ER Follies

“PCU, this is Wanderer, how can I help you?”  I said as I picked up the phone.

“Uh, yeah, this is Nurse FERN-tastic down in the ER, I’d like to call report on Patient So-and-So, going to room such-and-such.”

“Right,” I replied looking at the clock…10 minutes since I gave the bed away, “Let me grab who’s getting them.”

“Hey Nurse Floor-tastic, report’s on #1”  I call across the station.

“Already?” she says, “I thought you just gave the room away?”  as she picks up the receiver.  “Hold on a sec,” she says into the phone, “I’m putting you on speaker so my orientee can hear this too.”

From the desk I hear the muted wah-wah-wah from the ER nurse, kind of like the teacher in Charlie Brown.  “They’re 60 sumthin’,  wahwah-wah-wahwahwah, cardiac history, wahwah-wah, discharged today at 1700,wahwahwahwah.”  I tune out the rest as I go back to charting on my patients.

“Hey Wanderer,” I hear a second later as a phone is hung up, “so, downstairs has no idea why they’re even being admitted at this point,” says Nurse Floor-tastic.  “He just read off the labs and said the ER doc is still in there trying to talk to them.”

“Right, so I just gave the bed away, and they’re not even sure if they’re being admitted?” I ask.  “And they’re calling report?”

“Yep,” she says, “Nurse FERN-tastic said he had a moment to get report out of the way, not that he actually told me anything worthwhile that I couldn’t have gleaned from the chart notes in the system.  He said the rezis haven’t even been notified yet.”

So we wait.  And wait.  And wait.  I keep looking at the screen on the system that shows the ER status.  Then next to the name of the patient where it had said, “Admit PCU” I see, “D/C”.  At that moment the phone rings.  “This is Wanderer.”

“Hey Wanderer, Nursing Supe.”

“Hey.”

“I’m sure you saw already,” she says, “but they’re sending Patient So-and-So home.”

“Right, saw that.  OK, well we still have that room open.  Is the person I assigned to the other bed still coming?” I ask.

“So far.  I haven’t heard otherwise.” the nursing supe says.  “But I’ll try to keep you posted.”

“Thanks.”

*********************************************************************************************

“PCU, this is Wanderer.” as I pick up the phone again.

“Yeah, this in Nurse FERN-tastis Jr.  I’m calling to give report on Chest Pain going to room such-and-such.”

“OK, let me grab Nurse Part-time-tastic.”  I say.  “Nurse Part-time-tastic, report on Chest Pain on 1”

Time slips by.  The clock marches forward.  Midnight.  1am.  I finish my chart checks, finish the staffing report.  2am.

“Hey Nurse Part-time-tastic,” I say as I look over, “Chest Pain here yet?”

“Nope,” she says.  “Still waiting.”

More time.  I have a snack staring at the rack of new charts awaiting the arrival of the patients.  Then from around the corner I hear the dulcet tones of the ungreased wheels of an ER gurney.

“Chest Pain, right?”  I ask the tech as they roll past.

No answer, but since they’re headed into that room, I guessing it’s them.  Look back at the clock on the wall:  2:40.  3 hours since report was called.  Up date?  Nope.  I guess it really doesn’t matter all that much, they’re still breathing.

*********************************************************************************************

“PCU, this is Wanderer.”

“Yeah, this is FERN-tastic, calling report on Chest Pain 2.”

“Right, they’re mine.  Lay it on me.” I say

“OK, Chest Pain 2, 60 sumthin’, chest pain post-gardening, lower-sternum radiating to neck, called EMS.  VSS since arrival.  Chest pain free.  Took ASA at home and have 1 inch of NTP on.  Just gave them Advil for a headache.  So the labs..”

“It’s OK,” I interrupt, “looked at them already.  Looks like they had something of an event with that troponin of .54.”

“They’ve got an ER special (IV in the antecubital space) for a line.  They’re AOAx3, a real walkie-talkie.  The ER doc wrote holding orders to send them up to ya’.  You ready?”

“Sure,” I say, “Bring it on.”

“See you in about 15.” they say.

Sure enough, as I’m putting the finishing touches on the room, up they roll.

As I dig into the orders, I’m missing something.  In fact I’m missing a whole lot of something.  Labs?  Nope.  Serial enzymes?  Nope.  I have tele orders, nitro, morphine and EKG orders.  No diagnostics, no guidance that maybe, just maybe they’ll be going somewhere, like the cath lab or at least nuke med.  Nothing.  Page the resident.

“Are you following Chest Pain 2?” I ask.

“Who?”

“Chest Pain 2,” I repeat, “let me spell it for ya’.”

“I have no idea who that person is,” she says, “we’re not following.”

“That’s all well and fine, but I need to know who’s going to write orders.” I say, “I have bare bone orders and nothing else.  D’ya’ want to order enzymes?  Maybe an EKG?”

“Oh, wait” after much paper shuffling and a muted conversation in the background, “looks like Cards will follow.”

“Any idea who?  It’s not like I can just call around and ask about it.  Don’t feel right just letting them hang out with nothing.  Sure I can’t persuade you…”

“Sorry, I ain’t crossing them.  If you don’t hear soon, call me back, sorry.”

And the powers that be wonder why weekend survival rates are so dismal.  The right hand and left don’t even know they exist.  Never good.

*********************************************************************************************

Edit: I re-read the post and realize I need to be less trigger happy on the “Publish” button.  I’m going to leave the final summary and wrap-up and assorted ramblings below, but realize that I’m probably just adding fuel to the fire that is ER/Floor relations. It was a bad, bad weekend and this crap burbled out.  I’m not so usually full of vitriol and am able to make sense of what I’m trying to say in a more constructive way. Still wearing flame-proof Attends though! So if you just want to stop reading here and avoid the crap-tastic content of the post, do so now…

*********************************************************************************************

So what’s the point you ask?  First, jumping the gun to give report, just to “get it out of the way” defeats the whole purpose of giving report.  Especially when the patient doesn’t even show up.  You’ve wasted your time and ours.

Second, a hell of a lot can happen in 3 hours.  Shit, it only took 20 minutes for my patient to circle the drain on me the other night.  From the time they started circling to the time we hit the Unit, was less than an hour.  A hell of a lot can change in 3 hours.  How about an update?

Third, that’s the way it should be, except where the docs dropped the ball.  Give report, clear, concise, and then bring the patient in a reasonable amount of time.  None of this lolly-gagging around. Unfortunately though none of the docs are talking to one another so the patient languishes.  Granted, the elevation was not critical, but it is relevant.  A coughing fit ain’t going to cause that. Something’s going on, and when your patient tells you that pretty much everyone in their family has, or had, cardiac issues, alarm bells start going off.  Things need to be done.  And we can only the push the docs so far.

Fourth, FYI Nurse Fern-tastic, there are other sites for IV starts besides the AC.  Really, I swear.  And on a “healthy” person, it’s even easier.  You’re picking that just out of convience.   But c’mon, if you’re going to drop a line in the AC on a Chest Pain-er, shouldn’t at least be a 18 gauge?  Yeah, a 20 guage will work in most situations, but if you’re using the biggest vein in the arm (typically), why not drop a bigger guage IV?  I know you feel like you don’t have anyting to prove anymore, as you told me that yourself once, but if we can get a 20 guage on the demented confused LOL who does not want it, I think getting at least an 18 in a “normal” person shouldn’t be all that far out of your ability.

Now I know that the ED is a different world.  The culture is very different from the floor.  Yes, you have multiple patients.  We do too.  I know that multiple nurses take care of the patients as a way of unloading the nurse in emergent cases, but wouldn’t you at least want to look at the patient before you call report?

And people are always wondering why the floors make life hard on the ED.  Really, it’s because we’re too busy hiding beds, playing canasta, taking our breaks and eating lunch.  Far be it from us to actually work.  I can’t speak for others, but on my floor unless we’re in the middle of some shit, like someone’s crumping, or we’re up to our armpits in poop ensconced in an isolation room, we take report when it’s called.  And when we can’t take report we offer to call them back.  Do we get snarky?  Sure, when you sit on a patient for over 2 hours to flush them at 0645 right as you change shift and just before we do, we get a little snarky.  It’s not you, it’s us, we know that the expectation of the day shift is that all the admit stuff will be done and if it’s not we’ll just get a bunch of flak, makes the last little bit of the shift oh so wonderful.  If we were to work together, there might not be such animosity.

And don’t get me started on the residents that admit these folks.  They’re starting to piss me off.

Any thoughts?  Don’t worry, I’ve got my flame-proof Attends on.

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2 Comments

  1. #1 – what is AOAx3? Alert, Oriented, and Apple-juice seeking? This is a term I’ve never heard before.
    Alert, Oriented and Appropriate x3

    #2 – Does “giving a room away” mean making it available so that a patient can be assigned because that’s what I got from context, but I’ve never heard the term before.
    Means the room is ready for the patient.

    #3 – In trying to clear up some of the misconceptions that ER nurses have about floor nurses, you muddied up the impressions that floor nurses have about ER nurses. Remember that it is a two-way street.
    Yup.

    #4 – It does not seem as thought you truly understand what the ER nurse goes through. You say that we have “multiple patients”. True, and beyond that, we have multiple patients at the most critical part of their hospitalization. Remember that patient that you were talking about who was “circling the drain” for an hour before going to ICU? We are full of those patients who you will never see. You may occasionally get a difficult or needy patient; that is our bread and butter. We know that you have even greater amounts of worthless paperwork heaped upon you (pointless nursing care plans, anyone?), but having worked on the floor (admittedly as a CNA) and having worked in the ER, the level of urgency and busyness of the nurses do not compare. Not even close.
    Having done both, it is just, different. Those critical folks that don’t necessarily need the Unit? They come to us. See the “Edit” above

    #5 – Speaking for myself, I try very hard as an ER nurse to accept that you are not up on the floor playing Canasta and I try very hard to give the benefit of the doubt when, 45 minutes after I’ve faxed report, I still haven’t heard back from the nurse accepting the patient. I try very hard to give the benefir of the doubt when I arrive on the floor with my arrhythmia patient who is on an IV drip, etc. only to find that there is no tele box at the bedside, no IV pole anywhere to be seen, and despite the fact that the patient is clearly listed as “strict bed rest”, there is a standing scale in the room and an eager CNA trying to get the patient out of bed to weigh him while the nurse is off doing something else and can’t come in just for a minute to get any last-minute report changes and lay eyes on the patient. I try hard.
    We do appreciate!

    #6 – I can’t speak for why after such a long delay in getting the patient out, there would not be at least a call from the nurse saying “there was a delay but the patient is coming. No changes to report” or whatever, except to offer that as a rule, an ER nurse is generally about 2 or 3 important tasks behind, and this was probably one of those days.

    #7 – In a chest pain patient, an 18g IV may be indicated, but remember that the chances of IV complications increase with increased catheter size, so if we are not expecting the need for intense fluid resus or maybe CT contrast studies (although those can usually be done just fine in a 20g), then putting in an 18g IV just increases the pain and discomfort (and future willingness), and also increases the chances of complications. As for why the IV gets put in the AC – because you only see the 10-20 percent of patients that get admitted. Most patients get sent home. The AC is the most readily available, safest, and fastest place to get a line in somebody. If someone is going to need a liter of fluid and some zofran, I’m not going to do a painful hand or wrist insertion. If someone is going to get potassium or phenergan or vanc, I’m not going to risk the weaker veins. If someone may need a contrast CT, I’m not going to put it anywhere except the AC. If I’m 2-3 tasks behind (see above), I’m not going to prod and poke.

    In conclusion (and I have a lot more I want to say, but I have to get out the door for work…) if you are going to ask for the respect of FERN-tastic nurses, you need to give us some respect as well.
    as I said above, see, “Edit”

    Braden

    Reply

  2. Having worked both floor and ER, I’m going to keep it simple. They are both impossibly hard jobs (at times), and are as different as chocolate cake and sirloin steak.

    ER nurses want to know what the likelihood of the patient dying in the next 30 min is, and what needs to be done NOW so the patient doesn’t die. Beyond that, we’ll be onto the next ALTE (acute life threatening event). Floor nurses want to know the specifics b/c they’re responsible for that patient for the rest of the shift. Each knows what they need to know to provide the best care for the patient.

    Best way to get along? Give a good report; take report quickly; transfer the patient when you say you will; have the bed ready as quickly as you can; and smile when you hand off the patient. We all have shitty days, and if we could remember that, we’d get along much better.

    Reply

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