have been.

I don't think there is an ER or ER staff in the country who would have given any less.

I also have no doubt that it is their ability to vent, even if the vent takes the form of humor some may see as rude or uncaring, that helps them give everything they have to patients like this young woman. They see this kind of thing often- tragic, heartbreaking cases where nothing they do is enough. Nothing anyone could do is enough.

They need to cry- but they also need to be able to laugh.

That goes for all nurses. We all have things that drive us crazy, and things that break our hearts. Laughing, and crying, are much safer ways of dealing with those than drugs, alcohol, and so forth. We have to deal with what we see and do and our feelings about those things so that we can keep on doing it.

If you don't understand this, then maybe it would be good for you to learn not to pass judgement on things you don't understand.

[whichone'spink, BSN, RN]

Here's a rule: If you overdose on your bipolar medication, one that can be lethal in large quantities, you can bet your butt you are going to be held against your will. We are doing this for your own good, not to treat you like an "infidel terrorist".

[Roy Fokker, BSN, RN]

Boy did I need to read this thread! I think this is "therapeutic communication" - for nurses, by nurses

To all you people moaning about our griping and demanding "compassion for the patients" ... how about some "compassion for the nurse" ?

Yes, people aren't going to be on their best behavior when they are sick. I get that. Didn't get my license from a crackerjack box y'know...

Which is why I don't really care when someone lets out a cuss word or two because they're in pain, or when they're stuck with needles - anxiety can sometimes be worse than physical pain. Which is why I also don't take offense when someone with dementia swings at me or someone with AMS knees me in the gut.

And sure, if it's not going to be an issue medically [we're not looking for a PE, you're not hemodynamically unstable etc.] - I'll work with you on that IV and where you want it. Happy patients usually = happy nurses.

But you bet your bippy I have a problem with REPEAT offenders who are mean, nasty and disgusting simply because they chose to be. Who chose to treat me like garbage just because they happen to be intoxicated. Who are verbally abusive because they aren't being treated for the 9th time in 14 days for chronic abdominal pain who refuse to comply with treatment and instructions. Who try to punch me in the face as they are being discharged and then demand a cab voucher!

I mean, what blessed planet do you come from where ANY of this is "acceptable behavior"??!! Being verbally abusive shows you have no class, being physically abusive shows you have neither class nor sense nor shame!

* To the hysterical 19 year old female carrying on during the IV stick like someone was cutting off her arm - I understand IV sticks can be uncomfortable, painful even. I don't mind the whimpering or the ocassional shout... but the shrieking has got to go. You're not a 3 year old - please act your age.

* Wife comes in at 5 am with husband in tow for intermittent nosebleeds x 2 days. Yes she is on coumadin. They get my last hallway bed open (should give you and idea how busy we were for 5 am). I give the wife the same advice the doctor will give: "pinch you nose real hard, like so and hold for 20 minutes." I know this can be a challenge sometimes [i get frequent nosebleeds too] so I McGyver up a nose-clip (two tongue blades held together with rubber bands - works pretty good :)) Pt. is annoyed and frustrated but bless her heart, she's a patient trooper. Her husband on the other hand, is an absolute jerk. In my face every 10 minutes "why hasn't she been seen yet".

Guess I'm chopped liver... but anyways I tell him (the first dozen times): "Sir, I'm real sorry but we're real busy right now and there's only one physician on duty. We've called in additional people. The Doc will get to her when he can. I've already sent off her blood work and her vital signs are stable."

"This is crazy! What if there was a real emergency?!"

Well, you kinda answered your own question there now didn't you sport?

Of course I didn't say that out loud... but I was tempted!

* Yes, I understand that you don't have medical training or knowledge. I totally understand you were worried and you just wanted to "get it checked out". We'll happily work you up and pronounce the results.

What I cannot understand is you trying to tell me how to do my job - do I come over to your place and tell you how to do yours? You came to me and asked for my help, not the other way 'round, right?

What's even more baffling is that when we come back and say "nothing emergent is going on. It's probably ABC or XYZ. We'll fix you up with some medication for now. If you think you need more follow up, here are some suggested specialists"; you get visibly upset - even angry. Being told "you aren't going to die" or "you don't have some horrible disease or life-threatening condition" would make me relieved ... not some folks I guess!

Yeah, not knowing what's wrong can be frustrating - hence the discharge instructions with referral to specialists. Just because we can't find anything wrong today doesn't mean someone else can't - we're pointing you towards those people who can probably help you better than we can. But I guess it's still our fault.

* Yes, it's incredibly frustrating to be stuck down in the ED because there are no more beds in the hospital. We're full. What would you like me to do? Kick another patient out?

I think that's going to be my go-to phrase the next time I'm dealing with an incredibly insensitive person - "what would you like me to do?"

* "But I'm not pregnant!" Yes, I know. Pee in the cup for me anyway - seriously, what do you care? How is it going to make any difference to you?

I won't even get into how many 'immaculate conceptions' I've had. Never mind that TV show that's on these days...

* Every SINGLE room in the ED has a sign that says "ATTENTION PATIENTS: Please remove all clothing and put on a hospital gown prior to exam." It's in a nice, bold, easy to read print. The triage nurse ALSO tells everyone to do the same "Have a seat. Take off your clothes. Put the gown on open to the back".

You've been in the room 15 minutes: so why the hell are you still dressed?

* "You've got to help him! He can't get out of the car!"

Yeeeah - how did he get IN the car then?

* If you as an adult through your actions or inactions endanger the health or welfare of a child - directly or indirectly - so help me God! This includes frightening my 4 year old pt. with nursemaid's elbow because your drunken, drug-seeking, meth-abusing, cocaine-snortin' butt refuses to stop screaming and hollering for more "pain medicine" and generally carrying on and being verbally abusive to everyone around.

* I saw an ad on TV the other day for Children's Motrin. The ad claimed "the most used children's pain and fever reliever" (or something like that). I laughed my *** off...

Sometimes I wonder what parents did before there were EDs open 24x7 - what did yours do when you were sick?

*sigh*

It occurred to me the other day that everybody else in the world can say no.

Heck, even hookers can refuse to see someone.

We can't.

No matter how trivial or what BS complaint - everybody gets seen.

Takes a special kind of person and a special je ne sais quoi to do that.

ED nurses handle drama, trauma and sometimes 'drama & trauma' with great aplomb. That ain't the issue - it's having to constantly put up with "drama greater than trauma" that drives us to drink.

But we still take care of 'em.

Shift after shift after shift.

Because it is our calling. Or our sacred duty. Or our job.

Whatever the reason, we do it.

And we're darned proud of it!

[DebanamRN, MSN, RN]

A few thoughts on your post:

* To the hysterical 19 year old female carrying on during the iv stick like someone was cutting off her arm - I understand iv sticks can be uncomfortable, painful even. I don't mind the whimpering or the ocassional shout... But the shrieking has got to go. You're not a 3 year old - please act your age."

I've stuck 3 year olds who didn't scream as much. Shut up. I'm the person who need high-tech to get an iv on me. I came out of this hospital with my left arm black from shoulder to fingertips when my daughter was born. I didn't complain. You can deal too.

Which is why I don't really care when someone lets out a cuss word or two because they're in pain, or when they're stuck with needles - anxiety can sometimes be worse than physical pain. Which is why I also don't take offense when someone with dementia swings at me or someone with ams knees me in the gut.

Or spits at me, tries to bite me, claws me, throws food at me, etc. They can't help it. Anyway it could be me someday.

And sure, if it's not going to be an issue medically [we're not looking for a pe, you're not hemodynamically unstable etc.] - i'll work with you on that iv and where you want it. Happy patients usually = happy nurses.

Just please tell me before I stick you. I ask where you want it and where the lab finds a vein. I'd rather know!

But you bet your bippy I have a problem with repeat offenders who are mean, nasty and disgusting simply because they chose to be. Who chose to treat me like garbage just because they happen to be intoxicated. Who are verbally abusive because they aren't being treated for the 9th time in 14 days for chronic abdominal pain who refuse to comply with treatment and instructions. Who try to punch me in the face as they are being discharged and then demand a cab voucher!

I've pushed more narcs than the local drug dealer. And don't abuse me because you are killing you pancreas with your drinking. We have discussed this multiple times in your multiple visits. And don't abuse me because the cops once again picked you up from a snowbank outside the liquor store and brought you here. You know the score.

Wife comes in at 5 am with husband in tow for intermittent nosebleeds x 2 days. Yes she is on coumadin. They get my last hallway bed open (should give you and idea how busy we were for 5 am). I give the wife the same advice the doctor will give: "pinch you nose real hard, like so and hold for 20 minutes." I know this can be a challenge sometimes [i get frequent nosebleeds too] so I Mcgyver up a nose-clip (two tongue blades held together with rubber bands - works pretty good :)) pt. Is annoyed and frustrated but bless her heart, she's a patient trooper. Her husband on the other hand, is an absolute jerk. In my face every 10 minutes "why hasn't she been seen yet".

Guess i'm chopped liver... But anyways I tell him (the first dozen times) : "sir, i'm real sorry but we're real busy right now and there's only one physician on duty. We've called in additional people. The doc will get to her when he can. I've already sent off her blood work and her vital signs are stable."

"this is crazy! What if there was a real emergency?!"

i get nosebleeds too. I had my nose cauterized and it still bleeds. I like the nose clip great critical thinking at work. Plus, if you were unstable, you would be in a room.

* Yes, I understand that you don't have medical training or knowledge. I totally understand you were worried and you just wanted to "get it checked out". We'll happily work you up and pronounce the results.

What I cannot understand is you trying to tell me how to do my job - do I come over to your place and tell you how to do yours? You came to me and asked for my help, not the other way 'round, right?

What's even more baffling is that when we come back and say "nothing emergent is going on. It's probably abc or xyz. We'll fix you up with some medication for now. If you think you need more follow up, here are some suggested specialists"; you get visibly upset - even angry. Being told "you aren't going to die" or "you don't have some horrible disease or life-threatening condition" would make me relieved ... Not some folks I guess!

I've never seen so many people be so unhappy over good news. And no, we aren't going to do that MRI you have a prescription for. This is not what the er is for.

Yeah, not knowing what's wrong can be frustrating - hence the discharge instructions with referral to specialists. Just because we can't find anything wrong today doesn't mean someone else can't - we're pointing you towards those people who can probably help you better than we can. But I guess it's still our fault.

Of course it's our fault. We can't be expected to expect people to go to specialists. That's our job. Get out the magic wand.

* yes, it's incredibly frustrating to be stuck down in the ed because there are no more beds in the hospital. We're full. What would you like me to do? Kick another patient out?

Yes. Because its all about me.

I think that's going to be my go-to phrase the next time i'm dealing with an incredibly insensitive person - "what would you like me to do?"

I've actually done this. The looks you get are priceless.

* "But i'm not pregnant!" yes, I know. Pee in the cup for me anyway - seriously, what do you care? How is it going to make any difference to you? I won't even get into how many 'immaculate conceptions' I've had. Never mind that TV show that's on these days...

Surprise!

* Every single room in the ed has a sign that says "attention patients: please remove all clothing and put on a hospital gown prior to exam." it's in a nice, bold, easy to read print. The triage nurse also tells everyone to do the same "have a seat. Take off your clothes. Put the gown on open to the back".

You've been in the room 15 minutes: so why the hell are you still dressed?

Yes, this includes your bra. Its very hard to do an ekg with it on. I know. That's why I have scissors in my pocket for emergencies. I'll cut that bad boy off if I have to to save you life. Besides, its a hundred years old and the elastic is shot. I know you are on a fixed income, but come on, you can get a new one cheap at Walmart.

* "you've got to help him! He can't get out of the car!"

Yeeeah - How did he get in the car then?

Or, I can't wipe myself. What do you do at home?

* If you as an adult through your actions or inactions endanger the health or welfare of a child - directly or indirectly - so help me god! This includes frightening my 4 year old pt. With nursemaid's elbow because your drunken, drug-seeking, meth-abusing, cocaine-snortin' butt refuses to stop screaming and hollering for more "pain medicine" and generally carrying on and being verbally abusive to everyone around.

Yes!

* I saw an ad on TV the other day for children's Motrin. The ad claimed "the most used children's pain and fever reliever" (or something like that). I laughed my *** off...

Sometimes I wonder what parents did before there were eds open 24x7 - what did yours do when you were sick?

"I wanted you to see how high the temerature is" ok now watch your kid have febrile seizure. Btw, my folks gave us baby aspirin (no reyes then) and I give my kids generic adult Motrin (they are teens), but I've used tylenol and Motrin for every age group and usually generic. Guess what? It works! If the fever doesn't come down, come on in. Than something really is wrong.

*Sigh*

Double sigh.

It occurred to me the other day that everybody else in the world can say no.

Heck, even hookers can refuse to see someone.

We can't.

No matter how trivial or what bs complaint - everybody gets seen.

Takes a special kind of person and a special je ne sais quoi to do that.

Ed nurses handle drama, trauma and sometimes 'drama & trauma' with great aplomb. That ain't the issue - it's having to constantly put up with "drama greater than trauma" that drives us to drink.

But we still take care of 'em.

Shift after shift after shift.

Because it is our calling. Or our sacred duty. Or our job.

Whatever the reason, we do it.

And we're darned proud of it!

You go. And yes, I am proud of it. And I do have compassion. And unless you have walked in our shoes, please don't judge me. Because first i'll save your butt, than i'll wipe your butt, and lastly, for hcaps, I'll kiss your butt (OK not really but you will think I am). I am an er nurse.

[Raven Sierra, BSN, RN]

TazziRN said:

Caller #1: Are you guys really busy?

Me: Yes, we are.

Caller #2: Can you tell me how many people you have right now?

Me (counting staff bodies as well): A lot.

Caller #3: Is the wait really long if I come in right now?

Me: Yes. (I don't add, "If you're coming in for a hangnail I will make you sit out there as long as I can.")

Had this conversation with a caller almost verbatim, although mine wanted to make a reservation. I did manage to not laugh in the phone and tell them that the ED doesn't do reservations.

Oh, and this is for the posters who are saying, "Well, if you'd ever been on the patient's side...." I have. Several times. Acute pyelonephritis, meningitis, daughter's tongue lac (she bit it almost in half), son with anaphylaxis at 4 months old (banana allergy). It takes a serious condition to make me even consider a visit to the ED. And I expect to wait a LONG time. And I don't expect to be waited on, hand and foot. Yes, I know how awful you can feel (pyelo sucks....), and so do the ED staff. They're not sadists. But, as a rational person, I also know there's probably someone more critical than I am who's taking their attention. And I'm just glad I'm not the one who's got seven RNs and two MDs in their room.

[DebanamRN, MSN, RN]

"Oh, and this is for the posters who are saying, "Well, if you'd ever been on the patient's side...." I have. Several times. Acute pyelonephritis, meningitis, daughter's tongue lac (she bit it almost in half), son with anaphylaxis at 4 months old (banana allergy). It takes a serious condition to make me even consider a visit to the ED. And I expect to wait a LONG time. And I don't expect to be waited on, hand and foot. Yes, I know how awful you can feel (pyelo sucks....), and so do the ED staff. They're not sadists. But, as a rational person, I also know there's probably someone more critical than I am who's taking their attention. And I'm just glad I'm not the one who's got seven RNs and two MDs in their room..

Amen. I've been there with my parents and my kids. I haven't been a patient in the ER since 1970, so when it comes it will be a doozy.

We had a patient and his wife get upset because the patient didn't get his pain med right away. We were doing a code in the next bed. Pain may be a priority, but life trumps pain any day. People watch enough TV to know what a code is. And yes, there were 3 RNs, 1 LPN, 2 Multi techs, 2 Doctors, 1 Paramedic, 1 resp therapist, and the xray tech. And yes, I have been in 10/10 pain (burst ovarian cyst, gallstones, kidney stone to name a few).

[Ruby Vee, BSN]

i'm not sure where some of these posters get the idea that we grizzled old nurses have never looked at healthcare from the patient's viewpoint. most of us have either been hospitalized ourselves or had family members hospitalized -- or both. we know how it looks from the patient's viewpoint!

[sissiesmama, ASN, RN]

You are right about that, as I am reading this thread from my tele bed in the hospital - but I have to get my AN fix! Lol!

[floridanurse1983]

I went to the ED for the flu. I had the flu for three days and thought I could just rough it out at home. Was a holiday weekend and I wasn't able to even keep a(as in ONE) tablespoon of ice chips down at a time. Everything that went down came right back up. Decided to go only because I was feeling progressively hot, flushed, was having palpitations and felt like was going to lose consciousness when I stood up. That was the reason I went to the ED and they looked at me like I was an idiot for coming to the ER for the flu. Wasn't the flu I came for, it was the dehydration.

[NurseVoldemort, BSN, RN]

Oh man I love it! These are so FUNNY and even more TRUE!! I've only been nursing for 3 years, but in the ED, you really see how... Uneducated... the average person really is! WOW - people are just dumb sometimes!

Here's some of my most recent:

1."My back hurts" when did this start? "2 years ago" ***!? REALLY!? AND YOU FELT IT NECESSARY TO COME IN BY AMB!!?? "It's more comfortable than my mom's car." HONESTLY THAT IS WHAT SHE SAID!

2. Is the saline supposed to be cold? "Yes" OK I was just checking cause it's been cold every time I get it. - Prompted me to look at her records... she's been here like weekly for the last 6 weeks! OMG! HOW THE HECK do you not now know saline is cold!? You get it every time! CAN YOU SAY CASE MANAGED!? Yup! She is now!