Archive for category Life in the Emergency Department

Charge Mommy

A few days ago, one of my colleagues said to me after a particularly frantic day in the ED, “You guys aren’t Charge Nurses, you’re Charge Mommies.” She is right. This is what we do:

  • tell all the kids don’t fight and play nice
  • fix boo-boos
  • give hugs as needed, or tissue
  • make sure all the kids get lunch
  • find things
  • repair broken toys
  • clean up little “accidents”
  • greet guests, and ensure they’re fed and comfortable
  • make sure everyone keeps the place tidy
  • assign chores
  • deal with the unpleasant relatives upstairs

The one thing I don’t do is enforce discipline. No spankings or time outs. I have a Manager Mommy for that.

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4 Comments

Generation Gaps

I recently took a course with nurses of varied years of experience and ages, but it was primarily made up of fairly new graduate nurses within the last year or two. During one lecture the facilitator was speaking about the future of nursing and how we need to address the current issues and challenges that exist in the nursing profession today, and asked the class to outline a few. Issues such as the global nursing shortage, heavier workloads, lack of education support, feelings of little public appreciation and individual unit situations were brought up. One nurse felt that on his unit there was a large divide between the older senior nurses and the new junior staff. This perked up my ears. He felt that the senior nurses were threatened by the amount of theory and knowledge that he and his fellow junior colleagues had and insinuated the senior nurses felt the juniors were going to take their jobs or roles on their unit. He continued to say that the generational and differing nursing requirement (degree vs. diploma) issues existing on his unit put a huge divide between the younger and older staff. (*disclaimer* While yes, I have written about how nurses can eat their young, I disagreed with the standpoint he took.) It’s terrible to think this is happening, and despite what I have written (that is only a handful of nurses FYI, by no means the picture of the entire Acme Regional ED senior staff in the least) I personally find that there is a great blend of ages and levels of experience within my unit personally.  He stated that perhaps the junior nurses should be on their own line with the senior nurses on another. I cringed at the thought of that. For any unit to run effectively and safely it is in my opinion, which I am almost positive would be shared with most, that there needs to be senior staff at all times. A line of strictly junior staff would be unsafe and potentially detrimental to patient care not to mention the amount of issues, disagreements and incidents that could and would arise. I think of inconsistencies in care and the potential for a patient’s change in condition to be overlooked simply due to inexperience until too late.  I have found that the novice and senior staff continue to learn from each other as each are on different ends of their careers with different types of knowledge to share.  This nurse went on to say that maybe the senior staff needs to go in for remedial courses to be brought up to the “standard” of the new grad degree nurses. *insert shocked look on face*. I nearly fell off my chair. If the experienced diploma nurse does not want to go for their degree how and why could one be forced to take theoretical courses that in my mind, often have little to no benefit to the patient at the bedside. I relayed my personal opinion that the diploma nurses he is suggesting should go for remedial courses to be “brought up to speed” in fact had far more clinical time as students than any of us degree nurses and as a result were far better prepared going to the bedside when they graduated as opposed to us. I reminded him of the amount of papers and classroom time we spent talking more about nursing than actually doing it. I could write a 10 page paper on how to properly sew an emblem on a jacket with 4-5 APA references if I was asked to (please no one ask me) as a result of the amount of theory referencing involved in the degree program. This nurse’s sentiments about how degree nurses are far more qualified to be at the bedside than the diploma nurses and generation gaps exist out of jealousy or by being ill prepared made me question what sort of nonsense he was spoon-fed upon his obviously very successful graduation from a degree program. I am the product of the degree program but I do not endorse the structure of degree nursing program, at least not the one I was in. I think I should have been at the bedside far more than I was. I had yet to give an IM injection to a real patient until I was consolidating in my final 4th year placement. I had however written an excellent 25 page paper on nursing leadership and how to effectively determine who should get Christmas vacation with examples of different leadership skills, roles and suggestions on effective management.. *insert vomit sound*. I suppose however it can depend on what one wishes to do with their career and the direction they want to take it.

Ultimately what I am trying to get at is while I am sure generation gaps exist on units, I do not believe it is entirely as a result of degree vs diploma more than it might be just personality related. Differing maturity levels, different interests, and people at different points in their lives not to mention the obvious that we are all individuals.  I enjoy working with the tough take no nonsense 15 year nurse as much as I like working with the 35 year veteran nurse who still gives every patient a bed bath and the novice 2 year nurse who wants to learn about every patient condition possible. A few of my closest coworkers have nearly 10+ years on me with a couple who could even be my parent.

Gaps exist only if we let them and really, we are not here to make friends. When we do that’s great, however, we have a job to do. If that 25 year nurse doesn’t like me, she at least knows I can get an IV on a 5 day old on the first poke and that’s all that matters. We often forget how our “issues” can affect the patients.

So i ask this, do generation gaps exist on your units? If so, are they related to degree vs diploma nurses or more just due to differing personalities and individuals at different points in their lives? Do you find yourself getting along with the nurses of the “opposite” generation?

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10 Comments

When the Police Come Calling

The police are more-or-less a permanent fixture in every Emergency department. They bring in the drunks, the suicidal, the psychotic, the homeless and yes, the criminal, who have either sustained injuries as a result of their activities, or else have developed sudden (and convenient) cardiac symptoms upon their arrest. Most of us in Acme Regional’s ED will cooperate with the police to the point of expediting whatever they need us to do, which usually means filling out the Form 1 or medically clearing the patient. At the same time, most of are pretty clear that ED nurses and physicians are not an extension of the Police Service: police objectives and those of health care, to state the obvious,  are not the same.

It isn’t exactly mistrust. It’s more a wariness. There are ethical and legal issues involved. We cannot, for example, divulge patient information, so there is the constant dance of the police asking for information they know we won’t give them.  Come back with a subpoena, we tell them. They try anyway.

Then there is this: what do when the police bring in someone who, well, they’ve been beating on. It isn’t common, I should emphasize, but it isn’t so rare that it excites comment either. The police will say (nudge, nudge) the patient fell on the pavement while being arrested. Or banged his head while getting into the cruiser. Or the wall hit his face. Which may even be partly true. The patient usually says nothing at all.

So what do we do about it? Approximately nothing. We might document the injuries, in case there are  legal problems down the road. Or not. We are definitely not going to make any allegations about misuse of force. Who wants to travel that road, full of traps and pitfalls and paper by the mile plus, of course, the undying enmity of the local cops? I have seen a few pretty egregious cases, and we did exactly that — nothing. As well, I suppose many of us don’t want to second guess the police: I mean, who knows how things really go down, right? And we say, didn’t he deserve it anyway?

But how does this make anyone accountable? Including ourselves? And don’t we have a legal system in place to adjudicate innocence and guilt, and administer punishment?

It’s a moral swamp. And having thought about it long and hard, I’m not clear what, if anything, that can be done about it in practical terms. ED staff are not the guardians of the guardians. So we document. Poor excuse, I know.

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2 Comments

The phrases junior nurses and most staff do not care to hear from senior nurses…

…or the negativity they can spew….

“You wouldn’t know what to look for in that type of patient assessment anyways…”

How do you know I don’t know what to assess for? Are you the textbook I read from? The online periodicals I continue to educate myself with? Are you every patient I have assessed in the last 8 years? Did you teach me? Were you my preceptor in some nightmare? Well since you are none of the previous and you’re not a bound textbook (despite how wound up you are all the time) please do not assume that since I have less experience than you, I won’t know how to assess a patient with XYZ diagnosis. Perhaps just ask if I know what the presenting signs and symptoms may be and any associated complications to monitor for, what the normal would be, etc… and take a supportive and educative approach if you are concerned about my assessment skills without any condescending tone or implied disregard for my apparent limited knowledge.

I recently had a patient with a skull fracture, (the head injury happened a day earlier), and the senior nurse asked if the patient had battle’s sign, (bruising behind the ears), which they did not, I informed her, to which she rudely replied with, “you wouldn’t know what battle’s sign looks like anyways…”. Between being 0645 in the morning after a long night shift and the only words coming out of my mouth would have been immature and highly offensive, I felt it right to walk away from the conversation.

As per this blog post, I’m clearly still stewing.

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10 Comments

Jean, ROSC*

So as J mentioned before, I was in a near catatonic state due to my VSA* computer which has fortunately been resuscitated. The hypothermia post resuscitation care was beneficial but it suffered an anoxic brain injury that may not be possible to overcome. Despite this crushing blow (more so financially really since I do not feel like purchasing a new computer) I am okay with the periodic laptop confusion for now. I’ll do neuro vitals qshift on the computer, continue monitoring and provide supportive care. (Sorry for the lame nurse humour; that I cannot fix.)

Aside from my near death computer experience I have been incredibly busy with working in the ER, updating necessary work courses, school work for a critical care course I’ve been taking as well as starting in Acme Regional’s CCU/ICU. It’s a very different world up there (literally not figuratively. . .it’s on the 4th floor). The pace will take some getting used to. On one hand I enjoyed just having one patient to dedicate time and care to, knowing their history and the pathophysiology of their recent admission and not feeling like I’m practicing unsafely or providing my patient with the bare minimum, however, at the same time, having only one patient is a bit boring. The ICU seems a bit tedious: lots of little details and new physician orders that my emergency brain isn’t wired for. We have a lot of autonomy in the ER, more then I think we realize. Either way, I welcome the change in general, be it pace, environment, meeting new people, learning some new skills and learning in general. I had been feeling stagnant in the ER for a while. I still enjoy the ER immensely and I am not leaving, simply picking up some hours in the ICU for now. If anything I hope the added critical care experience makes me a better nurse. I felt like I had hit a roadblock and I wanted to know more but I just wasn’t learning in my day to day work life, so back to school I went!

I’ll have some new posts soon on more phrases junior nurses and most staff do not care to hear, as well as some other burning ideas and issues (with possible sarcasm and complaints) that have been on my mind.  I have a few patient stories I’d like to share also. So, I hope to be more active soon, sorry for the absence!

*VSA – vital signs absent
*ROSC – return of spontaneous circulation

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2 Comments

Saved by Words for Friends

Ok, we’ve both been out of commission for a couple of weeks.  Our Miss Jean Hill, bright future of the nursing profession and co-blogger extraordinaire,  has a computer which has suffered last week the CPU equivalent of a massive cerebral bleed and maybe ethanol withdrawal too; the computer has since recovered, but Jean Hill’s nerves have been so shattered by the experience that it has left her tongue-tied, even catatonic. Which if you know Jean Hill, is a somewhat singular experience. At any rate, once she collects herself, she will be back. As for me, the schedule from hell and a lack of prewritten posts is my excuse. . . don’t you hate it when life gets in the way of what’s really important?

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The other day I was touring home from one of those interminable staff meetings about nothing at all, and I decided to stop in at an interesting-looking shop near Acme Regional. Since I live a little distance from my employment, my usual pattern is to race to the TorontoEmerg Lair and NurseCave on the nearest 400-series highway so I might more speedily savour the delights of Stately Doe Manor.

So I was innocently perusing the merchandise — mostly crap, alas — when someone tapped me on the shoulder. I looked around.

“Do you live around here?” a woman asked. She looked vaguely familiar.

“Uh, no.”

I need more vowels to spell crazy.

“You work at the hospital, don’t you.”

Goddamnit all to hell, I thought, except I inserted the f-bomb at least twice. Caught.

“Um, yes.”

And then she looked at me expectantly.She had the sort of blotchy complexion and body shape that suggested cholecystitis before 40. She seemed a little crazed, which made me a little, well, anxious. She clearly wanted me to comment on her mother’s/child’s/lover’s/nephew’s (or her) condition/prognosis/diagnosis/lab results/medications. Which, equally clearly, I couldn’t have done, even if I did remember her.

Then my phone buzzed.

“Excuse me,” I said. I stared intently at the phone and pretended the message was of such urgency and import as to leave me befuddled. I tapped the screen viciously.

She went away. I let out my breath.

There was no emergency. Of course it was nothing of the sort. It was my turn to play Words with Friends. Thank God for time-wasting aps.

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So I went to a second interview for a managerial position which in fact involves little actual management but is more administrative and actually fairly bomb-proof in an era of flat-lined hospital budgets. I actually really really want this position. I would feel fairly positive except the manager interviewing made what I have come to think of as the kiss of death statement: “It has been a real pleasure having the opportunity to get to know you.” Translation: Buh-bye, we will see you no more. Or am I parsing too much?

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5 Comments

Nursing Week Ain’t What It Used to Be

My Nurses Week joy was shattered last night when the son of a patient reamed me out for discussing the patient’s condition and treatment plan — wait for it — with the patient. He thought his father, who was a rather elderly but very independent and shrewd man who still lived in his own house and putted around in a low-mileage 1992 K-car, might be disturbed and upset. I thought the son was a controlling little freakazoid, but didn’t say so. Not very nurse-like, I know, but your humble writer smiled and nodded and went on, curiously enough, to validate and affirm the son’s distress even as the son was proceeding merrily along with the aforesaid ream spree.  Then I promptly charted the conversation because, as all nurses know, these things come back for endless amounts of arse-biting. My life as a nurse: Florence, eat your heart out.

Management Approaches with Nurses Week Greetings

Also, Acme Regional’s annual Token of Sincere Appreciation, a.k.a. the Swag Bag, has evidently been cancelled. So in other words they are replacing crap with no crap at all which, when I come to think about it, represents a net gain.

Hurrah.

Anyway, EDNurseasauras and I seem to be on the same page when it comes to Nurses Week. After listing all the cruddy, oddly depressing, and inevitably unattendable Nurses Week festivities at her workplace, she writes:

Bobo, our medical director and somewhat socially challenged on his best days has actually paid out of his own pocket for some nurses day gift (I think his wife is a nurse).  In the past we have received lunch bags, t shirts, and coffee mugs.  But slogans like “Nurses Call the Shots”,  “Love a Nurse PRN”, “Nurses Rock” and other silliness goes right to the bottom of the charity bag for me.  Let me say that I truly appreciate that he has taken the time and effort to do this.  I really do. But I actually hate that more than the company logo.
At my nursing school graduation 35 years ago, one speaker exhorted us as newly minted nurses never to condone slogans that exploit us as men and women in health care, perpetuate stereotypes, and fail to present nurses as professionals.  Big boobs, thigh highs and stilettos, giant syringes…..you know what I’m talking about.  I have a few Emergency Nurses Association coffee mugs from a former boss that are tasteful, but other than that I say NO to silly slogans.
The only Nurses Week recognition I’m looking for is just a little sincere appreciation for the job I do from my employer.  Sincerity is not one of their strong points, so hopefully my boss will come through with the ice cream.

Ungrateful wench! At least she might get ice cream.

So how is your Nurses Week going?

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7 Comments

The phrases junior nurses and most staff do not care to hear from senior nurses…

… and other examples of nurses eating their young…

A few statements I’ve heard in the last few years that I shall share periodically.

“It is more important that I get all of my breaks than you young folk because I’m older and need to rest more often”

I fail to understand how one person’s break is more valuable than anyone else. I realize that to-the-death cage matches can occur for which nurse goes first when it’s crazy busy, but seriously, just because you are senior staff does not make you superior and priority when it comes to a moment to stop, eat, go to the bathroom, etc. I like to think we are all the same as department staff members (obviously not including experience or department responsibilities for example…) but everyone is entitled to their break. Years of service to the hospital should not, in my mind, make you first up for every break.  I often see the charge nurses getting fewer breaks than the rest of the staff (which is unfortunate) because they are trying to see that everyone else is getting a chance to eat. And for the most part, the charge nurses are all very senior staff. If you cannot keep up with the pace and demands of a busy emergency department or other job area and feel you cannot miss any breaks because of your age then perhaps you need to work in a different environment. Or retire. Missing breaks sucks no matter what way you look at it, but we have to work together to ensure we’re all taken care of.

  • I do make the exception however for those with medical conditions, such as diabetes or a pregnant staff member (which is not a condition albeit) who is carrying/growing another human being inside of them. I have never personally grown a human, but from what I have observed, it’s tiring and your body needs extra food and having your lower legs elevated for a period of time in the day (that may have become the size of my thighs) is important too. So I personally would not have any issue with offering them the first available break.
  • please also note that this does not in any way encompass all senior staff. Just the few that can be particularly nasty.

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3 Comments

More on When Labelling Patients Causes Patients to Die

In the comments WhiteCoat (of WhiteCoat’s Call Room fame) strenuously objects to my take on the Anna Brown case:

Wow.

Someone on my blog suggested that I check out this post after I just posted about this story yesterday.

To all of you who think “something more should have been done,” what should that “something” have been? She had multiple tests and exams performed for the same complaint – including sonograms which showed no blood clots the day before she died. She was having the same pain in her legs since she was hospitalized the week before. Gold standard test for DVTs is ultrasound. Do we repeat the ultrasound every day? Every hour? What other testing was “necessary”?

TorontoEmerg – think of all the patients you see with back pain requesting narcotic pain medications. Do you order serial MRIs on them to rule out the possibility of cauda equina? Or tumor? If so, what is the medical basis for the testing? If not, why? I’m assuming you don’t. When you miss the one patient who has a tumor and becomes paralyzed, you’ll be harangued because “obviously” the patient had something wrong and you neglected to address it. Yet once you tell the patients that they won’t be receiving any narcotic pain medications, many of the patients in severe pain stand up, curse at you, and storm out of the emergency department.

You say that Ms. Brown was “unable to walk.” The article showed that a nurse saw her standing the same day that she couldn’t walk. How many patients do you see who come to the emergency department and can’t get out of their car when they arrive? That’s a “red flag” that something is wrong. Do you order a million dollar workup on all of them? How many patients do you see who have had dozens of normal CT scans for their chronic abdominal pain? Is that proper medical care? I could go on and on, but you get the point.

The problem is that your post suffers from horrible hindsight bias. You knew the outcome and now you’re bashing the people who treated Ms. Brown because they didn’t have the ability to look into the future to see what would happen.

Yes, the outcome was horrible. Yes, there were miscues and miscommunication. I’m sure that Ms. Brown was “labeled” as someone trying to game the system. Society “labels” every aspect of our lives every day. President Obama is “liberal.” Ron Paul is “crazy.” Pit bulls are “dangerous.” Doctors are “rich.” Baby pandas are “cute.” Doing so doesn’t make us bad, it makes us human. Someone who was articulate and polite to the providers and to the police may have been treated differently. One of my readers said this was the “perfect storm” of events leading up to Ms. Brown’s death.

To say that Ms. Brown didn’t receive proper care or that her complaints were ignored is just wrong. I’m betting if you ordered all the testing you think Ms. Brown should have received on all of the patients who walked through the doors at your emergency department, *you’d* be the one being ridiculed.

I appreciate WhiteCoat taking the time to post such a lengthy reply. He fully explicates many of his points on his blog. I won’t editorialize much here, because I think his perspective is important to how we discuss cases like Anna Brown. I don’t share his point of view for a number of reasons, but I do agree with him that labelling people makes us human. The trouble starts, for me at least,  when we allow our interior — and often unrealized — biases to influence our care.

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1 Comment

Just Because I Don’t Remember You Doesn’t Mean I Didn’t Care

In the Emergency Department where I work, the number of patients we see pushes 200 some days. We assess and treat a lot of people, mostly for lumps and bumps, breaks and bruises, but also for major, cataclysmic, life-altering events — MIs, trauma, stroke, what-have-you.

I have a problem. The moment to the patient leaves the department I tend to forget them. Completely. If you are a run of the mill STEMI, I swear I will not remember you the next day. I may not remember you in an hour. A little while ago, my manager asked me about a case receiving some, um, legal attention. It was only after a good deal of prodding that I vaguely remembered — and this was a Code Blue! (Fortunately the legal formalities were about treatment received on previous visits, so I wasn’t directly involved. My charting was good, anyway.)

I do remember some cases which for one reason or another have stuck in my mind. (For example, like here. Or here. Or here, among others.) But mostly, nah. Maybe it’s because of the sheer volume. Maybe because my head will explode if I remembered the details on each and every patient. Maybe it’s just coping skills. Who knows. Anyone else have this problem?

Anyway, I was triaging the other day, and a patient told me how much she appreciated the care I gave her husband. (He was a Triple A, and survived.) I goggled at her for a second — we don’t frequently receive compliments in the ED — and said, “Yes, of course, I remember him.” She beamed. I made her happy. But I didn’t remember him at all. The patient’s husband was all in a day’s work for me — and a hugely important day in her life. We tend to forget what impact we have on patients and families. So a small lie for a good cause, I guess, a tiny bit of therapeutic communication.

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Some stupid to ponder, or how a local employer treats their nurses like idiots. Our local CCAC — the provincial agency which arranges for Home Care and related services — hath decreed that case managers are no longer permitted to use hospital-provided educational materials because 1) they haven’t been vetted by CCAC and 2) because the case managers haven’t been in-serviced on them.

Really.

CCAC evidently thinks their case managers — all RNs, by the way — are complete idiots in that they can’t tell patients using a hospital provided form when to come back the ED because (for example) their saline lock is infected. And CCAC believes that hospital put out bogus and misleading educational materials.

Sometimes you just have to shake your head. And mutter. Who comes up with these bonehead rules, anyway? Do managers lie awake at night thinking them up?

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On a personal note, thanks to all who emailed or tweeted or otherwise left messages of support regarding the family medical emergency a couple of weeks ago. All is well again, but I was a little frightened for a while. Your concern was really appreciated, and made me realize that I — we — have a great little community around this blog. Thanks!

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9 Comments

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