I hate it when the nurse does X...

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Every patient? That's extreme. That said, my ED doesn't use precedex very often and if the BP is soft, the patient will wind up on versed +/- fent as opposed to prop +/- fent + levo.

Pressure is ok/high? Prop it is.


We do a fent gtt on all intubated patients with prop or Midaz if needed.


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Because if you order 0.1 mg/kg of morphine they'll LOSE THEIR LICENSE™.


...but then they give no push back when you change the order to Dilaudid 2 mg. After all, 2 mg is much smaller than 10 mg... thus it's safer, right?
 
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Every patient? That's extreme.

Take your finger and shove it down your throat. It hurts, right?

Take 2 benadryl and shove your finger down your throat. Does the fact that you're sleepy make it hurt less?
 
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...but then they give no push back when you change the order to Dilaudid 2 mg. After all, 2 mg is much smaller than 10 mg... thus it's safer, right?

2 mg of hydromorphone is equivalent to 10 mg of IV morphine, smaller numbers seem MUCH safer.
 
2 mg of hydromorphone is equivalent to 10 mg of IV morphine, smaller numbers seem MUCH safer.
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I had a nurse disregard a Doctor's orders as a patient once. I fell around 5-6 metres (16-18 foot) through a plasterboard ceiling, managed to break my fall somewhat by grabbing onto what was left of the ceiling at the last second but still hit the ground pretty hard -- landed on my tailbone, jarred my spine pretty badly. I was pretty blindsided by what had happened, so without really thinking I got up and managed to stagger down stairs and sit on the lounge, thinking I just needed to rest and calm down and everything would be okay. That's when the pain and muscle spasms started to really kick in, and I became concerned that perhaps I'd done a bit more than just jar myself. So I phoned for an Ambulance, still kind of expecting they'd check me out and say I just needed to take some over the counter pain meds and continue resting, perhaps apply some heat or an icepack, maybe. They decided I needed to go to hospital to be assessed properly, so fair enough off we go.

I end up being taken straight through to the ED as a priority 2 triage (urgent, to be seen within 20 minutes I believe it is) -- which admittedly surprised me, but I wasn't overly worried because I'm still thinking 'bruised my tailbone, jarred my spine, they'll give me a quick look over and send me home'. And then one of the Doctors on duty comes and assesses me, and starts barking orders at the attending Nurse - "I want a priority X-ray, do NOT move her without Fentanyl". Um, okay then? Don't move me without Fentanyl? Should I start panicking right about now? Yes, yes I think I will. It wasn't so much what the Doctor had said, but the way in which he said it. He made it sound like some dire calamity would happen if anyone dared try and move me without first having given me a dose of Fentanyl, and admittedly I started to panic and think that maybe I'd hurt myself way worse than I thought (I wasn't expecting to be given any sort of narcotic pain meds, let alone hear a Doctor sounding so adamant that I *had* to be given said medication before anyone tried to move me, so naturally all sorts of dire things were going through my mind). He scrawled his orders in my chart, handed it to the Nurse, went off to tend other patients, and when the hospital porter came to take me down to x-ray I still hadn't received the medication that was ordered by the Doctor so at the point I basically freaked the f**k out. I was completely embarrassed by the way I acted after the fact, but I started raising my voice, and shouting, and pleading hysterically for them to 'check my chart, the Doctor said not to move me without Fentanyl, you can't move me without Fentanyl, the Doctor ordered it, it's in my chart!' (I know, I behaved shamefully :sorry:).

The porter steps back at that point and indicates to the Nurse that if those were the Doctor's orders then he's not taking me anywhere until they've been carried out, so then I've got this Nurse glaring down at me and more or less informing me that she knows what the Doctor's orders were, but I didn't need to be given Fentanyl to be taken down to x-ray. Then she starts firing questions at me, 'why did I get up straight after the fall?' 'Why did I wait several minutes to phone for an ambulance?' 'Why didn't I feel the full amount of pain straight away?' etc etc (um, okay, hang on a sec and I'll just go get my medical degree so I can answer those questions for you, Nurse). Then she decides that I can't be taken to x-ray or given Fentanyl, despite what the Doctor had written in my chart, because she has to do a pregnancy test on me first -- and if I couldn't manage to give a sample by using a bed pan or commode chair, then she'd have to catheterise me (she made damn sure I knew just how painful that was going to be as well, plus I also had the lovely vision of the damage that was done to my Dad's urethera by a poorly placed catheter post prostate surgery, none of which was exactly helping me to calm down). So there I am in the middle of the ED, in full of view of everyone, struggling to give a urine sample, with a nurse yelling at me to get off the bed and onto a commode chair (which I was trying my best to actually do, except for the fact that almost every time I tried to move my back muscles would go into horrendously painful spasms).

The Doctor eventually comes back to check up on the progress of my case, sees what the Nurse is trying to get me to do, realises I've not been taken to x-ray, not been given any medication he ordered, basically had everything he'd written in my chart contravened -- and he starts demanding answers, and he's not exactly happy at what he's hearing. Of course by now the Nurse is being oh so nice and deferential, but nope, he's having none of it. Gave her a lecture about contravening a Doctor's orders, made her fetch the Fentanyl, and administered it himself. Off I went to x-ray and as it turns out I was right all along, bruised tailbone, jarred spine, and apparently my back muscles had locked up as a protective measure to prevent any further potential injury. I asked the Doctor the same questions the Nurse had been rapid firing at me, and his answer was basically 'Well adrenalin can do funny things sometimes'. I was discharged after another couple of hours observation, hubby came to pick me up, and all I needed was some bed rest, apply a heat pack if needed and take some over the counter pain killers.

Now maybe I did overreact when I called an ambulance, maybe I should have just stuck with my initial assessment which turned out to be right, and I know I definitely shouldn't have made a scene and started yelling and carrying on when I was in the Emergency Department. But a) I'm not a Doctor so I couldn't actually be sure of what injuries I did or didn't have, and b) the Nurse was given clear instructions by the Doctor overseeing my case, instructions which were were written up in my chart, and she chose not to carry those instructions out because apparently she knew better.

:rage: :rage: :rage:
 
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Every patient? That's extreme. That said, my ED doesn't use precedex very often and if the BP is soft, the patient will wind up on versed +/- fent as opposed to prop +/- fent + levo.

Pressure is ok/high? Prop it is.

How well do you sleep after you've had a night of drinking? Rested, refreshed and ready to start the day? Or groggy, foggy, mentally slow, and feeling that hangover until the next time you go to bed. Does it matter that the EtOH make you fall asleep easily?

Benzos and alcohol. Same receptor. Benzo gtt are terrible for routine sedation (not talking about DTs or Status). Worsening delirium, metabolite accumulation in pts who are old or have comorbidities, neurocognitive decline etc...

Got a patient with a soft blood pressure? Assuming it is more that a transient vasodilation peri intubation, if things are really that soft you may want to start pressors on the patient anyway, especially if they're septic.

If you don't think you are at that point yet and want to avoid precipitating hypotension: high dose narcotic gtt, low dose propofol, and if it is necessary, PRN benzos to get them comfortable. Your patient, and your ICU team, will thank you. Please no more routine benzo gtt
 
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its because youre an intern. as an attending, nurses comes in with me and dont interrupt. its a completely different world.

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Well thats f'ed up, you think being a doctor would get you some respect, but I suppose you don't get the respect until you make it to the very end ( attending), and how often do you have to " explain rationale" to nurses wtf.
 
How well do you sleep after you've had a night of drinking? Rested, refreshed and ready to start the day? Or groggy, foggy, mentally slow, and feeling that hangover until the next time you go to bed. Does it matter that the EtOH make you fall asleep easily?

Benzos and alcohol. Same receptor. Benzo gtt are terrible for routine sedation (not talking about DTs or Status). Worsening delirium, metabolite accumulation in pts who are old or have comorbidities, neurocognitive decline etc...

Got a patient with a soft blood pressure? Assuming it is more that a transient vasodilation peri intubation, if things are really that soft you may want to start pressors on the patient anyway, especially if they're septic.

If you don't think you are at that point yet and want to avoid precipitating hypotension: high dose narcotic gtt, low dose propofol, and if it is necessary, PRN benzos to get them comfortable. Your patient, and your ICU team, will thank you. Please no more routine benzo gtt
I'm sure you'd feel much better if you were shooting up heroin for a few days.

My interpretation of the data tells me it's not so much the agent as it is the level of sedation.

Ideally you'd like to have the patient awake, but pain free. That is difficult to achieve in the peri intubation period.

I don't pick benzos as a first line agent, but I don't think a dose or two is going to cause the kind of problems some claim.
 
I'm sure you'd feel much better if you were shooting up heroin for a few days.

My interpretation of the data tells me it's not so much the agent as it is the level of sedation.

Ideally you'd like to have the patient awake, but pain free. That is difficult to achieve in the peri intubation period.

I don't pick benzos as a first line agent, but I don't think a dose or two is going to cause the kind of problems some claim.
The data is about as clear in benzos vs propofol as in anything critical care related. Benzos have been shown to worsen ICU delerium, increase time on the vent, and increase time in the unit, among other things. Propofol is more expensive and does have more decrease in BP, but if someone's already on pressors... Cost/benefit analysis depends on who is doing it, but generally speaking, anything that can reduce ICU length of stay is almost always cost effective.

Precedex data isn't quite so well developed, but (outside of price) it almost certainly can't be any worse than benzos.
 
The data is about as clear in benzos vs propofol as in anything critical care related. Benzos have been shown to worsen ICU delerium, increase time on the vent, and increase time in the unit, among other things. Propofol is more expensive and does have more decrease in BP, but if someone's already on pressors... Cost/benefit analysis depends on who is doing it, but generally speaking, anything that can reduce ICU length of stay is almost always cost effective.

Precedex data isn't quite so well developed, but (outside of price) it almost certainly can't be any worse than benzos.

I'd like this thread to go back on topic, but I will give a response.

It's been a couple of years since I looked into these studies, so there may be newer data.
The studies I have read showed that the badness was related to level of sedation.
Patients on benzos alone had deeper sedation levels in the studies done.

I'll stand by my contention that it was the level of sedation that made the difference, not so much the agent.

Using analgesia first is likely the best method.
If you are running a fentanyl drip at 200-400 mcg/hr, you are not using fentanyl only as an analgesic.
It is working mainly as sedative at that point.
Deep sedation is what causes the problems with delirium, you are also likely going to have to deal with w/d once you extubate the patient.

Just like opioids have a sedative effect, benzos likely have an analgesic effect.
I've seen intoxicated patients with the worst kind of traumatic injuries who seem to have minimal pain.
There must be something going on there.
That's obviously not good data, but pain is something that's close to impossible to study.

My usual practice for post intubation sedation is to give a fentanyl bolus and start low dose propofol gtt.
Patients don't board where I work, so they are usually up in the unit pretty soon.
 
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Precedex data isn't quite so well developed, but (outside of price) it almost certainly can't be any worse than benzos.

Must be nice!


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The good news is that very few nurses will hang around for long due to being overloaded with too many patients and will move on. Then, you will have a fresh crop.
 
...interrupts me when I'm on a cath lab call, while dropping orders on an intubation & trying get to overhear a tele run, just to ask if a discharged patient can get Tylenol on the way out.

Wouldn't aggravate me much if the same nurse also didn't blow me off to finish an Amazon order. Grr...

Semper Brunneis Pallium


...or can they eat/drink lol. The docs I've worked with absolutely hate it when the pt comes in with something that has absolutely no bearing on whether they can eat or drink but the RN insists on interrupting orders for a rolled ankle.
 
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...or can they eat/drink lol. The docs I've worked with absolutely hate it when the pt comes in with something that has absolutely no bearing on whether they can eat or drink but the RN insists on interrupting orders for a rolled ankle.
To play devil's advocate here: you get a rolled ankle patient. No major mechanism. Pt can't bear weight. Looks like a sprain to triage. Good pulses. You see them and they're super tender but they're fat and you cant see much in the way of a deformity.

Nurse takes your advice and feeds them because it's a freaking rolled ankle.

Xrays show a pilon fx. That rolled ankle is going to the OR today unless the RN gave him a turkey sandwich.

I never give a crap if an RN asks if a patient can eat. If they ask but then demand that I enter the diet order instead of just putting it in themselves, then yeah, that patient probably isn't getting food anytime soon if I'm in the middle of something important.
 
To play devil's advocate here: you get a rolled ankle patient. No major mechanism. Pt can't bear weight. Looks like a sprain to triage. Good pulses. You see them and they're super tender but they're fat and you cant see much in the way of a deformity.

Nurse takes your advice and feeds them because it's a freaking rolled ankle.

Xrays show a pilon fx. That rolled ankle is going to the OR today unless the RN gave him a turkey sandwich.

I never give a crap if an RN asks if a patient can eat. If they ask but then demand that I enter the diet order instead of just putting it in themselves, then yeah, that patient probably isn't getting food anytime soon if I'm in the middle of something important.

Yeah, I suppose you could probably turn most cases into something where they can't eat and it makes perfect sense. But even after discussing plan of care with the nurse, sometimes common sense isn't as common as it should be.
 
...or can they eat/drink lol. The docs I've worked with absolutely hate it when the pt comes in with something that has absolutely no bearing on whether they can eat or drink but the RN insists on interrupting orders for a rolled ankle.
It only bothers me if the question has been asked and answered multiple times.
I think food should be banned in the Er except for the hypoglycemic patient.
A giant waste of time and resources.
 
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It only bothers me if the question has been asked and answered multiple times.
I think food should be banned in the Er except for the hypoglycemic patient.
A giant waste of time and resources.

Definitely an amenity rather than a necessity in most cases but tis the way of American life.
 
It only bothers me if the question has been asked and answered multiple times.
I think food should be banned in the Er except for the hypoglycemic patient.
A giant waste of time and resources.
With 5-6 hr LOS during primetime, a patient population that is used to significant caloric intake continuously through the day, and and fierce competition for patients that actually have a choice about where they go... giving $2.50 in snacks and drinks to get $500 for a sore throat seems a decent deal.
 
It only bothers me if the question has been asked and answered multiple times.
I think food should be banned in the Er except for the hypoglycemic patient.
A giant waste of time and resources.

We have turkey sandwiches in the ED as well as a menu that patients can order from. I've started instituting a policy for frequent fliers and EtOH intox patients where they can get a snack box, but they no longer get to order off the menu.
 
We have turkey sandwiches in the ED as well as a menu that patients can order from. I've started instituting a policy for frequent fliers and EtOH intox patients where they can get a snack box, but they no longer get to order off the menu.

Menu?! Wow! I spent 11 hrs in the ED with my grandma once. She needed to be there. In that case, food for family seems fine. But I'd argue if you're a patient and you want food, other than broken bones etc, it's probably not an emergency.
 
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Menu?! Wow! I spent 11 hrs in the ED with my grandma once. She needed to be there. In that case, food for family seems fine. But I'd argue if you're a patient and you want food, other than broken bones etc, it's probably not an emergency.

The ED isn't a soup kitchen and the patient is the one with the disease, not the family.
 
Definitely an amenity rather than a necessity in most cases but tis the way of American life.

Same thing with TVs in every room. I HATE having to constantly turn down the volume to get the patient history. If you build it, they will come, and I hate that.
 
Same thing with TVs in every room. I HATE having to constantly turn down the volume to get the patient history. If you build it, they will come, and I hate that.

Turn down, not turn off? My first move when I walk in a room is turning off the tv.
 
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+1. My first move when called to a room for a complaint, is to politely ask the room's occupants to turn off the TV and put down their phones. If they don't care to do so, I offer to return when they're not so distracted (which will likely be sometime around 26:30 on the 42nd of Notever). Any complaint that isn't worth the complainer dropping their phone to pose to me in person, isn't worth my time to address.


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It only bothers me if the question has been asked and answered multiple times.
I think food should be banned in the Er except for the hypoglycemic patient.
A giant waste of time and resources.

Meh, I am of the opposite opinion. As far as I am concerned, patients with ESI levels 3-5 should be given a turkey sandwich at triage.

The current ABA guidelines recommend an NPO duration of 6 hours following a "light meal" prior to elective general anesthesia. The sandwiches/snack boxes at my hospital are definitely not more than a "light meal". Even if they eat said turkey sandwich immediately prior to my examination and even if I conclude that I have a moderate to high suspicion for, say, appendicitis (already less likely if they munched that sammich just fine), I am still going to get a CT scan before calling the surgeon. That's going to take, optimistically, 2-3 hours to get the CT scan done and read at my shop. It's going to take the survey resident another hour to come see the patient, talk it over with the attending and confirm their decision to admit. By the time an OR spot opens up, the transporter comes to get them but leaves and has to come back because the patient is off to get a random CXR, they are transported upstairs, various nursing stuff happens, they are almost done with the 6 hour waiting period. And if they have something that requires emergent surgery, their NPO status should be less relevant anyway.

Maybe this strategy would sometimes inconvenience some surgeon and/or delay some minor surgeries that can wait till the next day just fine, but the upshot is that you would have a much calmer, less hangry ER.
 
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The current ABA guidelines


Wait... people actually follow those instead of just waiting for the magical NPO after midnight order? (small glass of water? YOU'RE GOING TO SURGERY IN 7 HOURS, DO YOU WANT TO DIE?!?)
 
Same thing with TVs in every room. I HATE having to constantly turn down the volume to get the patient history. If you build it, they will come, and I hate that.

That's the first thing I do when I walk in the room because I need the history too. I also hate it when the patients' phone goes off and they refuse to silence it.
 
Meh, I am of the opposite opinion. As far as I am concerned, patients with ESI levels 3-5 should be given a turkey sandwich at triage.

The current ABA guidelines recommend an NPO duration of 6 hours following a "light meal" prior to elective general anesthesia. The sandwiches/snack boxes at my hospital are definitely not more than a "light meal". Even if they eat said turkey sandwich immediately prior to my examination and even if I conclude that I have a moderate to high suspicion for, say, appendicitis (already less likely if they munched that sammich just fine), I am still going to get a CT scan before calling the surgeon. That's going to take, optimistically, 2-3 hours to get the CT scan done and read at my shop. It's going to take the survey resident another hour to come see the patient, talk it over with the attending and confirm their decision to admit. By the time an OR spot opens up, the transporter comes to get them but leaves and has to come back because the patient is off to get a random CXR, they are transported upstairs, various nursing stuff happens, they are almost done with the 6 hour waiting period. And if they have something that requires emergent surgery, their NPO status should be less relevant anyway.

Maybe this strategy would sometimes inconvenience some surgeon and/or delay some minor surgeries that can wait till the next day just fine, but the upshot is that you would have a much calmer, less hangry ER.

I don't care about it for the npo prior to surgery.
It's more that if your biggest concern is eating, you likely shouldn't be in the Er.

I just don't like being interrupted from important tasks to be asked the same question 5 times by 5 different people.
 
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Wait... people actually follow those instead of just waiting for the magical NPO after midnight order? (small glass of water? YOU'RE GOING TO SURGERY IN 7 HOURS, DO YOU WANT TO DIE?!?)

Nah, of course not, don't be silly. I just use guidelines to prove I am not a complete heretic.

I don't care about it for the npo prior to surgery.
It's more that if your biggest concern is eating, you likely shouldn't be in the Er.

I just don't like being interrupted from important tasks to be asked the same question 5 times by 5 different people.

Which is why I say "if they are asking for it, they can eat". Eventually people get it.
 
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How is this OK? Are there standing pain management orders? I can't imagine that it's OK for an RN to just bust out fentanyl without a documented order in place.

I can see acetaminophen, ibuprofen, ondanestron or something like that, but not a schedule II medication.


Not done, but I am ICU/CC RN not a ED RN. Good ICUs are places of major anal-retentiveness.
 
This x 1000.

some shifts literally half the chart I have to spend documenting why 'X test' wasn't ordered or why I don't believe pt has 'symptoms YZ' because of some massive/rediculous/full of red flags that aren't true/more information than I want documented/ note documented by triage RN.

Literally makes me die inside and increases my serum agitation concentration.

Nurses, we will love you if you just put something to the effect of "Abd pain X 2 days" or something. Don't document anything else. Seriously.

Too bad that is not what they teach us in nursing school or post-grad practice or in the legal courses. Fine w/ me otherwise. Maybe just teach your ED RNs to hone their focused assessments and such. No one really likes writing superfluous patient notes. But they drum it into your head to cover your azz w/ assessment & documentation. It is what it is.
 
I had a nurse disregard a Doctor's orders as a patient once. I fell around 5-6 metres (16-18 foot) through a plasterboard ceiling, managed to break my fall somewhat by grabbing onto what was left of the ceiling at the last second but still hit the ground pretty hard -- landed on my tailbone, jarred my spine pretty badly. I was pretty blindsided by what had happened, so without really thinking I got up and managed to stagger down stairs and sit on the lounge, thinking I just needed to rest and calm down and everything would be okay. That's when the pain and muscle spasms started to really kick in, and I became concerned that perhaps I'd done a bit more than just jar myself. So I phoned for an Ambulance, still kind of expecting they'd check me out and say I just needed to take some over the counter pain meds and continue resting, perhaps apply some heat or an icepack, maybe. They decided I needed to go to hospital to be assessed properly, so fair enough off we go.

I end up being taken straight through to the ED as a priority 2 triage (urgent, to be seen within 20 minutes I believe it is) -- which admittedly surprised me, but I wasn't overly worried because I'm still thinking 'bruised my tailbone, jarred my spine, they'll give me a quick look over and send me home'. And then one of the Doctors on duty comes and assesses me, and starts barking orders at the attending Nurse - "I want a priority X-ray, do NOT move her without Fentanyl". Um, okay then? Don't move me without Fentanyl? Should I start panicking right about now? Yes, yes I think I will. It wasn't so much what the Doctor had said, but the way in which he said it. He made it sound like some dire calamity would happen if anyone dared try and move me without first having given me a dose of Fentanyl, and admittedly I started to panic and think that maybe I'd hurt myself way worse than I thought (I wasn't expecting to be given any sort of narcotic pain meds, let alone hear a Doctor sounding so adamant that I *had* to be given said medication before anyone tried to move me, so naturally all sorts of dire things were going through my mind). He scrawled his orders in my chart, handed it to the Nurse, went off to tend other patients, and when the hospital porter came to take me down to x-ray I still hadn't received the medication that was ordered by the Doctor so at the point I basically freaked the f**k out. I was completely embarrassed by the way I acted after the fact, but I started raising my voice, and shouting, and pleading hysterically for them to 'check my chart, the Doctor said not to move me without Fentanyl, you can't move me without Fentanyl, the Doctor ordered it, it's in my chart!' (I know, I behaved shamefully :sorry:).

The porter steps back at that point and indicates to the Nurse that if those were the Doctor's orders then he's not taking me anywhere until they've been carried out, so then I've got this Nurse glaring down at me and more or less informing me that she knows what the Doctor's orders were, but I didn't need to be given Fentanyl to be taken down to x-ray. Then she starts firing questions at me, 'why did I get up straight after the fall?' 'Why did I wait several minutes to phone for an ambulance?' 'Why didn't I feel the full amount of pain straight away?' etc etc (um, okay, hang on a sec and I'll just go get my medical degree so I can answer those questions for you, Nurse). Then she decides that I can't be taken to x-ray or given Fentanyl, despite what the Doctor had written in my chart, because she has to do a pregnancy test on me first -- and if I couldn't manage to give a sample by using a bed pan or commode chair, then she'd have to catheterise me (she made damn sure I knew just how painful that was going to be as well, plus I also had the lovely vision of the damage that was done to my Dad's urethera by a poorly placed catheter post prostate surgery, none of which was exactly helping me to calm down). So there I am in the middle of the ED, in full of view of everyone, struggling to give a urine sample, with a nurse yelling at me to get off the bed and onto a commode chair (which I was trying my best to actually do, except for the fact that almost every time I tried to move my back muscles would go into horrendously painful spasms).

The Doctor eventually comes back to check up on the progress of my case, sees what the Nurse is trying to get me to do, realises I've not been taken to x-ray, not been given any medication he ordered, basically had everything he'd written in my chart contravened -- and he starts demanding answers, and he's not exactly happy at what he's hearing. Of course by now the Nurse is being oh so nice and deferential, but nope, he's having none of it. Gave her a lecture about contravening a Doctor's orders, made her fetch the Fentanyl, and administered it himself. Off I went to x-ray and as it turns out I was right all along, bruised tailbone, jarred spine, and apparently my back muscles had locked up as a protective measure to prevent any further potential injury. I asked the Doctor the same questions the Nurse had been rapid firing at me, and his answer was basically 'Well adrenalin can do funny things sometimes'. I was discharged after another couple of hours observation, hubby came to pick me up, and all I needed was some bed rest, apply a heat pack if needed and take some over the counter pain killers.

Now maybe I did overreact when I called an ambulance, maybe I should have just stuck with my initial assessment which turned out to be right, and I know I definitely shouldn't have made a scene and started yelling and carrying on when I was in the Emergency Department. But a) I'm not a Doctor so I couldn't actually be sure of what injuries I did or didn't have, and b) the Nurse was given clear instructions by the Doctor overseeing my case, instructions which were were written up in my chart, and she chose not to carry those instructions out because apparently she knew better.

:rage: :rage: :rage:


Oh God. I have had this happen. It seriously does hurt like hell. It also sounds like the nurse and doctor were in dysfunctional mode. Damn, did they just get out of a bad relationship with each other? And if the nurse can't talk to you in decent manner, why doesn't she go home. God I hate when people are abusive to patients--even when some of the patients are a pain in the butt. You situation though, OUCH+. Many years later, and mine still hurt, though nothing close to the same level, to this day. :)
 
And if the nurse can't talk to you in decent manner, why doesn't she go home.
This is the bane of hospital based practice. I am not an employee of the hospital. I cannot fire them for anything. At best, I can report them to the board of nursing for gross incompetence or some other violation. But to complain to the next levels of management, who are all nurses, just makes them close the ranks and fight back harder. I can't think of any EP who was successful at getting a nurse fired because they weren't good at their job. But at a clinic, where you own the building and can manage your department like it's yours? You have that power. That's why FSEDs are so good at fixing burnout.
 
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This is the bane of hospital based practice. I am not an employee of the hospital. I cannot fire them for anything. At best, I can report them to the board of nursing for gross incompetence or some other violation. But to complain to the next levels of management, who are all nurses, just makes them close the ranks and fight back harder. I can't think of any EP who was successful at getting a nurse fired because they weren't good at their job. But at a clinic, where you own the building and can manage your department like it's yours? You have that power. That's why FSEDs are so good at fixing burnout.

IDK, the places I've worked have mostly been pretty tough on nurses. A doc gets upset, s/he brings the money in, so management caves in, whether nurse deserves it or not. I'm not saying there aren't nurses out there that should be sent packing, b/c there are. But at least where I have worked, it can be so ridiculous that if you just slightly piss off the wrong person, you are gone. You advocate for the patient, and instead of getting support, you get grief and someone's feathers are ruffled, when you sincerely are focusing on the patient.

In the units I have worked, people usually watch your carefully. It's OK if they watch you like a hawk. That's great. I accept this for smart reasons. But I have seen more nurses weeded out for BS issues, it's totally not funny. My suggestion to management, even as I was in management, was to develop and consistently maintain at least more objective systems of measurement. I worked at a non-profit teaching center that excelled at this. So I know that it can be done. Some stuff can't help but appear as more subjective and gets hard to evaluate when those people that can't treat others decently have a crew of support that have their backs. It can be really dog-eat-dog for nurses. I will say that much of that has to do w/ how nurses treat each other too.

Usually, at least from my experience, docs aren't the problem--although, they can be a few here and there. *shrug* But I've seen some cliquey nurse-doc-tech gang-banging on certain people that get hated on for BS reasons. Stupid politics. It happens.

It does suck working w/ miserable people. What's so funny is that some people don't actually know they are being miserable. A leader, a true role model, is secure and cool with teaching and works to bring out the best in others. They set the tone for this, and it makes a big difference in the environment. I worked with some medical directors that were amazing with this. About ousting a nurse for legitimate cause...well, it's about an accurate and fair paper trail.

Listen if I worked with docs that weren't pleased w/ me, honestly, I'd be nervous. For one, I have to work w/around them, and I like a positive atmosphere and people pulling together. Second, yes, they do have the power to get rid of a nurse. The smart ones employ other nurses around to keep the record of "offenses" or whatever. Sometimes these records are fair and accurate, and other times, they are not. It is for this reason many nurses were hopped up to be unionized. I understand where they are coming from, but I like to do my own negotiating, and unions can be a huge waste of time--sometimes they help unfairness, other times they don't. I really haven't worked at any unionized centers--or at least they weren't so when I worked at those medical centers.

Why do people have to make the whole working together process so damn tough??? And nurses shouldn't be anyone's go to for displacement either. Listen, honestly, I am not a tech--I have a formal education in this and experience whether any docs get it or not. Also, I am not anyone's whipping boy.

At the same time, I don't deal well w/ disrespectful nurses--whether if it is to other nurses, patients, docs, or other staff. Why can't people get that that all of healthcare has it's own huge, inherent stressors???? Why add to this? Why can't people just have some talk-to-talks with each other? You'd be amazed at how some people think they are above this kind of thing. They have the greater education, so that means, they don't have to waste their time with nurses, docs, RRT, whoever. The truth is, if people are humble and care, it's at least worth the effort to set a productive, healthy tone. Yes, sometimes that does work. Sometimes it doesn't; but it's worth the effort. I can take blood and guts, but the interpersonal disharmony is just too much insult added to injury. And please note, sadly, that too often, administration doesn't care either. Top mgt doesn't set the tone well, and crap rolls downhill.
 
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Oh God. I have had this happen. It seriously does hurt like hell. It also sounds like the nurse and doctor were in dysfunctional mode. Damn, did they just get out of a bad relationship with each other? And if the nurse can't talk to you in decent manner, why doesn't she go home. God I hate when people are abusive to patients--even when some of the patients are a pain in the butt. You situation though, OUCH+. Many years later, and mine still hurt, though nothing close to the same level, to this day. :)

Yeah it was pretty damn painful for a couple of weeks after, but I was lucky there wasn't more serious injury done -- 2 weeks following Doctor's orders and resting up with some heat packs and OTC pain relief and I came good. The Doctor's attitude at the time as well was more because the ED was full to being over capacity, and they needed to be able to effectively assess, treat and either admit or discharge patients as quickly as possible to keep things moving. It's just unfortunate that the abruptness of his manner made it sound to me like I was way more seriously injured than I first thought, and resulted in me being sent into a panic. As it was though all that Nurse had to do was follow what the Doctor had charted in my notes: I would have been taken down to X-ray in a timely manner, cleared of any serious injury, been given my discharge instructions and sent home -- 'next patient thanks'. Instead her decision to contravene the Doctor's orders, and then take the time to harass an already terrified patient into an even greater state of fear, succeeded in doing nothing but just holding everything up when at the time, considering the entire ED was absolutely flat chat, they really needed to be kept moving along as efficiently possible.

And of course I don't expect any Nurse or Doctor (or anyone who works in an ED for that matter) to just take **** from people, but by the same token to my mind a Nurse should know the difference between a patient who's starting to act up because they're just really scared, and one who's doing so because they're being an entitled pr*ck. I did feel genuinely bad about carrying on the way I did (scared or not), so I made several apologies to the staff when I was being discharged. The Doctor was very understanding and more or less told me that I had nothing to apologise for, that he knew I was just really frightened, and that he didn't believe I had meant any malice -- in contrast the most I got from the Nurse was a very brief and reluctant nod of acknowledgement (with a bonus snort of derision added in for good measure).
 
Yeah it was pretty damn painful for a couple of weeks after, but I was lucky there wasn't more serious injury done -- 2 weeks following Doctor's orders and resting up with some heat packs and OTC pain relief and I came good. The Doctor's attitude at the time as well was more because the ED was full to being over capacity, and they needed to be able to effectively assess, treat and either admit or discharge patients as quickly as possible to keep things moving. It's just unfortunate that the abruptness of his manner made it sound to me like I was way more seriously injured than I first thought, and resulted in me being sent into a panic. As it was though all that Nurse had to do was follow what the Doctor had charted in my notes: I would have been taken down to X-ray in a timely manner, cleared of any serious injury, been given my discharge instructions and sent home -- 'next patient thanks'. Instead her decision to contravene the Doctor's orders, and then take the time to harass an already terrified patient into an even greater state of fear, succeeded in doing nothing but just holding everything up when at the time, considering the entire ED was absolutely flat chat, they really needed to be kept moving along as efficiently possible.

And of course I don't expect any Nurse or Doctor (or anyone who works in an ED for that matter) to just take **** from people, but by the same token to my mind a Nurse should know the difference between a patient who's starting to act up because they're just really scared, and one who's doing so because they're being an entitled pr*ck. I did feel genuinely bad about carrying on the way I did (scared or not), so I made several apologies to the staff when I was being discharged. The Doctor was very understanding and more or less told me that I had nothing to apologise for, that he knew I was just really frightened, and that he didn't believe I had meant any malice -- in contrast the most I got from the Nurse was a very brief and reluctant nod of acknowledgement (with a bonus snort of derision added in for good measure).


No matter what you do as an RN sometimes, no matter how much you kill yourself, no matter how understanding and so forth, **** runs downhill, and nurses can take the load of the crap. Sometimes those in charge are entitled. Everyone is busy. Everyone is under stress. The other person that commented and said that some nurses hold on to their patients so that they don't get the next hits is right at times too. I have seen this in recovery and other areas as well. Other nurses that see this kind of thing get pissed off too. The holder-on-ers end up having friends in nursing/admin mgt, and so they get away with it, while others of us continue to bust our arses. You can be getting hit hard, but a balanced approach is key. If you came off as snappy when you didn't want to as doc or nurse or whatever, you should apologize--own up and say so. Do you know, sadly, how many people are sincere and secure enough of human beings to do this??? At the same time, I'd argue that the most recent studies show how multi-tasking causes trouble in brain-processes and decreased effectiveness in work. People don't understand that the nurse, as stupid and under educated as you may think he or she is, is actually using a process of their own, which is a legitimate process of effective nursing, balanced care, and good advocacy. They are not techs. They are not robots. There is an art and science to their processing as well; it's just that some nurses understand it and use it better than others. It shouldn't feel like a challenge. It should be respected. Now stupid work is stupid work. I get that. But there is to be a method/process to nursing, and things such as paperwork and what not are required professionally and administratively and legally. I don't like slackers either. Some of this stuff of c/o's is legitimate and others of it can be tweaked w/ setting the right tone, respecting each other in their roles, and having everyone in focus on putting the patient and family as number one. I include family, b/c I believe in family-centered care, although this seems to get crazier in the ED setting, so I understand the tendency to roll eyes when it is spoken. It means bypassing ego and intemperance and frustration in a very imperfect systems.

You may think you are helping by treating nurses as underlings on the lower end of the food chain, but you are not helping your patients, your hospital, yourself, or anyone else. And some nurses are new. Have patience w/ them in the same way, hopefully, someone had patience w/ you when you were a MS or intern.

Re: ED, maybe this is why I have liked the units more...you can often take more time and hone in deeper on problems and hopefully see patients get better--sometimes not--and either way, they get moved on also, but I can really focus in on them and give them my all. The good side of ED is that if you move your patients forward in a careful manner, you get the opportunity to focus on someone and something new, and then hopefully you get that chance to recharge when you can or hit the re-set button to get the place back in order, b/c you don't know what will happen next. But this also happens on downtime in units too--b/c what's in the ED is often just getting warmed up for the intensive care unit. I like to be ready, b/c something about ICUs, surgical recovery areas, and the like makes you into a control freak.
 
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I love nurses even the ones who are rude to me or lazy


Rudeness and laziness needs to be addressed, whether it's regarding a nurse, a tech, or a doc, no?
 
Last night I had a nurse that just kept wanting to play doctor.

I had an elderly asthma exacerbation as well as CHF exacerbation as the pt has both crackles and diminished BSs with inspiratory and expiratory wheezes. The pt was breathing about 40/min but was still mentating well. She also had a HR of 150, which looked regular on the monitor and EKG. As I asked RT to place pt on BiPap w/ continuous nebs, nurse X got upset that I was not immediately intubating her. I tried to explain to her that it is a bad idea to go straight to intubation on a bad asthmatic, but of course she knew better. Then she decided to keep pestering me about treating the pt's HR which I explained to her was likely sinus tach, and even if it was SVT or a-fib it was likely 2/2 to her agitation and CHF exacerbation and the risk of "treating" that rate could lead to worse outcomes in this pt. She then went to my attending to tell him that I didn't know what I was doing and she needed him to step in, at which point he told her that he completely agreed with my management. At that point she decided to storm out of the room.

I did end up intubating, but only after I gave the pt a fair shot until she looked like she was tiring out.
 
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My favorite part of every shift is finding a triage nurse asking a patient who is sick, altered or in extremis some asinine question. I was taking care of a pretty sick DKA the other day (pH 7.02, AG 45, bicarb 6, glucose 1200s) when I noticed a 40 yo F BIBEMS for hypoglycemia on my board. 5 minutes or so pass without a FS so I peek my head out to see the triage nurse sternal rubbing the woman and yelling at her about whether or not she wanted an HIV test. She then yelled at me when I called for glucagon and an amp of D50. Talked to the EMS guys after I got a line in her. The FS was < 20, about 20 minutes before they got her to the hospital.

I also hate being pushed for a disposition because "we need to decompress the ER". I took signout on a 63 yo belly pain, we're following up a CTA to r/o AAA. Scan comes back as "enteritis" but my attending and I disagree, we consult surgery, get our in house rads to over read the virtual guy and long story short 3 hours later she's in the OR with a strangulated internal hernia. But I shoulda listened to nurse know it all and just admitted the patient to medicine . . .
 
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Last night I had a nurse that just kept wanting to play doctor.

I had an elderly asthma exacerbation as well as CHF exacerbation as the pt has both crackles and diminished BSs with inspiratory and expiratory wheezes. The pt was breathing about 40/min but was still mentating well. She also had a HR of 150, which looked regular on the monitor and EKG. As I asked RT to place pt on BiPap w/ continuous nebs, nurse X got upset that I was not immediately intubating her. I tried to explain to her that it is a bad idea to go straight to intubation on a bad asthmatic, but of course she knew better. Then she decided to keep pestering me about treating the pt's HR which I explained to her was likely sinus tach, and even if it was SVT or a-fib it was likely 2/2 to her agitation and CHF exacerbation and the risk of "treating" that rate could lead to worse outcomes in this pt. She then went to my attending to tell him that I didn't know what I was doing and she needed him to step in, at which point he told her that he completely agreed with my management. At that point she decided to storm out of the room.

I did end up intubating, but only after I gave the pt a fair shot until she looked like she was tiring out.

See, now, once you have shared your sound rationale, it's like, "Let's work this plan. We are watching her. God it's not like she is not being closely monitored. "

I disagree with this nurse's response and behavior. I am not a physician but a cc rn, and even I think you did the right thing. I don't necessarily think is is good idea either to necessarily jump to intubating an elderly, asthmatic patient. If her pressure was fine and her rate was sinus, and if she was making improvements in oxygenation w/ the current treatments, why in the hell put her through intubation unless you have to do so? Yes. I can see not wanting to poop her out, but if it were my mom, yes. I'd say give the first plan w/ med tx a fair chance, keep an eye on her, document her signs and other pertinent information, and then go to the bigger guns when it is clear that plan A isn't really cutting it and she's now at risk if you continue with the plan. I am certain the pt wouldn't have wanted you to jump to intubation, unless is was clear straightaway that this is step 1 priority.

Was this an experienced nurse, or a newer/younger nurse? This is what I like about the units over the ED too. You have more time to review the plans and discuss the rationales and people have opportunity to learn and grow. Sorry that she didn't take the right approach w/ you. Storming out is not the answer, doesn't help the patient, and is just unprofessional.

I am only weighing in here, and I know this is a vent thread, but please understand not every RN is like this. And sometimes, some people need more time to learn. I have been working as CCRN for years, and there is always more to learn. In fact, I am less yahoo and probably more contemplative, b/c this world doesn't work like a perfect science. I think the longer you work, the less you feel like you know in some ways. What seemed clear at one point, you learn, is not a clear plan for everyone. So many of us would have readily deferred to your orders and appreciated your rationale, and worked to work the plan. Don't write us all off. :)
 
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My favorite part of every shift is finding a triage nurse asking a patient who is sick, altered or in extremis some asinine question. I was taking care of a pretty sick DKA the other day (pH 7.02, AG 45, bicarb 6, glucose 1200s) when I noticed a 40 yo F BIBEMS for hypoglycemia on my board. 5 minutes or so pass without a FS so I peek my head out to see the triage nurse sternal rubbing the woman and yelling at her about whether or not she wanted an HIV test. She then yelled at me when I called for glucagon and an amp of D50. Talked to the EMS guys after I got a line in her. The FS was < 20, about 20 minutes before they got her to the hospital.

I also hate being pushed for a disposition because "we need to decompress the ER". I took signout on a 63 yo belly pain, we're following up a CTA to r/o AAA. Scan comes back as "enteritis" but my attending and I disagree, we consult surgery, get our in house rads to over read the virtual guy and long story short 3 hours later she's in the OR with a strangulated internal hernia. But I shoulda listened to nurse know it all and just admitted the patient to medicine . . .


Seriously, thank you for doing this. I love it when people care enough to go the extra mile. Good for you. She's not the doc, you are, period. Again, experience should teach smart nurses to shut up, think, and listen. Luckily I have worked in great teaching hospitals, where it's rare that an RN has to get nervous and go over someone's head. I'm an advocate, but I have to be reasonable and trust the docs. Given, I usually am curious and want to understand things. That's just my nature; but I don't pretend to know more. I try to give respect and work together. It has to be something really obviously detrimental for me to get real vocal. I have taught/teach nurses, so hearing this feedback is good. I don't like nurses being to passive and forfeiting their role as advocates. At the same time, you had better have some strong reasons to cause a fuss, or you just created a big mess.
 
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See, now, once you have shared your sound rationale, it's like, "Let's work this plan. We are watching her. God it's not like she is not being closely monitored. "

I disagree with this nurse's response and behavior. I am not a physician but a cc rn, and even I think you did the right thing. I don't necessarily think is is good idea either to necessarily jump to intubating an elderly, asthmatic patient. If her pressure was fine and her rate was sinus, and if she was making improvements in oxygenation w/ the current treatments, why in the hell put her through intubation unless you have to do so? Yes. I can see not wanting to poop her out, but if it were my mom, yes. I'd say give the first plan w/ med tx a fair chance, keep an eye on her, document her signs and other pertinent information, and then go to the bigger guns when it is clear that plan A isn't really cutting it and she's now at risk if you continue with the plan. I am certain the pt wouldn't have wanted you to jump to intubation, unless is was clear straightaway that this is step 1 priority.

Was this an experienced nurse, or a newer/younger nurse? This is what I like about the units over the ED too. You have more time to review the plans and discuss the rationales and people have opportunity to learn and grow. Sorry that she didn't take the right approach w/ you. Storming out is not the answer, doesn't help the patient, and is just unprofessional.

I am only weighing in here, and I know this is a vent thread, but please understand not every RN is like this. And sometimes, some people need more time to learn. I have been working as CCRN for years, and there is always more to learn. In fact, I am less yahoo and probably more contemplative, b/c this world doesn't work like a perfect science. I think the longer you work, the less you feel like you know in some ways. What seemed clear at one point, you learn, is not a clear plan for everyone. So many of us would have readily deferred to your orders and appreciated your rationale, and worked to work the plan. Don't write us all off. :)
She is actually a very experienced RN, and most of the time I enjoy working with her, but she tends to think she knows how to manage critical patients better than residents do and she takes it personally when we disagree with her.
 
She is actually a very experienced RN, and most of the time I enjoy working with her, but she tends to think she knows how to manage critical patients better than residents do and she takes it personally when we disagree with her.

Experienced? Hmm. Your plan was reasonable if the patient was being continuously monitored, etc. Also, for the last part, she needs to get over that. It's lame and unprofessional. Thanks for giving a balanced perspective too. It's not about knowing it all or usurping control. It's about the patient first and foremost, period. She needs to step back a bit. Take some breaths and reason things out. I like it when people take emotional elements out of the equation, when you can. They cloud judgment. Reminds me of the God Father Part III, where Michael Corleone says
"Never Hate your enemies, it affects your judgment."
 
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Just wondering if the majority of the docs here with these stories are residents or attendings? Im a female EM intern and we routinely have nurses who disobey orders and do whatever they want. There's a nurse we have here who sees a patient before we do, draws blood and puts in his own orders under the attendings name. By the time I see the patient some of the labs have resulted.

Today we had a nurse who I put in an order for a patient to be placed on a cardiac monitor. An hour later the attending complained to me that the patient was still not on the monitor. I verbally told the nurse two more times to do it and she responded "if you guys are so concerned do it yourself". 30 minutes later the patient was still not on the monitor, the attending got pissed and walked up to her and gave a verbal order, at which point she got up immediately.

Im too busy and have too many patients to see to fight these people or safe care them. Ive done it in the past and they just talk back. Im just hoping this is only happening cuz it's residency and things will change dramatically when I'm an attending.

Thoughts?
 
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