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  1. Pixie.RN

    Emergency Nursing

    The Emergency Nurse Emergency Nurses specialize in caring for patients in potentially emergent or critical condition, be it from illness or injury. Because this specialty is unique in that patients do not necessarily arrive with a diagnosis, emergency nurses must be able to rapidly recognize impending threats. Patients will range in age from neonates to centenarians, and will arrive in all conditions. Care of these patients is typically intended to be short-term in duration; however, with hospital crowding, lack of beds for admission, and lack of access, some patients become very familiar to staff. And no, it's nothing like on TV! Work Environment Emergency Nurses most commonly work in the hospital-based ED setting, though they are also employed at freestanding EDs, urgent care centers, and in prehospital environments in some areas. Typically an Emergency Nurse can expect to have Unlicensed Assistive Personnel (UAP) in the department, such as unit secretaries, registration associates, and Patient Care Technicians (PCTs). Other interdisciplinary team members may include radiology techs, lab techs, respiratory therapists, and/or other specialists who participate in caring for patients. The entire team, including providers, works closely to care for patients and arrive at a diagnosis and favorable disposition. Skills / Qualities of Emergency Nurses Emergency Nurses should possess excellent assessment skills to ensure that their patients are not experiencing an immediate or potential life threat. Often emergency nurses are the first to see patients, before the providers; as such, rapid recognition and identification of health issues is essential. Communication is also key to elucidating a patient's reason for visiting the ED, which may provide clues to a current or potential health issue. The environment is fast-paced and constantly changing. Duties of the Emergency Nurse The Emergency Nurse may fill many roles (not all-inclusive): Triage Nurse Charge Nurse (directing patient flow) Direct patient care Nurse Trauma Nurse The Emergency Nurse constantly communicates with patients, often acting as the patient's advocate. He or she must be attuned to any changes in patient condition that require a change in treatment or intervention, and must keep the rest of the team apprised of any such changes. Emergency Nurses often make arrangements for admission or transfer of patients, which can be a complex and time-consuming task requiring close communication with the accepting facility staff, the patient, any family, and the transport team. Education Requirements Graduate from accredited nursing program (RN, LPN/LVN) Successfully pass NCLEX-RN or NCLEX-PN Current, unencumbered RN or LPN/LVN license in U.S. state of practice An Emergency Department (ED) may employ a variety of types of nurses, including LPNs, ADN-prepared RNs, BSN-prepared RNs, MSN-prepared RNs (often in department management or education), and even Nurse Practitioners (NP) and/or Clinical Nurse Specialists (CNS) in a mid-level provider role. Not all types of nurses will be present in all EDs as hiring preferences vary by location. Additional certifications that an Emergency Nurse may be required to obtain or might want to pursue include: Basic Life Support (BLS), Advanced Cardiovascular Life Support (ACLS), Pediatric Advanced Life Support (PALS), Trauma Nursing Core Course (TNCC), Emergency Nursing Pediatric Course (ENPC), and Advanced Burn Life Support (ABLS). Additional courses may be required by or available at other locations; this list is not all-inclusive. Emergency Nursing as a Specialty As the "Emergency Room" (ER) has morphed into the full-fledged "Emergency Department" (ED), so has the emergency nursing specialty grown in prominence. There have been emergency nurses for decades; the Emergency Nurses Association (ENA) was founded in 1970 and was only officially recognized by the American Nurses Association (ANA) as a specialty in 2011. Board Certification BCEN Two primary emergency-related board certifications for RNs are the Certified Emergency Nurse (CEN) and the Certified Pediatric Emergency Nurse (CPEN) credentials from the Board of Certification for Emergency Nursing (BCEN). To qualify for the CEN, one must be an RN with an unrestricted license in the US or its territories, and there is no minimum practice requirement, though two years is recommended. To qualify for the CPEN, a candidate must hold a current unrestricted RN license in the United States or Canada. The certification board recommends 2 years’ experience in the specialty area however, it is not required. A trauma-specific board certification is the BCEN's Trauma Certified Registered Nurse (TCRN) credential. To sit for the exam, one must hold a current, unrestricted RN license in the United States or its Territories. A nursing certificate that is equivalent to a US RN is also acceptable. The certification board recommends you have 2 years’ experience in your specialty area, but it is not required. There are other certifications available through the BCEN. Additional Certifications Additional certifications that an Emergency Nurse may be required to obtain or might want to pursue include (not all-inclusive): Basic Life Support (BLS) Advanced Cardiovascular Life Support (ACLS) Pediatric Advanced Life Support (PALS) Trauma Nursing Core Course (TNCC) Emergency Nursing Pediatric Course (ENPC) Advanced Burn Life Support (ABLS). Additional courses may be required by or available at other locations; this list is not all-inclusive. Job Outlook Though the downturn in hiring has certainly affected nursing across the board, this is a specialty that has been relatively stable for experienced nurses. New graduate nurses may have more difficulty with direct entry into emergency nursing practice, but emergency nursing opportunities remain available and desirable. Salary (2020) According to salary.com, the average annual salary for the Staff Nurse RN in the Emergency Room in the U.S. is $76,332 with a range typically falling between $68,162 and $84,782. Salary will vary by education and location. Emergency nurses typically work in shifts, which results in shift differential and other benefits. Choosing a Specialty but not sure which one is best for you? Download Nursing Specialties Guide!
  2. The Emergency Nurses Association's Annual Conference was held in Austin, Texas recently. With almost 200 presentations, the 3800 attendees had the opportunity to learn much and network among colleagues. One of the interesting presentations involved complications of the legalization of recreational marijuana. The presenter was Lisa Wolf, PhD, RN, CEN, FAEN, ENA's Director of Emergency Nursing Research. allnurses.com was able to interview Dr Wolf. First, we asked what types of complaints do you think will be more commonly seen in the ED due to legalization of recreational marijuana? Hyperemesis syndromes - one of these is cannabinoid hyperemesis syndrome (CHS) which according to Cedars-Sinai hospital is a condition that leads to repeated and severe bouts of vomiting. It is rare and only occurs in daily long-term users of marijuana Pediatric ingestions of edibles (brownies, cookies, and gummies) - According to a Journal of Pediatrics article, "Unintentional cannabis ingestion by children is a serious public health concern and is well-documented in numerous studies and case reports. Clinicians should consider cannabis toxicity in any child with sudden onset of lethargy or ataxia" Geriatric ingestions can also result in a myriad of issues; Acute asthma exacerbation Pneumomediastinum and pneumothorax suggested by tachypnea, chest pain, and subcutaneous emphysemas caused by deep inhalation with breathholding Occasionally angina and myocardial infarction We discussed the possible increase in MVAs associated with the legalization of recreational marijuana? Dr Wolf stated that this would be difficult to discern as "edibles have a delayed onset of effect, and people may misjudge." Drugged driving is being addressed by state legislatures; "Detection of marijuana in drivers involved in traffic crashes has become increasingly common. According to the National Highway Traffic Safety Administration, 12.6 percent of weekend nighttime drivers in 2013-2014 tested positive for tetrahydrocannabinol (THC), the component that gives marijuana its psychological effects, compared to 8.6 percent in 2007." Some of the first states to legalize recreational marijuana are on the forefront of developing tests to determine impairment: "In Colorado, the first state to legalize marijuana use, the Colorado State Patrol (CSP) includes specialized drug recognition officers. Any driver arrested after a trooper observes signs of impairment is given a blood test. “When driving a motor vehicle in Colorado, any driver has given their consent to submitting to a chemical test if they are presumed to be under the influence of drugs or alcohol,” Sgt. Rob Madden, a CSP representative, told Healthline. “Drivers can refuse a test, but that leads to an immediate revocation of their driving privileges.” Madden also noted that the CSP is entering the final phase of testing of new “oral fluid” devices. California, where the recreational use of pot became legal on January 1, also has specialized drug recognition officers and rules stipulating drivers arrested for driving under the influence are required to take a blood test if marijuana is the suspected intoxicant. That suspicion is formed during a 12-step roadside evaluation process that includes some familiar elements — walking in a straight line, standing on one foot, touching fingers to nose — as well as checking pulse rates at three different points in the process and checking pupil size in ambient light, near-total darkness, and direct light." We then shifted to what ED complaints are being seen in states where there is legalized recreational marijuana. Dr Wolf does live in a state, Massachusetts which has legalized recreational marijuana and she reports the most common complaint they see is hyperemesis. As more states move to the legalization of marijuana, I asked if she had any tips for those EDs in states where recreational marijuana will soon be legalized to prepare for this suspected onslaught? Her comments included these tips: Educate the ED staff Push for good community education in the same way we educate about alcohol Access protocols for managing cannabinoid hyperemesis (Colorado has some good ones) Thank you Dr Wolf and ENA for facilitating this interview. Has legalized recreational marijuana impacted your ED? Please share.
  3. Brian

    Keeping Trauma nurses employed

    Check out our Critical Care forums and our Emergency Nursing forums!!
  4. While at the 2017 ENA Convention in St. Louis, allnurses got the opportunity to interview Alex Wubbels, the Utah nurse who in July 2017, was violently secured in handcuffs and placed in a squad car for not complying with a police officer's request to draw blood on an unconscious patient without a warrant or consent. The video of the incident went viral. Alex has received support not only from her place of employment but also from an outraged nursing community. "The University of Utah Health supports Nurse Wubbels and her decision to focus first and foremost on the care and well-being of her patient," said Suzanne Winchester, the hospital's media relations manager. "She followed procedures and protocols in this matter and was acting in her patient's best interest. We have worked with our law enforcement partners on this issue to ensure an appropriate process for moving forward." We talked with Alex at the 2017 ENA Conference about how she is coping with this traumatic event. Alex Wubbels also shared with us that there has been an update in the investigation. The Salt Lake City Mayor announced that "The findings of the IA investigation and the Civilian Review Board will be sent to Chief Mike Brown who will use them to help guide his decision as it relates to the employment status of the two officers involved." The officers were found to have violated department policy. The following video gives additional details.
  5. So, one day my manager gave me the choice... go home or go to the ER and help them out. She assured me that I would just stock shelves and help out the nurses and not actually take care of any patients since I had not taken care of an adult pt since school. I needed the money so I said I was up for it. I was really excited to see the happenings in a busy ER, after all, it always looks so exciting on TV right?? Would I see gunshot wounds? Multiple traumas? Impaired people? Time would tell. The nurses were great! And very happy to have some help- adult challenged or not! I stocked some supplies, helped transfer some patients to the floors, they even let me start some IVs and draw some blood. I was having a great day. But where was all the "TV drama action"? Don't get me wrong, this ER staff was BUSY! And busy saving lives and impacting every patient they came to contact with. I had a great admiration for the work they did. I was just hoping for the "TV drama". Finally, 3/4 through the shift an ambulance rolled in and on the stretcher was this Bee Keeper- he had the protective gear on and everything. WOW this was what I had been waiting for! Anaphylactic shock maybe? Just as they were coming in the door, I was asked to go into room 3 for a 4 day old with fever and lethargy. Got the baby all taken care of and impressed the ER nurses with my IV skills! I think I could get used to this! So, time to take a break with some of my fellow ER "buddies"- they thanked me for my help and asked me what I thought. Being a little overconfident, I told them that I thought maybe I'd like to work ER someday. I also told them of my hopes to see more "excitement". They rolled their eyes. "Oh, by the way", I asked, "what happened to the Bee Keeper?" "What Bee Keeper?" they asked. "I saw EMS bring in a Bee Keeper a couple of hours ago." I insisted. Laughter erupted!! These gals could not breathe they were laughing so hard! "What?" I said. "She means the guy in 6!" one blurted out. Well....... apparently he is no Bee Keeper at all! He is some crazy belligerent dude who spits on people! And the "beekeeper" that protects the staff from being spit on!! I wanted to crawl under the table! Thank goodness there were only 2 more hours to go because I never heard the end of it the rest of the shift. For years I'd see these nurses in the cafeteria and they would tell me about the new "Bee Keeper" that just came in!
  6. As 2015 was nearing its end, so too was my final semester of nursing school. My mood was good. I already had a job lined up, and I felt fairly confident that I would do fine on my final exams. Some time in those final weeks, however, a surge of anxiety came upon me. The cause of anxiety: Whiteboards. The ever-present beings that hung in every patient room, scrawled with beautiful calligraphy of the (mostly female) staff nurses. And yet here I was, with handwriting that resembled a cross between a serial killer's manifesto and a ransom note. This was my fear. This was my anxiety. But I'm not really here to talk about handwriting. I'm here to talk about something that I think is probably a much more prevalent fear, especially among nursing students: the death of a patient. I think one of the reasons the thought of death wasn't really at the forefront of my mind is because, as a student, I never saw it. Sure, my classmates and I were sometimes assigned sick patients. But they were mostly fairly stable. Any death that did occur during my rotations did so quietly and behind closed doors. My first nursing job wasn't much different. I worked on an orthopedic floor for six months. While complications can and do occur, all of the hip and knee replacements weren't leading to the demise of my patients. The most action I ever saw is when one of my patient's oxygen saturation dropped to 86%. She also had COPD. And she made it through. Like I said, I only worked this job for six months. And while I normally stay with my employers for much longer than this, at some point during my time there, I caught wind of a job opening at another hospital in the emergency department. And that's where I really wanted to be. I remember my first patient death pretty well. I'll call him Mr. Gonzales, which was not his real name. He wasn't too old, maybe in his 50s or 60s. He came into the emergency room in cardiac arrest, his heart being mechanically stomped by the Lucas machine that EMS had placed him on. I was new at the time, maybe in my second month, still in orientation. I had no idea what to do (thankfully, everyone else did), so I tasked. I hooked him up to the cardiac monitor, placed a blood pressure cuff on him, then pretty much just observed. We didn't code him for very long before he was pronounced by the physician. His wife and daughter were outside of the room and were called in. They were Spanish speaking, but the stillness in the room by both the patient and the staff told them all they needed to know. They started crying. The doctor instructed my bilingual preceptor to inform them of what happened. As if by magic, my preceptor pulled a box of Kleenex out of thin air and handed it to the patient's wife. He expressed his condolences (I think). I stared at the floor and uttered a "Lo Siento", and my preceptor motioned to the door. Back to business. I had to do all of the code charting. Phone calls were made to the coroner's office, the local organ procurement agency, and the funeral home. More code charting. Put a call in to the chaplain. Charting. Check on the family. Try to tidy up the room, bring in chairs, bring more Kleenex. Charting. The chaplain came down and spoke with the family for the while. Then she came to me with a pink bag that contained a condolence card, a pack of Skittles, and a candle that the other nurses instructed me to never light because if I did, someone in MY family would be on that stretcher. Who knew nurses, with all of their anatomy and physiology and pharmacology, were such a superstitious bunch? I was honestly a little confused by the latter gesture. Why was the chaplain offering ME condolence? I didn't know this patient. I never heard him speak. At the time, I honestly probably didn't even remember his name. I felt terrible for the family, of course, but even those feelings were muted by all of the charting and phone calls that I had to make. The whole ordeal had a very much "part of the job" feeling to it. If there's some sort of macabre spectrum out there of "good patient deaths" and "bad patient deaths", then working in the ER probably falls more toward the left. We typically don't get to know our patients very well, especially the ones who ultimately die. If a dying patient comes to us, they're either stabilized, or they die within a short period of time. It's probably a cliche, but most of the death-related sadness that ER nurses experience is more for the family than the patient himself. And that can be hard. And it can stick with you. Luckily, there's always someone or something to help distract you behind the curtain next door. I work in a busy but small facility, and it's not a trauma center. That's not to say that we don't get traumatic death, too. A few months after my first patient death, a 16-year-old patient was brought into the ER. He had been shot. Many times. EMS was en route to the nearest trauma center, but had to divert to us because his condition was rapidly deteriorating. All of the doctors and all of the nurses rushed into the room, hoping against hope that there was something that we could do to be useful. It didn't work. He was pronounced about 20 minutes later. And it was devastating. What seemed to be his entire family was in the waiting room, and upon hearing the news, they (understandably) lost it. There was screaming. There was crying. There was punching walls. And our hearts broke for the family. But there was more. It was quickly determined that this was a gang-related shooting. And the patient's friends began showing up en masse. As a result, the hospital was locked down. Triage was now taking place not in the waiting room, but in a vacant patient room behind the locked doors of the department. There were police and security guards everywhere. Our focus quickly shifted from the loss of the patient and his family members to the safety of all of the other patients. Mr. Gonzales's family was beginning to file out. I was starting to think (hope) that his wife had cried as much as she could, but leaving him at the end of the night proved me wrong. After she left, my preceptor began instructing me in the ways of post-mortem care. He had been cleared by the coroner, so we were able to extubate him, wrestle the IO from his leg, and remove his IVs. I still hadn't really had too much of an emotional response to the ordeal. We got to the point where we were placing him into a body bag. I began zipping it and stopped when I got just below his chin. And that was my moment. That's when the finality of it all finally struck me, after hours of calling and charting and cleaning. I began to feel that warm, stinging feeling behind my eyes. My preceptor was still present, though he was in the far corner of the room doing some other task. I wanted to make a joke, anything that would distract me from the emotions I was finally feeling. Instead, I looked down at the floor, uttered one last "Lo Siento", and zipped the rest of the bag.
  7. Details have been changed to protect the patient and her family. The facts of this case are true. The ambulance page pierced the silence. Most nights it could barely be heard over the din of a busy ER, but tonight the snow had fallen in heavy layers and this seemed to keep people in their homes. The nurses, slouched at our stations, straightened to attention upon hearing the dispatcher's voice crack over the radio, "28-year-old female, difficulty breathing, conscious." The address was announced and everyone gave a concerned glance. The call was to a narrow, notoriously treacherous dirt road, high in the mountains on the west side of our small Colorado town. In good weather and broad daylight, it was a 30-minute response time. That night we had unforgiving snow, whipping winds, and a dark, moonless sky. The ambulance crew rounded the corner past the nurse's station, bundled in their coats, and headed out the door. Twenty-five minutes later, we heard the ambulance crew speaking with dispatch. They were hopelessly stuck in a snow drift- forcing dispatch to page another ambulance to the address. Thirty-five minutes later, it was stuck too. The woman was still having difficulty breathing, now admitting to the dispatcher that she had huffed two cans of commercial keyboard dusting spray just a few moments before her respiratory distress began. She stated her heart felt like it was racing. In our small Rocky Mountain community, we have a team of highly skilled volunteer fire and emergency medical services who had also been activated when the initial call came an hour earlier. One of these responders had managed to get his oversized pick-up truck near the cabin where the patient was waiting for help. His voice came over the radio, "Patient is pale, diaphoretic, tachypneic. Her heart rate is 140 beats per minute. She is having chest tightness." He measured her oxygen saturation at 90% on room air. She had no medical history other than occasional street drug use. As per the previous report, he confirmed that she had huffed a propellant just minutes before the start of her symptoms. He made a judgment call - this woman needed the ER right away, so he did a rather unconventional thing and hiked the woman through the thigh-high snow, bundled her into his truck, and began the unpredictable journey to the hospital. On the way, he encountered one of the stuck ambulances and was able to help them back onto the road. Over two hours had passed, but the patient was finally in the back of an ambulance and headed our way. The phone rang and the charge nurse took the ambulance report. The woman's heart rate and respiratory rate were still elevated, but supplementary oxygen had improved her condition. Her heart rate was 105 bpm and her respiratory rate 24 breaths per minute. On a simple mask at 8L, her oxygen saturation was 100%. The EMTs thought perhaps she was having a bit of a panic attack and that the delayed response had increased her anxiety, but they felt that she was relatively stable. We prepared our cardiac/respiratory room, just in case. Everyone was optimistic - this patient was young, relatively healthy, and she was already improving. This was no big deal. The patient arrived. The updated ambulance report was relatively the same. The patient was a slightly overweight Latina female with hot pink hair. Tattoos snaked her arms and calves. She was indeed pale. Smeared mascara was streaked all over her face - she'd been crying. Her initial vital signs were reassuring. Mild tachypnea was present and she was still slightly tachycardic, but otherwise she looked good. The ER doctor working that night was a gentle and highly skilled provider with over three decades of experience. He immediately evaluated the patient upon her arrival and told her he suspected a mild reaction to the inhalant she had huffed with a subsequent panic attack. Reaching for his hand with wide eyes, she said to him, "I feel so scared." He comforted her and ordered labs, an EKG, a small dose of IV Ativan, and a chest x-ray. He assured her we would do a thorough work-up and get her some medicine to help her stay calm. She nodded and appeared relieved. I left to obtain the Ativan, the charge nurse went to get the EKG machine, and a phlebotomist began to set up for labs. As I was preparing to administer the IV Ativan, the phlebotomist began to draw her blood. The patient's heart rate suddenly spiked to 110, then 120. I thought she was anxious about the needle stick, so I said to her, "Try to stay calm, take a deep breath." Eyes wide, she looked at me with pleading desperation and said something I'll never forget, "I'll never do it again. I am sorry. I am trying," she gasped. The monitor began screaming. HEART RATE 186. "SVT," I thought. Then it quickly converted to ventricular tachycardia. And before I could even blink, ventricular fibrillation. She was coding. I snapped into autopilot, a rush of adrenaline hit my body. I checked for a pulse, but it was obvious she had none. I rolled her onto a board and began compressions. The phlebotomist smacked the code blue button and our ER team streamed into the room. We ran the code for 55 minutes before the doctor announced that he was going to talk to her family, who had arrived in the waiting room 10 minutes before. We continued the code while he was gone. When he returned he informed us that the patient's mother, father, and 5-year-old son were in the waiting room. The room fell into a hush. "She has a child?" I asked. I felt totally deflated. There was no promising sign that she was going to make it. The only sound in the room was the rhythmic, mechanical thrusting of the LUCAS machine, an automated chest compression device we had placed on the patient 15 minutes after she coded, relieving the staff of the breath-taking work of chest compressions. The doctor nodded, then said, "Let's continue for another 15 minutes, and then I'll have to call time of death. Does anyone have any ideas? Anything at all?" No one in the room spoke. "Okay," he said, "another round of epi please." Fifteen minutes later, we called time of death - 0428 - almost four hours after she initially called for help. She was translucent, still, and mottled. I began post-mortem care. I cleaned her, changed her gown, wiped the mascara off her face, gently closed her lifeless eyes, and tried my best to smooth her hot pink locks, only able to guess which way she parted her hair. The doctor guided her mother and father into the room. Her mother wailed, screamed, her knees buckled. We had to hold her up so she could say goodbye to her daughter, her baby. The rest of the night is a blur of tears, tissues, crushing hugs from her mother and the reverberating question "why?" The young woman's body went to the morgue and I left for home. On my way, I saw her son, unaware of what had transpired, sitting on the lap of the grandmotherly woman who works registration. He was coloring and drinking apple juice - a picture of complete and blissful innocence. I hope someday he will know how hard we tried to save his mommy; how sorry she was for making the mistake to use drugs. But it is likely he will always wonder those things. I got in my car and the tears began. First, a hot stream down both cheeks, then a sob. I cried the whole way home. My 5-year-old daughter was awake when I walked into the house. "Mommy!" she laughed as I gave her a big squeeze. My heart was breaking, but I smiled at her. My husband rubbed my back, encouraging me to get some rest and go to bed. "No," I said, "Today, I am going to have breakfast with my baby." Author's note: You may be wondering about the more clinical aspects of this story. There are many different chemical compositions to propellant-based keyboard dusters. According to the pharmacist in the room during the code, this particular dusting compound is known to bind to cardiac muscle and deplete the body's stores of calcium. When the patient's initial labs resulted, approx. 30 minutes after she arrested, she was found to be profoundly hypocalcemic. Many efforts were made to restore her calcium levels during the code, but clearly, it was too late. I often wonder if the precious hours wasted getting the patient to the hospital would have allowed for us to correct her hypocalcemia before it led to cardiac arrest. We will never know.
  8. Like Phil Jackson once quoted, "The strength of the team is each individual member. The strength of each member is the team" (Jackson, 2014). How true is this quote, we all have our strengths and weaknesses that blended together with other members of the team can only culminate a synergy. The recipe can only be blended when members of the team are aware of each other's strengths and weaknesses, have high respect for each other, and have trust and open communication to assist one another in building those weaknesses to accomplish the unit goal. We all know that in order to have a successful patient outcome everyone caring for that patient must work together and have excellent communication skills. Although, many times communication breaks down somewhere along the line and things get missed. As we have all experienced sometime in our career working with different personalities, and work ethics, not everyone communicates the same or has the same work ethic. Some feel that the minimum is sufficient where others will go beyond what is expected of them knowing that the outcome of a patient is primary. Another team ingredient for a successful result that increases a positive patient outcome is the patient and their family. How many times have we had a patient who has been noncompliant with the care of their disease? Yet, their expectations are demanding and unrealistic. Once upon a story, there was a patient with diabetes mellitus insulin dependent, who was noncompliant with insulin or diet, came into the emergency department with complaints of vomiting and weakness. We had a difficult time starting an IV; the adult patient was moving, kicking and yelling "I don't want an IV". In the process of explaining the importance of the IV in order to improve this patient's outcome, the family started also yelling at us. This brings me to the importance of having the patient and family on board in order to have a good team and a better outcome. After the team (doctor, nurses, and specialist) spoke to the family and explained the process, and how our primary goal was to save a life and improve an outcome, the family then spoke to the patient and calmed the patient down explaining what needed to be done. "Coming together is a beginning, staying together is progress, and working together is success", Henry Ford (Ford, 2014). Building and maintaining a good team is work and will need each member's patience, respect, and excellent communication skills. Teams bring successful outcomes and are being used in all organizations throughout different disciplines. So when any one person thinks that being part of a team is not necessary think again. We have all experienced being part of a team sometime in our professional life or even our personal life. How many of us have experienced satisfaction with a positive outcome. I know I have, making me proud to have been part of that team, and when the outcome could have been better, knowing I could talk to the team to improve things. Teamwork is crucial in building teams. Teams will always be needed to yield excellent outcomes. Excellent outcome is the team's goal as a unit and organization. Organizations will always need team players. Be or become an excellent team player by having an open mind and building excellent communication skills. References Quotes for Teamwork Teamwork Quotes (329 quotes)
  9. Emergency Room nurses are a special breed. They are highly skilled, compassionate folk who work well as a team. They are open to experience, and agreeable. Here are some more traits common to most ED nurses. Game On ED is a noisy, fast paced environment with stimulus coming from every direction. There is no normal in the ED. It's noisy and chaotic. ED Nurses Thrive In Chaos Unlike their neatnik ICU sisters and brothers, ED nurses don't require a controlled, structured environment. They adapt quickly to rapidly changing conditions. They tolerate ambivalence and prefer change to structure. Emotional Intelligence ED nurses are high in emotional intelligence. They can establish a rapport with an elderly woman desperately grasping her husband's hand as he is being rushed to surgery, and seconds later, elicit a giggle from the feverish two-year old in the next room. They can smoothly manage both the wife and girlfriend showing up at the same time situation. They can approach the busy doctor and get him/her to order the pain med they need for their patient...now. ED nurses may cry inside, but not on the job. They're not seen as overly emotive types. They remain calm while projecting an attentive demeanor. They have the ability to put highly anxious family members at ease while listening for the vent alarm in the next room over. Breadth Over Depth They prefer broad to deep. An ED nurse will not study H&Ps from previous encounters to delve deeply into patient history. They don't get bogged down in the details and are not interested in non-presenting patient complaints. They aren't there to study; they're there to stabilize. But they are comfortable with babies to toddlers to middle-agers to seniors. Heart rhythms are either normal, too slow or too fast. If it's too slow, speed it up. If too fast, slow it down. Done. Treat 'em and street 'em and.... next, please! Fast on Their Feet ED nurses make instant decisions, react quickly, and think fast on their feet. Often they do this with minimal information. Should they see the 58-year-old male clutching his chest or the 24-year-old doubling over with cramps or the 18-year-old with hand wrapped with dripping bloody gauze first? They can sniff out sepsis and spot an impending code. They make rapid assessments in under 30 seconds and can manage several emergent patient situations at once. ED nurses have excellent time management skills because they RACE from pod to pod, and front to back. They efficiently discharge, admit, transfer, treat and triage in record speed. Adrenaline Junkies Self-proclaimed junkies, ED nurses love the rush they get from true emergencies; a trauma, a pulseless John Doe...and never knowing what's rolling in next! They thrive on change, and preferably change with an element of risk or harm. ED nurses need high stimulation, charged action, and immediate results. Esprit d'Corps: High Fivers ED staff are often tight knit, team oriented, and socialize across job titles. They value their team identity and count on each other to survive. They form close ties to their work friends. They are highly social, known for having a wicked sense of humor, and are witty and sarcastic. They are friends with the EMTs, paramedics, policemen, and prison guards. Breakfast after your shift? They're in. Volleyball challenge from Respiratory Therapy? Accepted. Game on. Physical/Kinesthetic They're physical, always moving, have stamina, and cannot tolerate sitting for a shift. They can rig up practically anything and are creative at dressings. Always ready to Spring into action, they dislike paperwork and routine, repetitive tasks. Street Smart ED nurses score high in common sense and street smarts. They are down to earth and sensible. They are not easily conned, and they can spot maligners a mile away. Does this sound like you? Did you read this and keep thinking, "That's me! That's so me!" If so, you may be an ED nurse at heart. I hope this helps you find your nursing niche. Are-You-Cut-Out-to-be-an-ED-Nurse.pdf
  10. NurseEdward

    Did You Hear Me?

    To the man that presented to me dead on arrival. We intubated you, gave you 3 rounds of epi, followed by 3 rounds of atropine, continued CPR and the whole time you were in pea (pulseless electrical activity; this is where the pt. Has no pulse but the telemetry monitor shows the heart beating with a rhythm, the pt is dead.) we were unable to bring you out of p.e.a . And after having worked on you for a while, the doctor pronounced you dead on arrival. Did you hear me? I said a prayer for you as I closed your eyelids. Did you hear me? When I found out that you had no family and that the state was your legal guardian, did you hear me? To the 30-year-old male that was brought in by the paramedics for being found drunk lying in the alleyway. Your blood alcohol level was 296.2 mg/dl (the legal limit is 80 mg/dl or 0.08) I made sure you were safe at all times even though you were cursing me out in Spanish. Did you hear me? To the 36-year-old Indian woman who presented with vaginal bleeding who was 16 weeks pregnant. Thank you for confiding in me about your story. A story of a different country, a story of a different tradition, culture. Thank you for confiding in me about your husband forcing you to have sex with him and banging you roughly in and out of your vagina -wanting you to lose the baby. Thank you for crying on my shoulder. I am glad the baby was viable and safe but I hope I have helped you. Did you hear me? I spoke both silently and verbally. Did you hear me? To the 39-year-old man whose ex-wife took his son away and moved to San Diego. I felt your pain. I listened to your story. A story of you drinking two 750ml bottles of absolute vodka and various other drinks in a weeks period. I sat with you and cried along with you about your suffering and struggles. I pray to god, (or at least my god, we all may have different gods.) that you one day find the strength and sobriety to face your pain and day to day struggles without having to take a drink. Did you hear me? And lastly, to the man who presented markedly intoxicated -drunk, because it was the 13 year anniversary of his father's death and to his surprise ended up in the same exact hospital where his father had died. I felt your fear. I knew that even though you drank to escape something it came back to stare you right in the face. I stayed by your side making sure you were safe and knew that someone was there. When it starting becoming dark outside and you cried that you had to get out the hospital by midnight because "it was the day your dad had died on that night" I called for someone to come get you for safe transport to home. Making sure you were out of the hospital by midnight. Did you hear me? I could go on and on, but you were just a few of the patients that I cared for on my shift last night. Did you hear me? Did you...Hear me?
  11. I blame nursing school for beating the "reflection dead horse". However, on this particular day where I needed to straight cath an 88 yo woman, I found myself with all kinds of new reflections. As a brand spanking new nurse in the ED, I feel that every day is trial by fire as I make tiny mistakes everyday. For example: 1) changing IV maintenance bags from the pole and forgetting to clamp resulting in fluids pouring all over me, 2) starting IV's and forgetting to apply distal pressure leading to a bloodbath, 3) removing an IO for the first time, accidentally scraping my hand with the needle (not sure it happened but I was required to check in), and being admitted to the ED as a patient for needle stick precautions. It's frustrating. It's embarrassing. It's overwhelming and terrible at times. But I keep coming back. And I never make the same mistake twice. Usually. My patient was being worked up after having three GLF. I had already made another mistake earlier in the day with her IV. I succeeded in putting an 18g IV in her RAC. I drew her labs and left the room to send them. Yet when I returned, the catheter was hanging out. The patient was alert and oriented x4 and her neighbor was in the room. Both denied messing with the IV. Regretting my decision not to stat lock, I put in another line (without a bloodbath). We also needed a urine specimen. Since she was incontinent and the likelihood of acquiring a midstream uncontaminated sample was low, the only option was to straight cath. I found my preceptor and she agreed to assist with the procedure. Since the patient expressed her urgent need to go, my preceptor suggested using a bigger 14fr because it would drain faster. I washed my hands. I set up my sterile field. I had my life reflections. I was ready to go. The opening was visible and I cleaned enough to make 'Monica' from Friends proud. And then I inserted the tube. Nothing. I start to inch the tube farther and farther in. I'm starting to get concerned when it's taking longer than usual. My patient is calmly watching basketball on the TV. She denies any pain. I keep advancing. It's in as far as a male. Still no drainage. I'm thinking it has to be in the bladder curled up. I wonder can it possibly be in the ureter? She would have to be yelling right? She suddenly yells something and I look up. She's mad at the TV and still denies pain. There's nowhere left for my tube to go and I look at my preceptor. She shrugs and says it's in the vagina. We leave the tube in. I repeat the setup and I'm all ready to go again. I assess the area and..... there's nowhere to go. I feel ridiculous telling my preceptor that but I do. We turn on the overhead light. She points to an area and I try to access it and the tube curls right back. My preceptor opens another kit (she doesn't have life reflections) and we open the site as wide as possible. We see another hole that we both agree is, quite clearly, the vagina. I remove the first tube, my preceptor repeats the cleaning, and inserts the smaller tube and urine streams out. Apparently, big tubes aren't always the best tubes. At the end of the day, I felt pretty defeated. I apologized several times to my patient for my mistakes and she only laughed. She told me I had done a wonderful job simply by listening throughout the day. She told me she felt comfortable and safe under my care. In fact, she told me that several times before she was discharged home. Now, I'm not one who 'fishes for compliments'. However, it made me realize how much I undervalued the non-technical skills I had performed. It's interesting because it's not 'doing the skills' that bring me back to the ED. The humor, the wit, the stories, the empathy, the being able to turn one of someone's worst day into something manageable,... those are what brings me back. Hope you think about that the next time you shove a tube up someone.
  12. The ALTO program (alternatives to opioids) in the ED. Last year the Colorado Hospital Association (CHA) pioneered the ALTO program. Ten hospital emergency departments across the state participated and decreased the use of narcotics from 31-46% (CHA, 2018)! Colorado, as well as the US, is in the grips of an opioid epidemic, as I'm sure you are aware. We have the 12th highest rate of abuse of prescription opioids in the US (CHA, 2017). According to the CHA (2017), "the vast majority of those who become addicted to opioids, both prescription and illicit, received their first dose from a doctor". This effort is to reduce the unnecessary use of opioids, and thus one of the pathways to abuse and addiction. The key to the program was creating treatment algorithms based on pain pathways. The idea that all pain can and should be treated with narcotics is not true. All pain is not created equal. So the Colorado ACEP (American College of Emergency Physicians) developed Opioid Prescribing and Treatment Guidelines. (This can be found on the CHA web site.) This method treats pain by targeting the pathway that causes it. They identified the following; Headache/ Migraine Musculoskeletal Pain Renal Colic Chronic Abdominal Pain Extremity Fracture/ Joint Dislocation For each source of pain, they prescribe a set of drugs or treatments, always starting with non-narcotics, progressing to opioids as the last resort. As previously stated, a major reduction in opioid use resulted, with no reduction in patient satisfaction scores! The medications that are used are familiar to us, but not necessarily as pain medication. Topical as well as IV lidocaine, low dose Ketamine, Toradol, Tylenol, nitrous oxide, Haldol, Benadryl, and a number of antiemetics were all used with good results. Trigger point injection is also an intervention, in which lidocaine is injected directly into a nerve bundle, or muscle fascia. It can relieve muscle tension and spasm, and works well for the release of scalp tension headaches and other muscle pain. As a nurse who was involved in the pilot, I can tell you this works. Not only are patients looking for alternatives, but we are providing better care with less risk. Patient satisfaction scores did not go down overall. Hopefully as providers get more experienced in using these protocols, satisfaction will go up. Preparing a hospital for the ALTO program is a huge project. Pharmacy, purchasing, IT, and physicians and nurses all have to be on the same page. New standing orders needed to be written, new order sets generated, new dosing guideline for smart pumps, and new products, such as lidocaine patches had to be ordered. The Colorado ENA (Emergency Nurses Association) provided nursing education that included scripting in how to explain the program to patients. Nurses explained that we are looking to make patients more comfortable, or reduce their pain. Complete pain relief is not always a realistic goal, as we know. It is also realistic to discuss with patients the risks of narcotics, and the risk of abuse and dangers of having narcotics in the home. It will be exciting to see how far we can go. There were many lessons learned that will only serve to improve this model and how it is delivered. References: CHA (2018), Colorado Hospital Association, Colorado Opioid Safety Pilot Results Report, retrieved from Opioid Safety | Colorado Hospital Association CHA (2017), Colorado Hospital Association, Colorado Opioid Safety Collaborative
  13. Pixie.RN

    Trauma Nursing

    What is Trauma Nursing? Trauma nurses specialize in caring for patients injured through trauma, be it accidental or intentional. Trauma nurses must be well versed in stabilizing patients and rapidly recognizing impending life threats. Patients will range in age from neonates to centenarians. Care of these patients can range from short-term in the emergency department (ED) or dedicated trauma unit to long-term in ICUs and rehabilitation units. When these patients enter the system, they don't necessarily arrive with an obvious diagnosis and can benefit from the clinical acumen of experienced trauma nurses. This specialty also requires close coordination and communication with members of the treatment team, ancillary services, and family members. Education Requirements Educational requirements include LPNs, ADN-prepared RNs, BSN-prepared RNs, MSN-prepared RNs, and even Nurse Practitioners (NP) and/or Clinical Nurse Specialists (CNS) in a mid-level provider role. Not all types of nurses will be present in all trauma units as hiring preferences vary by location. Additional certifications that trauma nurses may be required to obtain or might pursue include Basic Life Support (BLS), Advanced Cardiovascular Life Support (ACLS), Pediatric Advanced Life Support (PALS), Trauma Nursing Core Course (TNCC), Emergency Nursing Pediatric Course (ENPC), and Advanced Burn Life Support (ABLS). Additional courses may be required by or available at other locations; this list is not all-inclusive. BCEN Certification Two emergency-related board certifications that Trauma RNs may have or seek to obtain are the Certified Emergency Nurse (CEN) and the Certified Pediatric Emergency Nurse (CPEN) credentials from the Board of Certification for Emergency Nursing (BCEN). To qualify for the CEN, one must be an RN with an unrestricted license in the US or its territories, and there is no minimum practice requirement, though two years is recommended. To qualify for the CPEN, a candidate must hold a current unrestricted RN license in the United States or Canada. The certification board recommends 2 years’ experience in the specialty area however, it is not required. A trauma-specific board certification is the BCEN's Trauma Certified Registered Nurse (TCRN) credential. To sit for the exam, one must hold a current, unrestricted RN license in the United States or its Territories. A nursing certificate that is equivalent to a US RN is also acceptable. The certification board recommends you have 2 years’ experience in your specialty area, but it is not required. There are other certifications available through the BCEN. AACN Certification / Eligibility In the critical care/Trauma ICU arena, trauma nurses may have or wish to pursue the CCRN certification for critical care through the American Association of Critical-Care Nurses (AACN). To qualify to take the CCRN exam, RNs and APRNs must have a current, unencumbered license in the United States. Exam candidates must also meet one of two clinical practice requirement options: 1) practice as an RN or APRN for 1,750 hours in direct care of acutely/critically ill patients during the previous two years, with 875 of those hours accrued in the most recent year preceding application; or 2) practice as an RN or APRN for at least five years with a minimum of 2,000 hours in direct care of acutely/critically ill patients, with 144 of those hours accrued in the most recent year preceding application. The exam is available for three populations of care: adults, pediatrics, and neonates. Practice hours are those spent caring for a single patient population (adult, pediatric or neonatal) matching the exam for which you are applying. Applicants must include the contact information of a professional reference who can verify clinical practice. There are several other certification levels available (not all-inclusive): CMC (Adult) PCCN (Adult) ACNPC-AG (Adult-Gero.) ACCNS-N (Neonatal) ENA Training Course The Trauma Nursing Core Course (TNCC) training course is available from the Emergency Nurses Association (ENA) for RNs. Verification as a TNCC provider is earned upon successful completion. Participants must be a Registered Nurse with an unencumbered RN license. LPNs are eligible to attend except for the written and psychomotor evaluations. They do not receive verification and are awarded contact hours. Work Environment Trauma nurses often work in the hospital-based ED setting, though some facilities have dedicated trauma units that receive only trauma cases meeting certain criteria. Typically a trauma nurse can expect to have Unlicensed Assistive Personnel (UAP) in the department such as unit secretaries, registration associates, and Patient Care Technicians (PCTs). The broader interdisciplinary team also includes radiology techs, lab techs, respiratory therapists, and other specialists who participate in caring for trauma patients. The entire team, including providers, works closely to stabilize and care for patients. Some facilities also have Trauma ICUs (TICUs). These units are typically staffed with similar assistive personnel and also include a broad interdisciplinary team with the goal of moving the patient toward recovery and eventually a step-down unit or rehabilitation facility. Skills / Qualities Trauma nurses should possess excellent assessment skills to identify and reverse potential life threats. Often trauma nurses are the first to see trauma patients; as such, rapid recognition and identification of issues is essential. The environment is fast-paced and constantly changing, and a trauma nurse must be able to thrive in the chaos of trauma resuscitation. As trauma resuscitation methods are constantly changing and improving through research, trauma nurses should constantly seek new evidence-based information via professional journals and online networking. Job Outlook Though the downturn in hiring has certainly affected nursing across the board, this is a specialty that has been relatively stable for experienced nurses. New graduate nurses may have more difficulty with direct entry into trauma nursing practice, but because emergency nursing opportunities remain available and desirable, that specialty could serve as a gateway to a trauma nursing role. Salary (2020) Salary will vary by education and location. Trauma nurses typically work in shifts, which results in shift differential and other benefits. According to ZipRecruiter, the average yearly pay for an RN Trauma Nurse in the U.S. is $91,025 with ranges between $65,500 to $106,000. According to salary.com, the average annual salary for the Trauma Nurse Practitioner in the U.S. is $94,492 with a range typically falling between $83,718 and $105,878.