What's the deal with ER?

[JenniferSews]

Today I came on and a patient was struggling. The overnight nurse has been a nurse for 25+ years, worked in critical care, ER, surgery, everywhere you can think of to earn her finely tuned assessment skills. She is respected by the nurses and docs for good reason. The pt in question was admitted to our SNF following a CHF exacerbation and overnight had very low O2 Sats. After spending a good deal of time attempting to correct the desats with positioning, meds and O2, he was sent out. Apparently there is "nothing wrong" although the hospital docs saw fit to admit him. The doc then told the pt's family that the facility "probably left the pts O2 off all night long." The pt's family now thinks we are dangerously stupid and won't allow the pt to readmit.

REALLY!?!?! I can't even count the number of times something similar has happened in my one year of nursing. Just recently we had a patient go out for a hospital stay for a week after an intercranial bleed. They were readmitted and sent out 4 days later for AMS. Pt sent back to ER after running a battery of tests in facility that showed nothing. The ER said 1-the patient was over medicated and 2-they must have had an unreported fall based on bruising noted in ER. This triggered an abuse investigation which showed that 1- the hospital had decreased ONE med (non narcotic or psychoactive) despite the notes that many meds had been d'cd and 2-All but 1 bruise was present on readmission from THAT hospital just DAYS earlier. So if the patient had indeed fallen, they must have had an unreported fall at that very same hospital.

Why are docs so free to throw around such accusations? In the first the nurse is very well aware of the basic skills of ABC. If the cna reported a low O2 sat of course she would have checked his O2. The insult to our entire nursing staff's intelligence is beyond aggrevating. Our facility is well known for taking sick patients and we manage very well. Every time I try to give report the EMS is overtly ignoring me and I guess no one reads the written report sent with the patient. They continue to talk to each other, asking questions I just gave them the info for if they would give me the time of day. I end up repeating myself 2-3 times and still the patient arrives at the ER and no one seems to know why. I'm not dumb and neither are my coworkers. We called based on a skilled assessment and may have information that could be important. But if no one will listen, what am I suppossed to do?

[JenniferSews]

I don't have a problem with the ER nurses (used to be one), I have a problem with the doctors telling family members stuff that they have no valid evidence for. Then this causes the family to get all over the LTC that "the doctor said you all just about killed him" and crazy stuff like that. I have investigated WAAAAAYYY too many complaints that were the result of the physician, (not only just ER physicians- which don't get me wrong I have a great respect for physicians) telling something totally absurd to the family which was unsubstantiated, but caused a great deal problems.

Exactly! Dr flippantly tells the family something like the SNF uses trazadone to sedate the patient. Does the Dr not realize that the family then rightfully files a complaint with state, who then comes and investigates this very serious allegation. Or they take the patient to another facility, when the original facility did nothing wrong at all. The families of course are scared for their loved one and are grateful to the all knowing Dr for opening their eyes to the danger their loved one was in at that horrible SNF. All for nothing, since grandma has been taking trazadone at night for the last decade.

[CapeCodMermaid, RN]

Indeed. We just had a resident return from the hospital with an irate daughter who said she was taking mom home because the doctor in the hospital told her we hadn't given her mom enough fluids. Despite the fact that I did a chart review and found out the woman had not been on a fluid restriction (and drank more than all the nurses put together) the daughter would not believe me. She's taking her mom home...good luck to her! PS. Apparently we 'gave' her mom anemia and dementia, too.

[GM2RN]

I work in both a SNF and an ER and I have seen first hand that the problem is everyone thinks they are right. For example I heard a MD in the ER tell a family member that a SNF gives trazadone to "incapacitate" the pt due to low staffing ratios. I was appalled. So then the family will probably go to their respective SNF and demand she stop receiving it. Meanwhile, mama will be up all night, asleep all day and the worst part is, mama probably took trazadone prior to admission to a SNF like most medicated elderly, or elderly in general.

To be fair on the ER/EMT's behalf, I have heard some pretty bad reports in my time. I try to share my assessment and VS obtained with emt, mostly they ignore me. Oh well. But I have taken report from nurses who do not even remember who their residents are. Let alone any type of assessment.

Its due to a lack of respect. I am not really sure how to fix that other than continue giving detailed reports, document information give to EMT and keep doing a good job.

I get the point you are trying to make with the above statement in bold, but I gotta say that that I have cared for a LOT of elderly people and very few of them took trazadone. Be careful of making statements like this.

[Esme12, ASN, BSN, RN]

We have the same problem here. After carefully assessing the resident, writing out a detailed 3 page referral, calling the ED and speaking to the person in charge, we STILL get comments back from the hospital that they had no clue why we sent the patient. I had one doctor write "The nursing home sent the patient with 4 different lists of medications. Only the most observant person would have seen they were different" DUH....there were 4 pages of medications because the resident took that many different pills. I was standing next to the nurse when she called to tell them why we sent the resident to the hospital and read the 3 page referral which was extremely well detailed. I made the medical director go to the hospital and speak to the chief of medicine. His answer "The new psychiatrist in the ED is crazy'.

We have guys who drive the ambulance that think they know more than anyone and come in with a swagger. Aren't we all supposed to be on the same side here?

As far as saying the resident isn't acting quite right.....my old medical director had students coming into the facility with him. I heard him say on more than one occasion "If one of these nurses tells you the resident just isn't acting right or they know there is something wrong but they can't put their finger on it, LISTEN to them."

I've also had ER nurses call and threaten the staff saying they were going to call the state. We sent a woman to the hospital with a fractured hip...pathological fracture. The ER nurse called and told the charge nurse that we must have lied...she said we either hit the woman or dropped her. Icalled her back and asked her to clarify what she had said. She said we must have dropped her or hit her because little old ladies don't just break bones. I told her to look around the ER until she saw Dr X the orthopedic surgeon. Then I told her to put down the phone and ask Dr X about pathological fractures in 98 year old women with significant osteoporosis. She finally came back to the phone and said the doctor told her there is such a thing...OMG! I told her never to threaten any of the nurses again. I had already started the report to the DPH.

Let's face it, we still have a long way to go before we are respected as nurses.

Before we can ask to be respected we need to respect each other. That ER nurse needs to listen to others. Some nurses are so quick to point to that other nurse put her down so they feel better somehow.....always feeling better that the next guy. It's sad. It even occurs between floors........those floor nurses (as the ICU nurses roll their eyes) those nursing home nurses (as the ED nurses roll their eyes)......and so on.......and the MD's blame nurses or facilities because they can't admit they cannot find anything wrong with the patient or admit they just don't know.

I think It's really a respect thing............respecting another professionals assessment of a situation because you were not there and reassassing the patient when they arrive to their destination whether the ED,the floor, or the ICU.

I have moonlighted as a night super at a LTAC (long term acute care)and send my fair share of patients to the ED from the ICU (usually open hearts that have failed to wean) AND I have had those report phone calls where I have been spoken very disrespectfully by the recieving staff.........until they knew it was me......moonlighting down the street (slumming it I believe one nurse called it)..........only then did the patient I had sent became really ill...........we all need alittle respect for others.

[Esme12, ASN, BSN, RN]

I get the point you are trying to make with the above statement in bold, but I gotta say that that I have cared for a LOT of elderly people and very few of them took trazadone. Be careful of making statements like this.

Meanwhile, mama will be up all night, asleep all day and the worst part is, mama probably took trazadone prior to admission to a SNF like most medicated elderly, or elderly in general.

I am curious......why do they need to be careful? It was just an example to make a point......why do they need to be careful? What would happen to the poster? What could they be in trouble for?

I hear what you are saying that very few elderly take trazadone.......in certain parts of the country.......in other parts of the country it is perfectly acceptable and standard for them. When I have moved to different parts of the US I was stunned to find out how DIFFERENTLY medicine was practice form one area of the country to another........

[GM2RN]

Meanwhile, mama will be up all night, asleep all day and the worst part is, mama probably took trazadone prior to admission to a SNF like most medicated elderly, or elderly in general.

I am curious......why do they need to be careful? It was just an example to make a point......why do they need to be careful? What would happen to the poster? What could they be in trouble for?

I hear what you are saying that very few elderly take trazadone.......in certain parts of the country.......in other parts of the country it is perfectly acceptable and standard for them. When I have moved to different parts of the US I was stunned to find out how DIFFERENTLY medicine was practice form one area of the country to another........

Not careful as in you'll get in trouble if you don't, careful as in making sure examples are true statements.

[MelissaLPN, ASN, LPN, RN]

Actually I made that statement just from personal observation. I know from learning about the aging processes that they sleep for a shorter amount of time and have frequent interruptions in the sleep cycle. This increases with age and depending on medications that can interrupt sleep as well. I do not mean to imply that only elderly persons in SNF. I have seen in the ER numerous pt's whose medication record reflects the use of a sleep aid. Pt's in their 50's and 60's. We are a culture of pill takers, something to fix every ailment.

It depends on what your definition of elderly is. I find that those able to negotiate their own health care needs are the ones that ask for sleep aids. Then they continue on into their older age.

This is not a blanket statement of all older persons, but a reflection of my own personal observation.

In addition, I know nurses in their 30's and 40's who take Tylenol PM's or Bendryl to go to sleep when they have to work in the morning.

[canoehead, BSN, RN]

From the RN to the first responder, to the medic, to the RN, to the docs the story gets twisted a little bit each time. Everyone wants to make themselves look good, and wants to appear to have all the answers. So little white lies creep in, with things presented as fact when they are just "she might have," or "the CNA thinks." By the time some patients get to me no one knows who did what or why.

Please, for everyone's sake, put the phone number to the unit and the assigned nurse's name on the paperwork you send. I might need clarification, but I don't have time to go through a huge facility phone tree to track down someone whose name I don't know. Put it in bold letters because the faded number on the MAR may get cut off when you make a copy, and I may not be able to read your notes. Also, remember that when you call report to the ER you will likely not speak to the nurse that will ultimately be assigned that patient, so put your phone number right out there in big black Sharpie.