Semi-rant: There is a "reason" why...

Posted
by Roy Fokker Roy Fokker, BSN, RN Member Nurse

Specializes in ER/Trauma.

most of us strive to do our best to get our alloted tasks done in the alloted time to the best of our abilities. and what we are unable to complete, we pass it on to our colleagues following us with a sincere apology - "hey, i really tried to get this pt. work up going but i kept getting hit with one thing or the other and i never could. i'm sorry".

those of us on the receiving end blanch initially but accept it as part of the game and proceed to play catch up the best we can. often times, it works. sometimes, it doesn't.

but the merry-go-round doesn't stop. patients keep pouring in, their numbers and their needs inexhaustible. and the "thin white line" of nurses and aides struggle to hold the front and manage the deluge.

what helps us immensely, is our shared understanding of the attitude that "nursing is a 24 hour profession".

but some times, our attitudes clash.

a 'vignette' from last night:

case:: giving report on a (now) stable ffff presenting with a chief c/o of "ruq pain" also presenting with mild r chest pain (non reproducible pain increasing with inspiration) and sob.

pt. was worked up as a "chest pain" (which meant cardiac workup - because of prior cardiac history). eventually, the cardiac labs came back negative and abd. ct returned positive for gallstones. pt. was admitted to med-surg post surgical consult.

report -

"why do you ed people always put ivs in the ac? don't you know how uncomfortable it is when the pt. comes to the floor?"

"i'm sorry but yo..."

"yeah you're sorry all right! you just stick 'em down there where you please and we have to chase after the pump when pt. gets to the floor!"

"ma'm, if you'd jus..."

"whatever. is there anything else? when are you bringing the patient up?"

i started to say something but just swallowed my thoughts. "nothing else ma'm. unless you have any questions for me."

"no".

and she hung up.

i wanted to feel mad and angry - but i chalked it up to someone who'd been having a bad day and let it go at that (but it gives folks the right to take out their frustration on me?) besides, i had two patients on ventilators who needed my attention as well and a fresh "chest pain" brought in by ems to assess.

but there's a "reason" why...

because the ed doc was more concerned about the inspiratory chest pain/sob, i stuck the iv (18g) in the right ac while drawing initial labs - in the off chance that the doc would also order a cta to rule out pe. it's happened more than a few times to me, where i've started a line on patients who ended up getting cardiac workups - where i'd have to stick them again because of wanting to do cts.

why stick the patient twice? if you were the patient, would you prefer to be poked 2-3 times or once?

besides, when pt. presented to the ed, pt. was hypotensive and tachycardic - even if the cardiac angle was ruled out, pt. was atleast apparently hypovolemic. which meant pt. would need fluid resucitation (if not more. pt. was also running a temp. who the heck could tell if pt. was septic at that point or not?)

now, put yourself in your nursing shoes (no matter the department) - when you have to start an iv, wouldn't you go with your best shot? even if it was in the ac? or hand, or thumb, or pinkie for that matter? access is better than no access, right?

it's all well and good to grouse at me after the patient has been here for 4 hours under our care about the placement of the iv - did you see the patient when they initially got here? pale, dehydrated and retching and shaking all over? did you see the patient's veins when they got here? i'm not saying i'm "mister iv and i can draw blood from a rock" - but neither am i an oaf.

just as it's a "pain in the butt" to have patients with antecube ivs on a pump, it's just as much a pain in the butt to have a patient in the ed with no venous access, no way to draw labs, no way to administer meds/fluids... heck, no way to do anything!

fact of the matter is, unless it is absolutely required or an emergency - i first offer the patient the choice of where they would like the iv (which arm and where). if i can meet their choice somewhere between my requirement (e.g.: i need an iv in the antecube while pt. would prefer an iv anywhere in the non-dominant arm), i'll do my best to get one in the non-dominant antecube. if neither need nor emergency is a criteria, i let the pt. pick a site and i'm more than happy to oblige.

blood transfusions (or in critically ill patients), i'll strive to get 2 (if not more) large bore lines - with at least a 20g/18g in the forearm if possible. because i know what havoc an antecube iv site can play with blood transfusions through a pump. how do i know this? because i'm not speaking from ignorance. i worked a ridiculously short-staffed floor before i switched to the ed. i've lived the 'floor life' (and i quit not because of the patients but because of management).

i'm very tempted at times to tell folks who complain about my iv placements that "ok, i'm pulling this one out. please do as you please when the patient is your responsibility. after all, you know how to start ivs too, right?"

i don't question how you do your job - what makes it ok for you to question how i do mine? this isn't a question of "gross negligence" or "unsafe standards", is it?

on some nights, when i actually have a few minutes to spare and based on the admission orders of the pt., when giving report i'll even offer to start a new line on the patient in a less 'restrictive' area to the nurse accepting report and depending on their response, i'll start a new line if i can find a spot and i'll leave it up to the accepting nurse's discretion as to which line s/he wants to discontinue (or keep).

i guess all i'm trying to say (besides blow off some steam), is that "things get done in the ed the way they do for a reason". we are nurses just like you - we have to deal with similar pressures and expectations of the job just as you do. we aren't lazy and we aren't out to make your jobs harder than it already is.

but please - don't dismiss what an ed nurse has to do or say without hearing the "why" part of it. it makes it that much harder to defend your actions (why you can't take report right away, why the room isn't ready etc.) when the shoe is on the other foot.

a tired and mildly irritated,

roy fokker

ps: please - this is not a thread about ed nurses versus the rest of the world. let us not turn it into that. this is just one ed nurse semi-ranting about some recent unpleasantness at work.

pps: for the record - most of the nurses i give report to are professional, co-operative individuals. i would never dream of disparaging them - no matter what time of the shift i find myself giving report, they've always been courteous and respectful.

addendum: if an ed nurse seems apologetic about giving you report on a patient close to shift change, please understand it's not because we're 'mean', 'want to hold onto our patients' or whathaveyou. we have no control over the issue (this issue was addressed somewhat in depth here). we understand that you have morning meds, accuchecks, lab draws, vital checks and your own report to get through...

please don't laugh derisively over the phone and dismiss my genuine feelings on the matter - i'm not an idiot and i mean what i say.

Edited by Roy Fokker
Addes emphasis to post-script

Mulan

Mulan

2,228 Posts

Heck, I'd be glad that they had an IV.

Isn't nursing grand???

CoffeeRTC

CoffeeRTC, BSN, RN

Has 25 years experience. 3,734 Posts

Heck, I'd be glad that they had an IV.

Isn't nursing grand???

Me too. some people just don't have a clue.

eriksoln, BSN, RN

Specializes in M/S, Travel Nursing, Pulmonary. Has 15 years experience. 2 Articles; 2,636 Posts

https://allnurses.com/general-nursing-discussion/ok-ed-nurses-368296.html

Go ahead and rant. I started this thread with a rant, and learned some very valuable things. Appreciated the ED nurses who posted with the intention of teaching me a better/clearer way of looking at things. I now understand how harmfull nurses who refuse report or give ED nurses a hard time about it are to the pt. and nursing process overall. I never did that, but I had some resentments against ED nurses and they were killed by this thread.

I love talking ot people from different departments and getting a better picture of the whole process the pt. goes through from admit to discharge. Sometimes I get mentally stuck in my bubble world, think the care begins and ends with me. That attitude is bad in that it is arrogant for one, but also it is damageing to me. I personally used to really take it personally when someone under my care complained about anything at all.........took it too personally, got defensive. I didnt allow for the fact that there are times it has nothing to do with anything I did (for instance, the pt. who is in ED for 9 hours on a stretcher for reasons outside my control, then comes to me already upset and has already decided our care is terrible).

I think more threads like this can be good, if people post with the intent to teach and people read with the intent to learn. If that is truly our intentions, debate will assume and people will learn something like I did.

I've wondered why people like the AC so much for IVs. I was curious though, not anything I would mouth off about in the middle of report. Her focus during that report was herself.........could have spent that time asking questions about the pt. that may have been usefull in some way. Forget her. Dont be upset with the few RNs who cant help but vent on other departments. I HATE THAT. Continue to be kind to those of us who are genuinely interested in the whole picture, not just our little corner of the picture.

truern

Specializes in Telemetry & Obs. 2,016 Posts

Roy, let's hope that she had the sense to cease and desist with the attitude before the patient arrived. :(

I love these threads that let us get to know the other sides in nursing...hate them for the OPs, though.

(((((roy)))))

travel50

travel50

Specializes in LTC, geriatric, psych, rehab. Has 26 years experience. 224 Posts

I remember one time when working in the hospital, feeling slightly aggravated with the ED. Don't remember the details, but their timing was not suitable to me, neither was where they had put the IV. I quickly got over the IV part b/c I really was very grateful that they had one. By the end of my shift, I felt bad for being aggravated and determined never to be so childish again. Then I joined the army reserves, and was sent to the ED for my weekend drills. Oh, what an eye opening experience!!!! I gained such an appreciation for what those nurses have to deal with. I remember wishing for the days when I'd get a couple of new patients on my evening shift. The floor nurse who was rude needs to spend a little time in the ED. Let her get several accident victims at one time, followed 5 min later by the chest pain, then right after that by the young mother running in screaming holding her lifeless infant. That nurse would go back to the relative safety of her floor a changed person.

Roy Fokker, BSN, RN

Specializes in ER/Trauma. 2 Articles; 2,010 Posts

Go ahead and rant. I started this thread with a rant, and learned some very valuable things. Appreciated the ED nurses who posted with the intention of teaching me a better/clearer way of looking at things. I now understand how harmfull nurses who refuse report or give ED nurses a hard time about it are to the pt. and nursing process overall. I never did that, but I had some resentments against ED nurses and they were killed by this thread.
Hi Erik :),

Believe it or not, I'm quote glad you started that thread. And what's more, I'm pleased that it has turned out to be a learning experience for all of us - ED nurses, floor nurses and others too :) It's been a civil discussion and I really appreciate that (as a nurse, as a moderator on this website and also as a human being).

I didnt allow for the fact that there are times it has nothing to do with anything I did (for instance, the pt. who is in ED for 9 hours on a stretcher for reasons outside my control, then comes to me already upset and has already decided our care is terrible).
That's a GREAT point there Erik! Actually, I use the more "soft, comfortable beds in the floor" as a carrot when I round on my patients in the ED waiting for a bed assignment. I do my best to explain WHY they're still stuck in the ED (waiting for orders because ED docs don't follow pts. in the hospital or needing to 're-arrange' beds upstairs to acomodate the pt. etc.) - most patients understand (even if they're a little frustrated about it). The few that don't, well; somehow it has been my experience that NO AMOUNT of explanation will satisfy them.

I think more threads like this can be good, if people post with the intent to teach and people read with the intent to learn. If that is truly our intentions, debate will assume and people will learn something like I did.
To be honest, once I typed that whole mess out (congratulations if you made it to the end allnurses readers! :uhoh3:); I felt much better. I don't honestly consider it a "rant" in as much as consider it a "I'm a little ticked off and here's why" deal. I doubt my real 'rants' would be fit for PG-13 company :)

With that being said - I'm glad you appreciate threads like this. It's not an intention to finger-point but more - as you pointed out - with an intent to inform others about the "why". I happen to think the "why" is very important when it comes to nursing - no matter what the discipline or job or circumstance.... and I hope others see it that way too.

I've wondered why people like the AC so much for IVs.
If I may intercede for just a quick second and semi-add on to my earlier post:

Some of the reasons ED nurses choose antecube IV sites as a FIRST CHOICE over others:

* In an emergency, you find the quickest IV access. Antecubes are nice because they're usually very prominent, they sport good sized veins and have reasonably 'standardized landmarks' for the human species. To wit, antecube veins aren't ones you usually have to "hunt for". Especially helpful if your patient is retching, shaking, combative/violent/uncoperative, unresponsive etc.)

* It may not be an "emergency" but certain 'procedures' require large bore IVs - besides the afore mentioned 'CTA of the chest to rule out Pulmonary Embolism', certain other tests require IV access that can accommodate a high flow of fluids (be they IV dye or plain fluids).

Fluid resuscitation is a scenario that comes instantly to mind. Veins in the antecube are bigger, fatter, broader and more compliant to having high volumes of whatever (fluids, blood, pressors, antibiotics, and other vesicant medications etc.) being 'dumped' into them.

* Sometimes that's ALL someone can get (policy at my hospital: 2 RNs get 2 chances each. After than, a Doc has to put a line in - IJ, Femoral, Central etc.)

I was curious though
Don't blame ya (Hence why I titled my thread "semi-rant"). When I was a floor nurse, it used to intrigue me no less as to why so many of my ED admissions had antecube IVs. It intrigued me - but I never copped an attitude about it...

Continue to be kind to those of us who are genuinely interested in the whole picture, not just our little corner of the picture.
Thank you.

I'll keep that in mind (and vice-versa I hope) :)

cheers,

MAISY, RN-ER, BSN, RN

Specializes in ER/EHR Trainer. Has 6 years experience. 1,082 Posts

I only worked the floor briefly and for the nurses who can place IVs, using evidenced based practice the IV that fits the job is used for infusions. And I believe that is good practice.

HOWEVER,

ER mentality is be prepared for whatever...so large fluid infusions, blood, PE studies or IV Dye is preferred in larger veins and a larger catheter. So 20's and larger are the rule not the exception. I also access ports although my colleagues don't, WHY? It's a sure thing!

I am a big believer in sparing the vein, HOWEVER, if they(patients) present with any difficulties they are getting at least a 20 where I can place quickly and easily-that's usually the AC...caveat-I do try for the outer as I find that does not become painful, or positional. Usually not available on the sickies.

Another place that's great on the elderly and not so fragile is in the bicep area-that vein remains stable and fairly large, and now due to tissue loss VISIBLE. It will not blow, is a large vein, and usually comfortable for the patient. Hate seeing elderly patients with blown, bruised extremities.

PS If we are holding the first thing I do before shift ends is get hospital beds and barcolounger chairs. If I can ensure comfort I do, believe me the receiving nurse doesn't have to move the patient, the nurse taking my patient in the ER doesn't have to keep readjusting stretchers and patients for comfort, and the patients are happy and do not call. Thinking ahead saves you steps. Oh I also make an admission clean up kit, so they will have everything they could possibly need.

My :twocents: as usual,

Maisy

Edited by MAISY, RN-ER
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VivaLasViejas, ASN, RN

Specializes in LTC, assisted living, med-surg, psych. Has 20 years experience. 142 Articles; 9,964 Posts

Heck, I'd be glad that they had an IV.

Isn't nursing grand???

As a M/S and ICU nurse, I was GRATEFUL whenever the pt came up from the ED with a patent IV.......and when they had time, the ED nurses would insert the Foley and the NG tubes if the situation called for it. You wouldn't hear any guff from me about the placement!

Ah "Writer Roy" . . .. a little article/inservice might be in order. ;)

I agree with the reasoning behind AC's in the ER.

And, since I worked med/surg prior to that I would attempt to place IV's in areas more conducive to an admission to the acute floor.

I also worked OB - gotta have large-bore IV's for that too.

I also like the biceps area Maisy.

steph

As a M/S and ICU nurse, I was GRATEFUL whenever the pt came up from the ED with a patent IV.......and when they had time, the ED nurses would insert the Foley and the NG tubes if the situation called for it. You wouldn't hear any guff from me about the placement!

Oh yeah, we did that too!

steph

canoehead, BSN, RN

Specializes in ER. Has 30 years experience. 6,824 Posts

AC in the ER tends to be the first choice because the patients are going to be subject to lots of tests (CTs need AC IVs or they will stick them again), and fluid resuscitation, and multiple drugs landing in circulation in a relatively short period. Anyone vomiting or with poor color gets a big needle in the AC, and after an hour most would be fine with a 22, but we don't know who is OK, and who is really sick when they walk in.

Our hospital does a lot of holding in the ER, and if I have a patient bothered by an AC site I lock it, and put a smaller one elsewhere. No more beeping pumps and I have a backup site and a grateful patient. An IV stick takes what? 3 minutes if there are decent veins, so it's not a big deal. If they don't have decent veins then I'm darned grateful for the AC line.

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