Stressing myself in the ER...do I suck or what??

gonzo1, ASN, RN · May 5, 2009

Loricatus needs to update her years of experience. It is more than 4. Plus, having worked with her I can say she is a great nurse, and well traveled.

My friends and coworkers in the ER all say that it really took about 4 years to start to feel really comfy in that environment. So I would expect you to still be very worried after only 8 months.

When I go into a new ER for the first time I ask what is expected of me. Am I supposed to line and lab almost all the patients? Always draw a full rainbow even if just one lab is ordered.

If a pt comes in with altered mental status recognize that he is most likely going to need a CT brain. Abdominal pain will most likely need amylase, lipase for labs and CT abd. A vag bleeder will need type and screen. An old person from the nursing home with altered mental status might need a foley.

As soon as a patient hits my bed I get urine sample and for something like chest pain, stroke, difficulty in breathing I line and lab the patient. The blood stays in the room on the counter or table until it is ordered by me or the doctor.

ER docs are very busy, often ADD or ADHD kids and we need to direct them. Know what your patient is in for and go to the doctor. Politely say, "Did you want me to line and lab the chest pain in room 3, or should I wait?" He will be greatful (silently) that you reminded him this needs to be done.

What works for me, and has made me very popular with every doctor I work with is to approach with a "Did you want me to (whatever you think the pt needs or would benefit from)"

It is sad that we have to use the back door to quide pt care, but I am okay with this, and after a while you will notice that your doctors love you because you make them look and feel more effective.

When I started in the ER I was scared ********, and everyone thought I would never make it. I just kept plodding along and reading everything I could and now I have enough confidence and experience to have completed many travel assignments and I have only been a nurse 6 years.

Having traveled some I have to add that there is some cultural differences in relationships, but it also seems more related to the facility. I worked in hospitals in Illinois where I was expected to know and do and interact with the doctor on an almost equal footing, and then in the next town over told "Don't do anything until doc tells you"

This happened in Texas too. Some places want you to get it done, and some want you to wait. You just have to ask when you get there.

Funny story: one hospital in Tx I was told by all the nurses in the ER to not do anything until the doc tells you. Then one day I was sitting chatting with the ER doc in charge of the whole place and told him how much faster things would be if nurses could start the stuff. He said he had been telling them to do that for years and they won't. You could have knocked me over with a feather. Nuff said

clairebearrn · May 5, 2009

I want to thank everyone for their advice...I really do try my best...

Most of our patients, get seen by NPs in triage and labs are done and ekgs....Still, Once I get a new patient, I put in an IV line in every patient(you dont know when they go downhill) and draw labs...check blood sugars and hemacues...in mostly everyone...cp, I order an ekg...etoh, i get the ativan ready and assume they have a head bleed, diabetes, I assume they have dka, someone with a fever, I assume theyre septic and i start the fluids....but we need orders for everything...except emergency situations...i do tell the doctors, "you want to start a nitro gtt, etc" but I dont get it, I dont know what else could be wrong...Ive never gotten written up, like other nurses...there are other nurses in the same boat and we talk about it and have come to the conclusion we arent good enough for trauma...which really sucks...I also work on the tele floors on my days off, so I even get more experience there, but I dont get what Im doing wrong and everyone tells me am doing good...arghhhhhhhhhhh

loricatus · May 5, 2009

I want to thank everyone for their advice...I really do try my best...
Most of our patients, get seen by NPs in triage and labs are done and ekgs....Still, Once I get a new patient, I put in an IV line in every patient(you dont know when they go downhill) and draw labs...check blood sugars and hemacues...in mostly everyone...cp, I order an ekg...etoh, i get the ativan ready and assume they have a head bleed, diabetes, I assume they have dka, someone with a fever, I assume theyre septic and i start the fluids....but we need orders for everything...except emergency situations...i do tell the doctors, "you want to start a nitro gtt, etc" but I dont get it, I dont know what else could be wrong...Ive never gotten written up, like other nurses...there are other nurses in the same boat and we talk about it and have come to the conclusion we arent good enough for trauma...which really sucks...I also work on the tele floors on my days off, so I even get more experience there, but I dont get what Im doing wrong and everyone tells me am doing good...arghhhhhhhhhhh

From this post, it sounds like the only thing you are doing wrong is being too hard on yourself. Nobody can know everything, that's why a team approach is essential for trauma. The only suggestion I can think of is to start studying for your CEN and take a TNCC course-this may boost your confidence and make you realize that you know a lot more than you think you do.

loricatus · May 5, 2009

Loricatus needs to update her years of experience. It is more than 4. Plus, having worked with her I can say she is a great nurse, and well traveled.

Nahhh, rather keep it the way it is. Let people think what they want to. Some people are just happier when they can put another down and who am I to take away their enjoyment.

Ohh, and thank you for compliment. Personally, I think you are a much better nurse than I am because you can adapt to the nuances of each place a lot better than I do.

MassED, BSN, RN · May 5, 2009

You don't suck, but wow ... that doc sure does! Our docs never criticize like that -- they all love the opportunity to impart knowledge, too. I've been pickin' their brains for years, they're used to my questions by now.
Is your preceptor still available to you for advice, or do you have a nurse educator in your department?

I've met MANY Er doc's that are snappy and quite rude. You have to give off the aura of confidence, even if you don't feel it. It's almost like if you exude fear and doubt, they jump on it like tigers on prey! It's not fair, and there are real jerks out there, but stick up for yourself. I have changed in that sense since I moved to the ER world 5 years ago. It's a whole different world, really. You learn to navigate this strange place, but try not to become like that. That is an example of how NOT to be, if nothing else. It is incredibly frustrating and rude. I find that some doctors still like to put RN's in a place of inferiority - when we are peers. Without RN's, doctors would be in court all day!!! RN's keep doctors in the clear. Remember that. They need you.

MassED, BSN, RN · May 5, 2009

Loricatus needs to update her years of experience. It is more than 4. Plus, having worked with her I can say she is a great nurse, and well traveled.
My friends and coworkers in the ER all say that it really took about 4 years to start to feel really comfy in that environment. So I would expect you to still be very worried after only 8 months.
When I go into a new ER for the first time I ask what is expected of me. Am I supposed to line and lab almost all the patients? Always draw a full rainbow even if just one lab is ordered.
If a pt comes in with altered mental status recognize that he is most likely going to need a CT brain. Abdominal pain will most likely need amylase, lipase for labs and CT abd. A vag bleeder will need type and screen. An old person from the nursing home with altered mental status might need a foley.
As soon as a patient hits my bed I get urine sample and for something like chest pain, stroke, difficulty in breathing I line and lab the patient. The blood stays in the room on the counter or table until it is ordered by me or the doctor.
ER docs are very busy, often ADD or ADHD kids and we need to direct them. Know what your patient is in for and go to the doctor. Politely say, "Did you want me to line and lab the chest pain in room 3, or should I wait?" He will be greatful (silently) that you reminded him this needs to be done.
What works for me, and has made me very popular with every doctor I work with is to approach with a "Did you want me to (whatever you think the pt needs or would benefit from)"
It is sad that we have to use the back door to quide pt care, but I am okay with this, and after a while you will notice that your doctors love you because you make them look and feel more effective.
When I started in the ER I was scared ********, and everyone thought I would never make it. I just kept plodding along and reading everything I could and now I have enough confidence and experience to have completed many travel assignments and I have only been a nurse 6 years.
Having traveled some I have to add that there is some cultural differences in relationships, but it also seems more related to the facility. I worked in hospitals in Illinois where I was expected to know and do and interact with the doctor on an almost equal footing, and then in the next town over told "Don't do anything until doc tells you"
This happened in Texas too. Some places want you to get it done, and some want you to wait. You just have to ask when you get there.
Funny story: one hospital in Tx I was told by all the nurses in the ER to not do anything until the doc tells you. Then one day I was sitting chatting with the ER doc in charge of the whole place and told him how much faster things would be if nurses could start the stuff. He said he had been telling them to do that for years and they won't. You could have knocked me over with a feather. Nuff said

It's all about stroking their ego and need to be in control. As long as you do that, they will love you! What BS!!!!! =) It's true, but still BS!!!!!

drew9319 · May 5, 2009

Nahhh, rather keep it the way it is. Let people think what they want to. Some people are just happier when they can put another down and who am I to take away their enjoyment.

just let me be clear. I was not trying to put anyone down. your statement was

"Now, in the South, if I do what I described, I would be up before the BON for trying to practice medicine without a license. Can't even start a line in most places without the doc giving me a VO."

that was a blanket staement. thats what i was responding to. i do not doubt that you are a good nurse. but if your going to cover everyone and every institution you had better be sure that what you say is correct. the way it has worked in the facilities i have worked in is that there is a set of protocols for everything. yes you will need a DR order for these things as you would in any state I hope, otherwise you are practicing without a license. but the protocols of the intitution gives us as nurses cober to make decisions and use our judgement. because if we cannot use or own judgement then our practice act is worthless. but back to the issue, the institutional protocols tell you what you can and cant do. i would suspect her er has a set and that she could do the ekg and the ce set w/o having to ask the dr. she probably didnt know that due to her time in the ed. but that will come. i hope that she doesnt let this experience tait her view of nursing. we all develope thick skin after a while and she will too. hope all of you have a good night. it time to go take care of pts and familia

clairebearrn · May 6, 2009

just let me be clear. I was not trying to put anyone down. your statement was
"Now, in the South, if I do what I described, I would be up before the BON for trying to practice medicine without a license. Can't even start a line in most places without the doc giving me a VO."
that was a blanket staement. thats what i was responding to. i do not doubt that you are a good nurse. but if your going to cover everyone and every institution you had better be sure that what you say is correct. the way it has worked in the facilities i have worked in is that there is a set of protocols for everything. yes you will need a DR order for these things as you would in any state I hope, otherwise you are practicing without a license. but the protocols of the intitution gives us as nurses cober to make decisions and use our judgement. because if we cannot use or own judgement then our practice act is worthless. but back to the issue, the institutional protocols tell you what you can and cant do. i would suspect her er has a set and that she could do the ekg and the ce set w/o having to ask the dr. she probably didnt know that due to her time in the ed. but that will come. i hope that she doesnt let this experience tait her view of nursing. we all develope thick skin after a while and she will too. hope all of you have a good night. it time to go take care of pts and familia

I think regardless of what area we work in, we have our nursing judgement that tells us what to do...We do have a set protocol for CP, sepsis, etc in our ER, but the doctors have to fill them out first and then the orders are put in to the computer and we get the labels and send the blood, get ekgs, etc...but regardless, if I get a CP, the first thing I do is put in my line and draw blood, that is so simple we dont need an order and but I do need MD orders to send the blood....I put in my own orders in the computer, dont wait for the clerks, but since we are a county facility we cant be ordering things left and right due to cost...even though im semi new I know what has to be done for CP (CE, d-dimer, CT chest, ekg, etc)...

I havent worked in the north, but loraticus is right about the south, we cantr jump in and order things because then we would be practicing medicine...either way I will take everyones advice...maybe you guys are right and I need more confidence because I always regret going up to the doctors and asking for orders...I get scared when getting critical patients, and hate asking for help most of the time because I think people might think Im dumb ...There is certain people that help and that I trust and other wont, so that is also a problem...it just kills me to know that other nurses who have only been there 4 months are already in trauma, when Ive been there since last september and havent stepped foot in trauma...

drew9319 · May 6, 2009

stick with it. od not think that you are dumb. you passes nursing school. that in and of itself is an accomplishment and you cannot be dumb and do that. dont worry about others. it will just drive u crazy:banghead: i also woked in the south befor i joined the navy. i started out in the icu and did float pool for the ed and the ed holding area. i understand that you cant jump in and order things. i have been there. but i would say this, if you have to wait for the doc to fill in the the order to follow a protocol then something needs to be corrected with that. a protocol is there so that you can take care of business in an emergency ie cp, acs, dka, ami. you facility needs to look at that. thats just my opinion and thats how it works here and how it worked at my facility in LA. if trauma is your passion then get some experience by moonlighting or using some off days to work overtime to get that exp. thats how i got from MICU to the CCU and how I got to the or. If you show some initiative then you will get noticed. if you feel that you will not get respect or the chances you want where you are at then maybe you need to look elsewhere. i hope i dont sound like a recruiter or nothing but the Navy needs new nurses. we would be glad to have you. and you get to do alot more here than anywhere else. but i do hope that things get better for you.

GeorgiaK · May 6, 2009

Don't be so hard on yourself....doctors are hard to work with. Each has his/her own way of doing things. It will get better.

SCprincess08 · May 6, 2009

You will get the hang of it. Don't worry about it.

mwboswell · May 6, 2009

It sounds to me like you are in the Southern part of the US because of the dynamics of your ER.
I have worked in both the South and the Northeast and there are major differences. For a primary example: In the Northeastern part of the US, you would have known it was a r/o ACS because you would have had protocols to have started the workup on the patient (drawn the labs, started the line, ordered all the related tests, etc) prior to the doc even seeing the patient. Most of the results would have been in before the doc saw the patient to do the assessment (except for the brief review of the 12 lead after triage). I recall a few times that we had tachy patients and went to the doc saying I saw a possible goiter and other s/s r/t hyperthroidism, so I had drawn for a throid panel----to have the doc thank me.
Now, in the South, if I do what I described, I would be up before the BON for trying to practice medicine without a license.

ahem (clearning throat)...I am in the South, and I have NEVER had this problem. Currently in 2009 - the phrase is "protocols"; your Emergency Nurses' Association STRONGLY advocates for this to be in place. But even back in my "early" days, before we called them "protocols", we still had this in the south.

Just to be specific on my experience, I'll tell you WHERE I've worked, but not the Specific name...all these places IN THE SOUTH, had either "protocols" or "standing orders"

1) Greenville SC - protocols; and in our neighboring county (Spartanburg) they use protocols too.

2) Pensacola FL - Trauma center, protocols

3) Pensacola FL - Another trauma center, protocols

4) Crestview FL - community hospital, protocols

5) Milton FL - SMALL community hospital, "standing orders"

6) Atmore AL - VERY SMALL community hospital, -dont' need protocols, it's so small, the Dr better be able to see each pt that comes into the tx area as they come in!!!! :)

Hope this helps

-MB