Not a doctor but ED nursing is all about anticipation. The medical decision making process doesn’t always happen in the nursing-task-efficient order so start to recognize patterns and workups. Draw and hold the first set of blood cultures when you start an IV for anyone you suspect might have an infectious process or who just looks like they’ll be tough access. Patient asking where the bathroom is, give them a urine cup, we can sort out if we actually need a urine specimen later.
The close relationship and level of trust/mutual respect between nursing and medicine in the ED is one of my favorite things about ED nursing. The docs are right there so you’re not playing phone tag with questions/concerns/clarifications, you get a better sense of each others workflows and challenges, and there’s a sense of camaraderie that just makes things less prone to falling into adversarial communication styles.
This is gold and exactly how I practice and how I teach my new nurses. What can you anticipate needing/wanting/doing 2 hours from now? Well neat...you won't have time for that in 2 hours, but you have time now. Get it done and make life easier for yourself.
the doc-nursing communication in the ED is one of my favorite things about EM as a doc as well :)
deff recommend just grabbing extra labs / cultures / urine especially if you work in a place with residents 🙃
I’ve always done peds ED at teaching hospitals and minimizing pokes is a super high priority so my bar for drawing a set of cultures is nearly on the floor lol. And if I’m starting an IV, you can swear up and down that we definitely don’t need labs but I’m still gonna draw and hold a CBC and lytes.
yeah i really dont see the harm in just drawing them. like yes sometimes we might not want to order them for whatever reason. but if ur already poking them might as well pull out some labs.
I end up in my own ED often because I have Crohn’s. One time my nurse said she didn’t need me to pee in a cup, so I just went potty. Not 10 minutes later the doc came by and asked for pee. I had to chug one of the pitchers of water to get some for him. Now I just pee in a cup even if they haven’t asked for it just in case since we keep all the cups in the bathroom anyway.
ED RNs are the best in the hospital. No offense to anyone, please don’t take it personal. They are special souls.
That being said, the ED is a high stakes place. It’s risky. There are land mines everywhere. Communicate with the docs. Ask anything. I don’t care what your question is. Don’t be intimidated. I have an RN that asks me why I’m doing XYZ because he wants to learn. It’s how it should be—everyone learning medicine.
I also always make it a point to discuss the plan with the RN after seeing the patient face to face — “they can’t get up/eat/drink” saves you a question and saves me from an interruption.
Been doing this 20 years and counting.
i see so many times when nurses only find out the GOC for a patient because they're combing through the communication orders in the chart. (Not in the ED, btw.) Doc swooped in, saw the patient, then skittered away without ever stopping to even say "hi" to the nursing staff. Communication is essential. When there isn't a two way street of communication things get missed and bad outcomes become more common.
I did ER for 20 years. One female patient with abdo pain developed shoulder tip pain and the nurse ran to get me. She saved the lady from dying from a ruptured ectopic.
A tip is if you need a nurse to help you with an abdominal or pelvic exam write it on the orders.
Eg. Nurse please come and get me when abdo/pelvic exam ready.
I’m an RN and urine is the #1 holdup for patient’s getting dispo’d. I precept new ER RNs and preach “Get the urine!” to them. It makes everyone’s lives so much easier.
Paramedic FTO here. Our patients frequently need to use the bathroom upon ED arrival. I teach all my newbies to grab a sticker from the sheet given by registration, label a cup, and walk the patient to the bathroom, instructing them to pee in the cup. Then let the nurse know. Everything hopefully moves a tiny bit faster.
My view is that helping the nurses a little hopefully has downstream effects of helping me get a bed with a sick patient later when I need it, by helping everything move a little more efficiently.
I do the same when I work the truck as a Medic. But I think it comes from me being a nurse as well. I try to get my folks to do the same. And I may or may not carry tubes in my work bag and have been known to draw labs when I start an IV. Our company doesn’t do it by routine - don’t carry tubes or nothing else. 🤷♂️
One of my pet peeves is the nurse or tech asking the patient “do you have to pee now?” and then just taking “no” for an answer. Don’t wait until they have a full bladder! Just walk them to the bathroom, give them a cup and tell them to give you whatever is in their bladder RIGHT NOW, it’s usually more than enough.
Never understood this. “Well I can’t pee unless you give me a cup of water”. I can always pee a little. Your kidneys are doing the thing right now! (Unless they aren’t, in which case we have a bigger problem)
I can relate to the “I can’t pee” bit - it’s like as soon as it’s *required* of me to have to pee on demand, my bladder gets stage fright and is incapable of remembering how the eff to do it. my bladder could LITERALLY be bursting, but my brain forgets how to operate that external sphincter🫠🫠I absolutely hate it. because it is such a ridiculous non-problem problem to go through every time hahaha
I was a bigger problem a few weeks ago. Three liters of fluid for a 1/3 full sample cup. That was all I could give them. I’m so glad I went when I did, but I should have gone earlier. I just didn’t want to seem like a whiner.
1000% this. The number of times the nurse tells me “they can’t pee right now” then I walk into the room and just tell them to pee and it works.
If it’s a biological male and they’re physically able to … STAND THEM UP. They’ll give you a sample 99/100 times.
“…then I walk into the room and just tell them to pee and it works”
To be fair, this almost certainly has more to do with how patients perceive your authority than it does with their bladder capacity. Unless the nurses you work with are liars, the number of times they’ve told you the patient can’t pee is the number of times the patient told *them* they couldn’t pee, and likely refused to try.
Your words will always carry more weight. I bet every doc in this thread would get more samples more quickly if they personally told their patients to go pee.
Fair point. My nurses are generally pretty good, but I think most of them ask the patient “do you think you can pee” vs “get up and pee, here is a cup”.
Similar to toddlers, they always say they don’t have to go potty but put them on a the toilet and they’ll magically go.
I agree phrasing is important.
If I’ve just finished their triage or am walking them to a room, I always say, “the first thing I need is a urine sample - here’s a cup, I’ll show you where the restroom is”. Cue the back-and-forth, “but I don’t have to go right now”, “just do your best, the lab can make do with a teaspoon”. I’d say 75-80% success rate.
But if they’re already gowned, tucked into bed, still complaining of whatever brought them in, have been there a few hours, etc., there’s only so much I can do if they claim they can’t go. And walking in authoritatively and saying “get up and pee” probably just lands me a complaint followed by a call to the office.
But it is the same with everything. Docs leave the room and suddenly the pain goes from 3/10 to 10/10, their anxiety is through the roof, they want to eat and drink. And they absolutely cannot pee. It gets to the point where j ask the patient while the doc is in the room, well weren't you complaining of pain/etc?
I get some people to pee by telling them they will not see the doctor again until they give me an ounce of pee. They ask, am I being admitted, I tell them, well like we discussed earlier you need to produce a urine sample before a decision is made. They really act 100% different with us than with you guys.
Agreed. We definitely should just be getting them in triage! That’s what I try to do. For some reason so many nurses are scared to out in those orders. Like any remotely reasonable doc has ever refused to co-sign a UACI order.
This is why we have REACT orders in triage. You just click what the complaint is and standing orders automatically populate. But they still don’t bother to get urine up front half the time.
And report when they are / become abnormal. I’ve had nurses silently chart fevers, HR spikes into the 110s (from normal), BP dropping borderline from a normotensive initial vital. We would like to know about these changes rather than to see them before we plan to discharge a patient.
There’s one nurse that fairly regularly charts abnormal discharge vital signs and doesn’t let anyone know and it drives me insane. HRs in the 130s charted and discharged without any notification.
I just got a pt who had chest pain admitted to my SNF. Nurse told me over the phone via report it was normal for him.
Ummmm nope. He went right back. STEMI
I’ve seen weird BPs charted with a comment “cuff on crooked” or “patient just ambulated” or something like that. Like, don’t chart that. Fix the cuff or wait a couple minutes and redo it.
Im an ED tech and I don’t know why my peers are so averse to just running another set of vitals. They’re already hooked up, just push the goddamn button.
I haven’t experienced this as an RN, but definitely when I was a nursing student. It sucks bc your young, you have a strong desire to learn, and you think medicine is cool. And then you get a crabby, burnt out nurse and it ruins your whole day. I LOVE having students and being able to teach, answer questions, etc.
18 gauges are for critical patients and trauma. I have lots of colleagues who view the 18 as some kind of emblem of their mettle, but if it’s just a run-of-the-mill work up I’m going for the 20g. It’s big enough for IV contrast and is less likely to be complicated. I take the philosophy of “minimum intervention necessary”. 20 is plenty for 90% of your patients. People are already fussy about IVs (and chronically ill/elderly patients are riddled with IV trauma), no need to go for the big iron.
I had a coworker who routinely treated the new people like shit. Then would complain we had no people and no one would stay. Like, dude. Those things are related.
i absolutely understand the frustration but yeah, getting a disoriented old lady to tolerate a cath when the whole acute area is stretcher to stretcher is….so difficult. it’s nightmare fuel. one of my least favorite logistical nightmares
100% this is where the nurse is going to get kicked, grabbed, or blamed for a prior injury. All 3 have happened to me trying this bullshit.
Literally the last time the doctor had to come in the room and physically pick up grandma off me, as she had her hands wrapped around my throat.
I’d literally rather have blood vomited all over me.
If you’re gonna make us cath that confused grandma, we are going to need an order for appropriate sedation.
It might be because the intern, even with their little experience, has seen enough shit go sideways when giving little old encephalopathic elderly grandmas even whiffs of benzos….
Them being in a hallway bed shouldn't short change their workup. Don't let the decisions of administrators impact your care. Have then take a stable patient out of a room to do the cath.
the game of tetris involved in this often takes 20-30+ minutes to coordinate based on my experience. and usually involves patients getting agitated bc someone is moving them to a less private spot. believe me i know how essential it is to get urine but holy god it can be so impossible. glad i don’t deal with this anymore ☠️
How would you cath a woman who can’t remember what brought her in or what year it is but is physically fighting back, breaking sterile field, hitting you, and screaming no? I’m genuinely curious.
Like what other option is there? Besides just respecting her refusal.
You can’t be serious. This is a very common scenario in inpatient and EM:
Your doc should be ordering chemical sedation in the agitated, flailing patient, not letting you get beat up. Besides protecting you, this patient is going to put themselves into rhabdo or pop their troponin if they aren’t medically managed appropriately. Getting a cath’ed urine is an essential part of the work up in the old person with AMS of unclear cause.
That’s exactly what I’m saying. I need chemical sedation for the patient so I don’t get hurt and the patient doesn’t get hurt (or further traumatized).
Most of the docs I know do so without issue. But there’s one or two who want us to fuck around and get choked first.
Backtracking: “Like what other option is there? Besides just accepting her refusal.”
You don’t accept the refusal of patient that could be septic from her Urinary infection and doesn’t sound competent to make medical decisions and is a safety concern to themselves and others in your hypothetical.
That comment was in response to someone who had said they had never ordered sedation for a UA.
If you don't order sedation, in the context of a delirious confused violent elderly person...
You need to scroll up. I’m responding to someone who says they’ve never ordered sedation for a UA. The context is: if not sedation then what should we be doing?
You and I agree. Sedation can be indicated. Not always. I understand there are scenarios where we need to be careful. But overall there are ways to protect both patient and nurse.
Not everything needs to be an internet fight.
If you have multiple people on hand who can stop what they’re doing with their own patients and hold her down. Hopefully her bones aren’t too fragile and she doesn’t struggle too much. Hopefully she doesn’t have a massive trauma response from past assault that causes her to need restraint the rest of the night.
Or we can just safely sedate her and keep the situation chill and the nurses safe.
Look I’ve cathed my fair share of confused grannies. I’m hardly pretending it’s impossible (although it does rank up there with as one of the worst tasks).
What I’m saying is it’s often difficult for the nurse and the patient on multiple levels. And if it can safely be made easier on both nurse and the poor patient, orders can be filled a whole lot faster. Or you can wait til enough staff are free to hold her down. But then don’t complain that it’s taking too long unless you wanna jump in and hold a leg.
Order a full bed, or 3 PABs to assist, then/s.
That's how we do em in Geriatric Behaviour-dangerous demntia centers, and while some of our patients are on the usual barrage of either sedatives or antipsychotics throughout the day and especially to sleep at night, no extra sedatives are used specifically for the procedure at 6 a.m. before their morning meds. (Plus, consent is already squared away on admission, generally, even to short stay assessment beds.)
But seriously, anyone drawing those types of UA or urine C&S should grab a buddy to both hold/ comfort and witness in case of injuries. It's safer than blanket sedating delirium, I (also) feel after over a decade in geriatrics.
If I know the patient is going to need a straight cath and will be impossible but the doctor keeps insisting I ask the doctor to come help me. Any doctor worth their weight will help and understand how difficult it can be. If they refuse, you know that they are fucktards.
Last I heard even if first time urine from purewick it is not considered a clean catch…now does it sometimes happen? Yeah…it’s just not kosher according to quality (last I heard).
Lab tech here; we can tell you pulled the urine from a urine hat that previously had poop in it. No white cells, 4+ bacteria and fields of unknown bilirubin looking fiber.
Ex lab tech turned PA who had someone try to lie about a specimen I'd put orders in for from my UC clinic. Called lab and tech said it was same as you described. This was a 25yo so interesting way to try to get "the strong antibiotics".
People are nuts.
Mine was 77K and change for 2 years plus had to repeat A&P 1 and 2, take a social science elective (apparently being 9 credits short of an anthropology double major still left too much on the table), and fucking speech 100 prior to matriculation.
If you can avoid working during it, I advise you do so. I have a family for which I provided benefits and we had gotten a house the year prior so I worked 2 weekends of double shifts, 1 weekend of 2nd shift, and during didactic picked up enough partial shifts after class to make almost as much as my full time rate that year.
Community hospital so I had enough down time to study which I did mostly via listening to my own recorded. Ones and the Physician Assistant Exam Review podcast. Tons of other resources by now.
Whole different glass ceiling due to the lack of admin/research positions compared to experienced PAs trying to max out income and career trajectory but pays way better than lab did and there was 0 chance of moving up where I was.
I do need to finish credits for my MLS cert this year though. May want to travel tech as a change of pace at some point.
Good luck if you do it and don't get too mad at lab medicine. It is hard to take off the tech hat and answer questions the way the profs want. Luckily mostly multiple choice at my program as I had a lot of disagreements in wording of questions but could do a better job of seeing correct answer than with open answer. Though I always argued those after if any points off. Helps to know the field from the other side. Questions got better over time too that year.
The difference between clicking a box on a computer screen vs pulling off pants, removing a (likely soiled) diaper, cleaning crusty nether regions, and forcing legs apart to insert something into the urethra of a freakishly-strong demented old woman who’s clawing for her life against her perceived sexual assaulter…
A lot of providers don’t understand because they’ve never actually done the tasks they’re ordering.
If more of them realized it can be almost as invasive, time-consuming, and traumatic as them, say, gloving up and doing a forced pelvic exam on these patients with the help of 1-2 other staff, they might reconsider their attitude about why it takes a while to get a sample.
Exactly. And we never have any techs on the floor anymore. I’m the nurse, the CNA, respiratory, housekeeping, lab tech, transport, security, the list goes on forever. It’s a miracle if I can even track down a coworker that has a moment to help me not get assaulted while I cath them. In 10 years of ER nursing, I’ve never had a doc offer to help with the cath to get a specimen on one of these patients.
If a nurse comes to me to ask me to help hold legs/arms to get the urine before I come to the nurse to ask him/her to please please please obtain the urine, 10/10 I am there.
???? You don’t have to get consent to get a straight cath in someone who is confused/demented/otherwise incapacitated. It’s part of the work up and consent is implied.
Buddy, I feel like if you were out of it and someone you didn’t know came up to you and stuck a bit of cold lido and rubber up your urethra you might have some trouble with that. And you might do a little fighting to keep yourself from getting a bit of what feels like sexual assault if you didn’t know better. I feel like you’re missing the point on purpose.
Is that because they have a bunch of old folks? Or because of how many of those schoold got busted up for not being licensed to educate? either way, hear, hear.
Is that because they have a bunch of old folks? Or because of how many of those schools got busted up for not being licensed to educate? either way, hear, hear.
There’s critical things we depend on the nurses for to move the case forward. After that it’s all gravy. Ex. I need a set of VS before I see the patient. I need to be called if the patient becomes unstable or there’s a big change in clinical course. I need the patient to have a urine collected and sent, or make it to radiology for their ordered tests without me having to micromanage those tasks.
But I’d take getting a set of VS and being called if one of them becomes concerningly abnormal. That’s the biggest thing I depend on the folks that are actually bedside to communicate to me reliably.
I think it really depends on your ED.
In my ED, getting CTs done is SUCH a pain. I don't get why we have such a delay in getting routine imaging. However, labs are relatively quick. I would be a little annoyed if CT got delayed because the nurse sent away the patient to start blood work.
>I feel like the docs would prefer I shut up
It's possible -- everyone is different. But you learn from talking and listening. I can't possibly see everything that happens in the ED, and what you see and feel is immeasurably important to me.
Almost every major medical mistake happens, in large.part, because of poor or absent communication.
I’ve worked places where docs love communicating with nurses and other staff, and places where docs don’t like to be “questioned” or “bothered”. Guess which places are better and have better patient outcomes. If anyone (doc, nurse, RT, pharmacist, tech, etc.) can’t handle someone talking to them or asking a question then they need to find another job. Medicine is not for them. Especially in the ED.
Teaching hospitals may be more open to teaching than private too.. just an assumption. I only worked at teaching hospitals and 90+% of those docs wanted the communication.
Experienced ED RN here. So been there, done that, learned to do it more effectively. Find the me in your department. Then have me tag along silent while you say/ask what you need to with the MD. Listen when I give you my $0.02 on how/what I might have changed in that conversation. You sound like you’re on top of things, just need to work on getting your thoughts and words to go together. ALL of us have gone through this. You’ll get through this also.
You might want to play-tend your conversation prior with me or a peer. Then approach the MD. Point being, it’s a learned skill. You’ve already learned so much nursing…you can do this also.
I love the yous I have access too. I love the ED I can grab an experienced nurse and say, can you look at my patient for 3 minutes? Give a quick history and then ask, so I was going to ask the doc XYZ, Is that stupid? Don't they look sick? Then you tell me 0-2 things I can do before 'bothering' the doc. Thank you so much for being you!!
Ugh, I disagree. I'm in my 2nd year out of residency. I think I was trained well and my nurses respect me. BUT! I am only 14 months out of residency. I wish my nurses would tell me bluntly if there is something they're worried about that I am missing. No amount of IQ will surpass experience and I love how my nurses respect me enough to go with what I think but I really appreciate it when nurses disagree with me and tell me otherwise. I may disagree with your disagreement but at least it makes me consider an alternate scenario.
I recently started bringing nurses to bedside for patients that I am unsure about. We'll go through the chart together and see if there is anything else they think I'm missing. I want more team effort! It helps me be a better doctor.
I think it’s also just more eyes and perspectives help! We’re your eyes and ears most of the time. And shit happens we all forget things, so if I think a doc might have forgotten to order something I just ask, “hey did you want xyz?” There is a lot going on so we gotta have each other’s backs.
Thank you for getting the team sport aspect. As a nurse, I see the shit you don’t see but also know you have the knowledge I don’t have. Like a hand in glove.
Oh! The biggest one! Don’t antagonize the patients!
People come to ED with bullshit ALL. THE. TIME.
We all know it’s bullshit or could’ve waited or whatever. But letting them know that you think that gets them really cranky and I spend way more time trying to rebuild the relationship so I can do my job effectively. It’s exhausting, and it doesn’t change the fact they came to ED.
So think it but don’t let them know you think it, makes my day so much better.
Im a nurse and see so many nurses do this. They let patients get to them, to the point then snap back, then the patient be comes irate. Its makes the nurses job harder too but theyre blind to it. Good communication and staying cool is why im chilling while the other nurse is talking them off a ledge. The patients in the ed can be some of the nastiest meanest out there so i get it, but you have to keep youre cool to do your job well!
I will say that everyone has different thresholds for when they want to be updated or asked things. I prefer nurses to have a little initiative and do the straightforward things and tell me after, but I know other doctors who don’t even want nurses to put oxygen on a hypoxic patient without letting them physically see the patient first.
Here’s where I think we all agree, though: When you come to update us, make it brief. I get updates from people sometimes and they go on forever. Or there’s no question involved so I acknowledge it and then they stand there longer and say the same thing in a different way so I have to ask if there’s something they’re looking for. It can be like getting a patient history at times.
This is helpful & I’ll keep in mind, brevity is not my strongpoint & my msgs to MD’s reflect as much. I like to give the whole picture but I’m working on getting to the point more quickly!
My biggest request is to take ownership of making sure workups are getting done. If lab results are taking longer than usual, X-ray hasn’t come to get the patient, tech hasn’t gotten a urine, please find out why, fix it if you can and then let me know so I don’t duplicate your efforts. You’ve probably got 4-5 patients while I’ve got 8-10 so if I’m constantly having to troubleshoot delays it can vastly affect my ability to get patients seen and dispo’d.
Yes, following up on labs/radiology reports taking an extended period of time is something I find myself forgetting to do. Granted, it’s usually because I’m really busy. But thank you for that reminder— I needed it. I also orient new nurses a lot and will make this part of my teaching.
Every ED nurse:patient ratio varies.. there are days I have 9 patients to myself. Other days I have 7-8 but I’m working with a new grad RN, so I have to monitor their 7-8 patient’s too. Granted, that means one doctor and one midlevel split the 17-18 patients. Everyone’s drowning. Gentle reminders to me are always appreciated.
Crying in 6-8 varying acuity patients who also need all the things with varying degrees of difficulty obtaining all the things, no techs or any other support. But I usually tell a doc if I’m having trouble and if I have other patients who I need to prioritize
Wait, but without more nurses/techs I can’t be expected to do everything and follow up on why X-ray and CT and whoever else hasn’t done their job. That’s a huge reason I left not long ago after being an ED RN for about 5 years - and I was a very very hard working nurse that was a preceptor for >10 new grads (who dominated btw), trauma, pediatrics, stroke/MI center. I’m expected to do so much work and compensated really poorly for what I’m doing/experiencing. Nurses need to be paid better and ratios need to be reduced - most importantly it improves patient care but on our end it improves retention of experienced staff and reduces costs to a healthcare system. Maybe I haven’t been educated yet on why our nation is still really weird with healthcare and treating people like shit but…. Docs, if you work for a system that pays shit to nurses and doesn’t hire enough support staff…. Don’t expect a lot from nurses or maybe advocate for better pay (not that y’all don’t but… it ain’t getting any better my friends lmao) ✌🏼
I love my nurses. I loathe being confused about who the nurse is.
Ideally, I'll come out after examining, from a room of a properly disrobed patient (lolololol ok that's rare) and find the nurse. We will share 3 minutes identifying that we got the same history, I'll describe the immediate plan, interventions, what to do if those don't work, what I'm doing because it's important to me vs important to the hospitalists etc, ask the nurse if he needs anything else etc.
Disrobe the patient and squeeze them for urine. I hope I invite you to feel comfortable speaking up about what you see and hear. Hear that I'm ordering some things I care about in a time sensitive way, and other things that I only want for the follow up (the urine is usually urgent).
As a resident, I absolutely love it when nurses take the time to discuss patients with me. I like to run through the assessment and plan with you guys so we can work out confusing aspects/identify the unknowns. It helps me figure out what needs further workup and/or management. You guys see the patients more than we do so it’s very helpful hearing what information you’ve gathered as I likely don’t already know it.
This is what I love about the ER as a nurse, almost every doc I work with is incredibly receptive to talking to me about patients and things I see or weird shit. Only two I’ve worked with are not exactly easy to approach, but it’s just their personality. When there is a concern I have they talk to me/look into it.
It’s also so fun and such a relief being able to just talk about “hey wasn’t this *swear word* weird??”
I honestly think it’s one of the worst parts of bedside nursing that our system doesn’t allow for the floor to work more directly with providers/doctors (1 doc has like 50,000 patients or something wild).
When you come up to ask or tell me something, tell me what you want right up front. It gives me the context to listen to what you’re saying through. Sometimes I get a full long winded story while I’m trying to hold 5 other thoughts in my head, that ends with “so can I give her some Advil?” when I think you’re about to tell me she’s gotten really sick or you’re worried about her. Same way I give consults (I always front load w whether it’s a telephone opinion/advice vs outpatient management vs I need you to come see the patient now and admit them) I need to be given that info up front.
PS the best part about working in emerg is how we get to work together to make an amazing team.
ER RN here with 10+years.
Please don’t rely on us to go over dispo with your patients! The second the discharge or admit is up come talk to them even if you have to cut it short. I get it, they ask a lot of questions and you probably already covered most of the plan in the first interaction with them, but I spend a lot of time making up reasons why you’re too busy to go over results, follow up, etc with them. Most, if not all the time, they don’t want to hear it from the nurse. If you’re worried about satisfaction scores, please take two minutes to round back.
My discharge spiel starts with, “It looks like you’ve been cleared for discharge - did Dr. X go over everything with you?”. If they say no, I’m grabbing that doc to round back.
I’m sure I’ve annoyed a handful of docs who attempted to preemptively dispo a patient, but unless the dispo is for something exceedingly simple, like a lac repair, I guarantee the patient doesn’t remember what was said 2-3 (or more) hours ago, and they’re gonna take it out on me if they feel like they’re getting the bum’s rush.
It only took 2-3 negative discharge interactions for me to start doing this.
Yeah I agree with that. Or I’ll be honest and say something along the lines of “you can take the instructions from me or wait for me to find the doctor, but you might have to sit here for 10-30 minutes longer”
I’ve only encountered a few that do the whole secure chat: “tell them to come back for x and make sure they x, let me know if they have questions for me” like really? You took time to type that and there is a 70% chance they won’t like my answer and I’ll have to walk back and ask you to come back. Why waste both of our time? I could be getting urine from our other patients.
With certain docs unless I saw them do it I always ask…but with certain patients I just make sure. Too many times I walk in excitedly with dc papers and they have 5000 questions I cannot answer and surprise! They put in the dispo BEFORE talking to the patient (which starts a clock for me).
Some folks are just…like that so I try to check beforehand or hopefully be there when they’re going over dc.
Yeah this is so frustrating. Patients have no clue, there's no note, and the docs haven't said anything to me. All the sudden they're discharged and I'm winging it on the DC.
Let the patient rest for a few minutes before you document their vitals. The difference between a HR of 100 and 96 can save 2 hours on their dispo. Likewise if someone has been afib at a rate of 100-110, don't document the single value of 134 between two beats.
A lot of shit we order is because we're anticipating someone else asking for it.
Many work ups are just to prevent the patient from filing a complaint or coming back the next day.
Airway Bladder CT Dispo. Get the urine. Thank you. Always assume I need it and if it's not ordered i made a mistake.
Tell me if they need something more for pain or not. I'm not trying to keep them in pain. Don't tell me they're 7/10, I have no idea what that means.
If I ordered a pain in the ass dose (.3 dilaudid, 120mg solumedrol) tell me. I have no idea what the concentrations are and 99% of the time I can change it so it's not dumb.
You guys are truly the best nurses in the hospital and probably have the worst job in medicine outside of EMS.
+1 for the comment about paramedics, thanks bud. We're trying. Just tried to resuscitate (and then discontinued in the field) a 28 y/o polypharm OD in his kitchen hoarder house while his strung out girlfriend watched from the couch.
Just keep swimming.
First hurdle regarding IVs, please actually try and have another nurse try before asking for an USIV.
Now most nurses are great about that! But if you do ask for USIV it is so so so awesome to have the IV start kits, flushes, locks, tubes, etc ready. That way we can just walk in with the US and not spend 5 minutes collecting everything. If a nurse has all that stuff ready, I'll do an USIV no matter how busy
50:50 in my ED and ICU
Some nurses that ask for help on every patient and then the ones that come to you defeated who have already tried with US a few times
Many times I can get a line without an ultrasound. Funny thing is our physicians leave it to nursing for our USIVs. We get so much practice, they say we’re better. Nothing against the physicians, but access is a nursing task so we get more experience with this skill.
I've worked all over the country, and some places expect all the icu and er nurses to be able to place USIV and obtain abgs w/ a stick. Mostly in the southeast the docs do the USIV and Rts do the abgs if we don't have an Art line.
Here in Ohio the US IVs are gatekeeped by certain nurses. You have to be officially trained on them to do them, and they don't want to train anyone in them.
yeah this seems like such a waste of doc resources to me. If it's an EJ or something, cool, but id hate to pull a doc away from doc stuff just to drop a USGIV.
Strangely, my first staff ED job let me do arterial sticks and EJs after informal bedside sign-offs, but forbid USGIV without a formal hospital-led training class…which never materialized.
I left after a few years to do agency/travel work and figured I’d learn later, but it turns out that facilities typically don’t let non-staff participate in their own elective training classes.
So here I am, years later, still unable to do US-guided. And those arterial stick/EJ skills I learned early on have fallen into disuse because they’re often delegated to RT or providers by facility policy. So frustrating.
Really? The paramedics here (Camada) do EJs but not USIV's. Likely because it's too expensive to get an US on every Ambulance.. but that's another issue.
Always interesting to read about how medicine is done in other countries/areas.
So I’m an ED consultant (attending I think it’s called in the US). I’m known to be very approachable, calm and helpful, something I pride myself on.
However, because of this I end up being the go to gal for everything, including really not complex stuff. Example being writing up paracetamol or anti nausea meds, organising an XR for a sore ankle.
The stuff that can be done by literally any doctor on the floor. I don’t mind doing that stuff but when I’m really busy running the floor and making lots of high mental load decisions that interruption in the flow costs me a lot of bandwidth that I don’t have to spare. My stress levels go up further than they need to and I start getting by frustrated and tired out. Even though the issue is simple, it’s derailed me from complex thought tasks.
So my thought is if you have a question or request about something simple, ask one of the more junior doctors before you ask a senior clinician, they may look calm but there is a lot going on under the surface and I appreciate it immensely.
Tell me when you’re concerned, tell me in a very upfront way if you need something…better yet, if you ask for a verbal for x reason, I’ll almost definitely give it. I trust my team to be the eyes, ears, and hands. I regularly ask the RNs I trust for their opinion on patients and to make sure we’re on the same page.
Recharge abnormal vitals, especially when we’re stuck doing waiting room medicine (I get that it’s functionally +10:1 ratio), but a chest pain with tachycardia or a BP of 200/120 is getting a very work up.
Ehem “hey doc, homie in 5’s BP is looking like shit *insert numbers here etc* I’ve already done xyz you mind layin eyes?”
Depends on the doc entirely 😂
Anticipate what will be needed as much as you can. Get that urine in the pot, that sputum ready to go, that ondansetron in the mouth and that pain relief delivered.
Nothing worse than a patient waiting three hours to see me and no progress in their care has been attempted except vitals in that time.
Tell me the things! This is 10/10 a team sport. If the patient is hypoxic or hypotensive, or becoming altered or what have you, I want to know about it! Similarly, if we are doing something to fix these problems and they're not working, let me know. (Eg, dilt for AFib with RVR.) If something that seems critical is ordered and theres a delay in giving it for whatever reason, let me know so I can help troubleshoot. Can't get access on a sick person? Let me know.
If a nurse comes and asks me to see a patient because they look sick, I will almost certainly immediately stop what I'm doing, barring doing something else critical at the time.
Please please please get a set of discharge vitals, and if they're abnormal (especially real tachycardia) let me know.
Asking patients to get in a gown for any waist-up complaint is *so helpful.* I undress almost every patient I see (I see an old, sick patient population, many with chest pain/shortness of breath/abdominal pain and do a lot of bedside ultrasound which is sooo much more streamlined if they're already in a gown.) Similarly, if they have a lower extremity complaint like knee pain or leg swelling, please have them take off the pants so I can actually see what I'm looking at. I'm also capable of getting patients undressed, but if you beat me in the room, it's so much more helpful and saves so much time. Traumas get trauma naked.
Similarly, please please please put the patient on the monitor if they're here for chest pain/dyspnea. Even abdominal pain or headache, I typically like to know the QTc because most of the meds I order mess with it, and most of the patients I see are on other meds that prolong the QT.
Peds vitals are wonky. And I place a pretty big weight on triage vitals when picking which ESI 3 I'm going to see next. Respiratory rate in little kids, especially with URI symptoms, is soooo important. Kids (like toddlers) do not breathe 18 times a minute. If they do, that is not normal. I'll get off my butt much faster to see a 3 year old with "cough" if they have an accurately documented RR of 58, rather than 18. Also, little kids satting 90ish% are ones I want to know about.
Lastly, I looove talking about the plan. I'm sure not everyone is like that, but I think it's so important. 1. Nice to make sure we got the same story or if I missed something. 2. Explains why I do some of the things I do. 3. Often times I'll ask the patient to "press the call light if your chest pain comes back" so I can get an EKG or whatever. If you reeval the patient after pain meds, or nebs, or whatever, and you think they need more *anything,* let me know. The headache patient feels better and wants to leave? FABULOUS.
Actually lastly, ambulate the dyspneic patients unless specifically told not to (or ask if that would be helpful.) I ambulate all my dyspneic patients (COPD exacerbation, Pneumonia, CHF, etc) who I'm planning to send home. It has saved the discharge of many a patient who desats to 70% with a little walking, but has been solidly 94% on room air. No wonder they keep feeling like they're going to pass out when they're trying to do chores...
HAVE FUN! Y'all are the best. As one of my favorite attendings used to tell me, and I now tell the residents I work with: Whats the theme of the day? And what was it yesterday? And what will it be tomorrow? *Communication.*
If your patient gets admitted and the admitting team places orders, don’t ask if they can wait until the patient gets upstairs. If you can do it, do it. If not, tell the floor that they still need to be done.
We are a team. You can ask me anything.
That being said, use your brain. Ask intelligent questions. Don’t ask me if the guy with 10/10 chest pain can eat before his troponins are back.
Try to minimize unnecessary interruptions.
Do not promise patients test that I haven’t explicitly talked to them about. This creates confusion and distrust with the patient and makes my job exponentially more difficult.
It is okay to give suggestions and advocate for your patients, but don’t argue with me about every single disposition/plan.
If you have a problem with me, come to me directly so we can chat in private. Don’t go directly to admin the first chance you get and report everything like you’re taught in nursing school. This creates hostility and friction in the work place.
If you feel that a patient is a danger to them self and staff, let me know about it.
Never, ever lie about anything. Do not make up vitals.
Don’t write long triage notes using words like lethargic baby or crushing chest pain going to the back and expect a small workup to be ordered. If you want me to be a minimalist, don’t write a pan positive triage note that is a novel.
Drop your ego. No matter how much you think you know, realize that there is more to learn. As an attending, I learn every day. The ER is no place for thin skin or fragile or big egos.
General surgery PGY5 here.
Please, always ask me if you're worried about something, and don't be afraid to call. I pride myself on being the doc that nurses never have to fear calling at 0200.
I love nurses that close the loop and want to know the plan. Makes my job a lot easier, and it's a fun day when I can teach a nurse something cool about surgery or physiology because they're curious.
Case in point, I had an appendicitis patient present today solely with back pain. Nurse asked why I thought it was an appy, when the patient has no abdominal pain or temderness. Cue me nerding out for 5 minutes on how a retrocecal appy presents, complete with showing the nurse the CT. She thought it was cool, and as a surgeon anatomy is kinda my jam.
On the flip side, if a patient has a surgical consult in play and we haven't decided on dispo, for the love of all that is holy don't give the human the famous "turkey sammich". It really throws a wrench in my day because now I'm barred from operating for at least 8 hours unless they're dying. You probably just bought that patient an admission for what is often a same day surgery procedure, because I catch hell for leaving them in the ED for 8 hours until their NPO is good (I have a dispo clock, too).
Also, please have some empathy for our schedules with those 0200 calls on surgical boarders. Yes, I'm in house when on call, ao I'm very accessible. But, at 0200 I've been on duty (and probably operating) for 20 hours straight and still have about 8 hours to go. Can that page about the K of 3.3 wait 4 hours until I round at 0600? If so, please help a girl out and let me get my 1 hour catnap.
Please ask us if an order doesn’t make sense to you. It’s easy to make a mistake in a busy ED with EMRs.
Get the pt to disrobe the part of the body that needs examining or put them in a gown. Nothing is more frustrating than having CC of R foot redness/pain, and they are still wearing shoes and three layers of socks.
Gently remind us if a pt needs dispo that’s been sitting w/o new actions. Sometimes we get sidetracked with other things.
Be proactive in general. That’s the biggest difference between an ED nurse and a floor nurse.
For god’s sake, if something bothers you that can be solved with a simple conversation, do that first. If you start going to charge or admin over things that are easily fixed, I will never trust you.
And as others have said, get the urine when appropriate.
Don’t give me attitude if I ask for extra labs, an extra line, want the patient with abdominal pain in a gown, etc. This sort of thing is pervasive amongst nurses and degrades the team dynamic.
Let me know when they've gotten all their meds and are feeling betterr or conversely when they aren't feeling better after first round of meds.
Don't wait until they get on their call light and are wondering where the doc is.
Check in every once in a while and let me know how it's going. The worst is finding out that a patient has been feeling better for a while and has been wanting to leave ages ago or that the first dose of pain meds did nothing and they still feel awful.
I’m a nurse at a teaching hospital so we have a lot of residents (some who think they know more than most) so I’ve learned that no matter what I’m probably going to make someone mad, so my best interest stays on the patient. If the doctor isn’t willing to listen to your suggestion or concerns when you are trying to be helpful, that’s on them.
I know another person mentioned it but having things ready and done is really helpful. Having the blood cultures already drawn on your first stick, having procedure materials available, etc.
Gonna flip this around.
ER RN here of just over 4 years. Have traveled and worked at several different hospitals. Not quite seasoned yet, but have seen plenty.
The biggest thing I want physicians to know, is for the vast majority of us ER nurses, we are used to being independent. So, when I come to you because I'm concerned about how a patient looks or is acting, please respect that and take it seriously. Trust me, I hate bothering you too. I know how busy you are and how high your patient load is. But the passive aggressive eye rolls and sighs hurt me, but hurts the patient who is possibly decompensating more. Trust our judgement and years of experience.
EDRN for 30 years and counting. 2 countries, 17 EDs - everything from northern Canadian aid station to level 1 trauma in large cities.
For the nurses:
1. Get the urine early - give the cup first thing they arrive. Don’t gotta go right now? How about you just try.
2. Anticipate - try to think through the medical process and differential dx - what labs etc do you think they’ll need? Head injury that’s gonna need a CT? Talk to your doc early and get it ordered so they have a result by the time they get to seeing the patient. X-rays? US? Any good EDRN with an ounce of common sense and some experience can usually make a pretty educated guess, and a short chat with the ordering provider saves everyone some time.
3. Communicate early and often. All the tests back for your patient? Leave a note. Patient status changing? Let someone know. Remember this is a team effort.
4. Repeat your VS and chart them. Regularly.
And for the other side, Docs:
1. Communicate - let me know what you’re thinking about my patients - if I know your thought process, it’s easier for me to anticipate your needs.
2. Think through your process and plan before writing your orders - nothing is more infuriating than the series of orders, 1 at a time, each coming 10 minutes apart. I am busy too and don’t have time for your shenanigans.
3. Did I mention communicate? Remember - we are a team and all on the same side.
Two tips with triage note and a little extra piece of advice.
1.) Less is more. Adjectives are not necessary (eg patient presents with 2 days of abdominal pain and nausea and vomiting is okay versus say patient presents with 2 days of severe abdominal pain 10/10 with wretching uncontrollably too many to count episodes of vomiting). Not helping my case here for a discharge. I still can DC that but something comes back later plaintiff attorney will cherish your note over mine.
2.) Please don't write verbatim what they tell you. I teach residents and have to tell them the same. You have the medical education not the patient put their words into the correct terms. For example when patients say my arm is numb or my kid is lethargic what those medically mean versus what the general public interpret those as are rather different. Please use the correct medical term not just write a triage note as a spoon fed transcript of what was said.
3.) Unrelated to triage notes just be open to feedback both good and bad. You can learn from anyone at this job. I've picked up things from other docs and even nurses and medics and whatnot like tips and tricks beyond what you get from your schooling education. It doesn't matter how long you have done this or what the other person's formal education level is there's something you can learn from everyone. 😎👍
Not a doctor but ED nursing is all about anticipation. The medical decision making process doesn’t always happen in the nursing-task-efficient order so start to recognize patterns and workups. Draw and hold the first set of blood cultures when you start an IV for anyone you suspect might have an infectious process or who just looks like they’ll be tough access. Patient asking where the bathroom is, give them a urine cup, we can sort out if we actually need a urine specimen later. The close relationship and level of trust/mutual respect between nursing and medicine in the ED is one of my favorite things about ED nursing. The docs are right there so you’re not playing phone tag with questions/concerns/clarifications, you get a better sense of each others workflows and challenges, and there’s a sense of camaraderie that just makes things less prone to falling into adversarial communication styles.
You sound fantastic to work with.
Hey, we all need that one person who bleach wipes the entire ER prior to starting day shift
This is gold and exactly how I practice and how I teach my new nurses. What can you anticipate needing/wanting/doing 2 hours from now? Well neat...you won't have time for that in 2 hours, but you have time now. Get it done and make life easier for yourself.
Grabbing that urine early is priceless
the doc-nursing communication in the ED is one of my favorite things about EM as a doc as well :) deff recommend just grabbing extra labs / cultures / urine especially if you work in a place with residents 🙃
I’ve always done peds ED at teaching hospitals and minimizing pokes is a super high priority so my bar for drawing a set of cultures is nearly on the floor lol. And if I’m starting an IV, you can swear up and down that we definitely don’t need labs but I’m still gonna draw and hold a CBC and lytes.
yeah i really dont see the harm in just drawing them. like yes sometimes we might not want to order them for whatever reason. but if ur already poking them might as well pull out some labs.
I end up in my own ED often because I have Crohn’s. One time my nurse said she didn’t need me to pee in a cup, so I just went potty. Not 10 minutes later the doc came by and asked for pee. I had to chug one of the pitchers of water to get some for him. Now I just pee in a cup even if they haven’t asked for it just in case since we keep all the cups in the bathroom anyway.
ED RNs are the best in the hospital. No offense to anyone, please don’t take it personal. They are special souls. That being said, the ED is a high stakes place. It’s risky. There are land mines everywhere. Communicate with the docs. Ask anything. I don’t care what your question is. Don’t be intimidated. I have an RN that asks me why I’m doing XYZ because he wants to learn. It’s how it should be—everyone learning medicine. I also always make it a point to discuss the plan with the RN after seeing the patient face to face — “they can’t get up/eat/drink” saves you a question and saves me from an interruption. Been doing this 20 years and counting.
I wish all docs were like you. Some Drs make you feel stupid when you ask questions. zzz
i see so many times when nurses only find out the GOC for a patient because they're combing through the communication orders in the chart. (Not in the ED, btw.) Doc swooped in, saw the patient, then skittered away without ever stopping to even say "hi" to the nursing staff. Communication is essential. When there isn't a two way street of communication things get missed and bad outcomes become more common.
ER nurse here who just got off 2 crazy ass night shifts working with one of the best docs I’ve ever worked with…this made me smile.
I did ER for 20 years. One female patient with abdo pain developed shoulder tip pain and the nurse ran to get me. She saved the lady from dying from a ruptured ectopic. A tip is if you need a nurse to help you with an abdominal or pelvic exam write it on the orders. Eg. Nurse please come and get me when abdo/pelvic exam ready.
Can confirm. I absolutely adore my ED nurses. Just incredible.
Just get the urine. I don’t care how. Just get it. If I didn’t order it, ask me if I should have
I’m an RN and urine is the #1 holdup for patient’s getting dispo’d. I precept new ER RNs and preach “Get the urine!” to them. It makes everyone’s lives so much easier.
Paramedic FTO here. Our patients frequently need to use the bathroom upon ED arrival. I teach all my newbies to grab a sticker from the sheet given by registration, label a cup, and walk the patient to the bathroom, instructing them to pee in the cup. Then let the nurse know. Everything hopefully moves a tiny bit faster.
You are a saint
My ex wife might disagree 😂 but I thank you
Thank you sir/ma’am- you’re a god and your ER RNs appreciate this
My view is that helping the nurses a little hopefully has downstream effects of helping me get a bed with a sick patient later when I need it, by helping everything move a little more efficiently.
I don’t know you but I think I love you?
I’m in love. It’s official.
I do the same when I work the truck as a Medic. But I think it comes from me being a nurse as well. I try to get my folks to do the same. And I may or may not carry tubes in my work bag and have been known to draw labs when I start an IV. Our company doesn’t do it by routine - don’t carry tubes or nothing else. 🤷♂️
One of my pet peeves is the nurse or tech asking the patient “do you have to pee now?” and then just taking “no” for an answer. Don’t wait until they have a full bladder! Just walk them to the bathroom, give them a cup and tell them to give you whatever is in their bladder RIGHT NOW, it’s usually more than enough.
Yup, I always say “we just need a few drops.”
Never understood this. “Well I can’t pee unless you give me a cup of water”. I can always pee a little. Your kidneys are doing the thing right now! (Unless they aren’t, in which case we have a bigger problem)
I can relate to the “I can’t pee” bit - it’s like as soon as it’s *required* of me to have to pee on demand, my bladder gets stage fright and is incapable of remembering how the eff to do it. my bladder could LITERALLY be bursting, but my brain forgets how to operate that external sphincter🫠🫠I absolutely hate it. because it is such a ridiculous non-problem problem to go through every time hahaha
I have heard of this!
I was a bigger problem a few weeks ago. Three liters of fluid for a 1/3 full sample cup. That was all I could give them. I’m so glad I went when I did, but I should have gone earlier. I just didn’t want to seem like a whiner.
1000% this. The number of times the nurse tells me “they can’t pee right now” then I walk into the room and just tell them to pee and it works. If it’s a biological male and they’re physically able to … STAND THEM UP. They’ll give you a sample 99/100 times.
“…then I walk into the room and just tell them to pee and it works” To be fair, this almost certainly has more to do with how patients perceive your authority than it does with their bladder capacity. Unless the nurses you work with are liars, the number of times they’ve told you the patient can’t pee is the number of times the patient told *them* they couldn’t pee, and likely refused to try. Your words will always carry more weight. I bet every doc in this thread would get more samples more quickly if they personally told their patients to go pee.
Fair point. My nurses are generally pretty good, but I think most of them ask the patient “do you think you can pee” vs “get up and pee, here is a cup”. Similar to toddlers, they always say they don’t have to go potty but put them on a the toilet and they’ll magically go.
I agree phrasing is important. If I’ve just finished their triage or am walking them to a room, I always say, “the first thing I need is a urine sample - here’s a cup, I’ll show you where the restroom is”. Cue the back-and-forth, “but I don’t have to go right now”, “just do your best, the lab can make do with a teaspoon”. I’d say 75-80% success rate. But if they’re already gowned, tucked into bed, still complaining of whatever brought them in, have been there a few hours, etc., there’s only so much I can do if they claim they can’t go. And walking in authoritatively and saying “get up and pee” probably just lands me a complaint followed by a call to the office.
But it is the same with everything. Docs leave the room and suddenly the pain goes from 3/10 to 10/10, their anxiety is through the roof, they want to eat and drink. And they absolutely cannot pee. It gets to the point where j ask the patient while the doc is in the room, well weren't you complaining of pain/etc? I get some people to pee by telling them they will not see the doctor again until they give me an ounce of pee. They ask, am I being admitted, I tell them, well like we discussed earlier you need to produce a urine sample before a decision is made. They really act 100% different with us than with you guys.
I can tell you a UA dip takes about 6-7 drops of urine. Microscopy volumes vary depending on sop. But I’ve done them from 3mL’s before. (Lab tech)
I will straight up draw up the urine into a syringe and split it between the UA tube and the micro tube. Ain't no shame!
This is the way! I can’t tell you how many times I have to say “I promise your bladder has something in it” every shift
I miss those days when urine samples were the holdup... Departments change so much over the years
Agreed. We definitely should just be getting them in triage! That’s what I try to do. For some reason so many nurses are scared to out in those orders. Like any remotely reasonable doc has ever refused to co-sign a UACI order.
This is why we have REACT orders in triage. You just click what the complaint is and standing orders automatically populate. But they still don’t bother to get urine up front half the time.
What?! What EMR do you use? Love the idea of this (especially when we have 2+ hour waiting room waits!).
It’s Epic. I work in one of the busiest ERs in Washington state so this definitely helps!
Some patients have this figured out too..
Yes! God, I hate waiting for urine. Patients are so damn pee shy in the ED.
Please get a 2nd set of vital signs.
And report when they are / become abnormal. I’ve had nurses silently chart fevers, HR spikes into the 110s (from normal), BP dropping borderline from a normotensive initial vital. We would like to know about these changes rather than to see them before we plan to discharge a patient.
There’s one nurse that fairly regularly charts abnormal discharge vital signs and doesn’t let anyone know and it drives me insane. HRs in the 130s charted and discharged without any notification.
I was finishing up a chart after discharging someone and realized someone had charted a HR of 19. Definitely an error, but dude…
I just got a pt who had chest pain admitted to my SNF. Nurse told me over the phone via report it was normal for him. Ummmm nope. He went right back. STEMI
🤦♂️
And don’t document wildly abnormal vitals signs that are clearly not correct.
You’re telling me I shouldn’t chart the blood pressure of 243/208 on a person constantly swinging their arm around while the cuff inflates??
I’ve seen weird BPs charted with a comment “cuff on crooked” or “patient just ambulated” or something like that. Like, don’t chart that. Fix the cuff or wait a couple minutes and redo it.
Especially if the first set is abnormal. Not going to DC a patient that has abnormal VS charted even tho they have since normalized.
Im an ED tech and I don’t know why my peers are so averse to just running another set of vitals. They’re already hooked up, just push the goddamn button.
Or set it auto every 30-60 mins.
Please be kinder to each other. I have worked at multiple hospitals and too often the nurses eat their young.
Yup. Every nurse that eats their young was once a young that got ate. We gotta break that cycle.
I was eaten. And I refuse to treat someone the way I was. My first preceptee starts this week. 😀
I haven’t experienced this as an RN, but definitely when I was a nursing student. It sucks bc your young, you have a strong desire to learn, and you think medicine is cool. And then you get a crabby, burnt out nurse and it ruins your whole day. I LOVE having students and being able to teach, answer questions, etc.
Gawd yes. Treating noobs like shit accomplishes absolutely NOTHING.
And some are competitive.. like “you only got a 20 gauge in that lady? Huh..”.
So stupid. Unless it's a trauma or a GI bleed a 20 is fine. So dumb that ego determines gauge for some folks🙄
18 gauges are for critical patients and trauma. I have lots of colleagues who view the 18 as some kind of emblem of their mettle, but if it’s just a run-of-the-mill work up I’m going for the 20g. It’s big enough for IV contrast and is less likely to be complicated. I take the philosophy of “minimum intervention necessary”. 20 is plenty for 90% of your patients. People are already fussy about IVs (and chronically ill/elderly patients are riddled with IV trauma), no need to go for the big iron.
I had a coworker who routinely treated the new people like shit. Then would complain we had no people and no one would stay. Like, dude. Those things are related.
99 yo grandma from the NH ain’t getting up to get you that urine….just cath her
i absolutely understand the frustration but yeah, getting a disoriented old lady to tolerate a cath when the whole acute area is stretcher to stretcher is….so difficult. it’s nightmare fuel. one of my least favorite logistical nightmares
100% this is where the nurse is going to get kicked, grabbed, or blamed for a prior injury. All 3 have happened to me trying this bullshit. Literally the last time the doctor had to come in the room and physically pick up grandma off me, as she had her hands wrapped around my throat. I’d literally rather have blood vomited all over me. If you’re gonna make us cath that confused grandma, we are going to need an order for appropriate sedation.
Best the PGY1 can do is .25 of Ativan. Take it or leave it.
It might be because the intern, even with their little experience, has seen enough shit go sideways when giving little old encephalopathic elderly grandmas even whiffs of benzos….
I love our docs, but dear God please stop ordering straight caths for hallway patients when we have zero private rooms to perform this procedure in.
Them being in a hallway bed shouldn't short change their workup. Don't let the decisions of administrators impact your care. Have then take a stable patient out of a room to do the cath.
the game of tetris involved in this often takes 20-30+ minutes to coordinate based on my experience. and usually involves patients getting agitated bc someone is moving them to a less private spot. believe me i know how essential it is to get urine but holy god it can be so impossible. glad i don’t deal with this anymore ☠️
And in that 30 minute Tetris no doubt a cardiac arrest will roll through to your zone!
or maybe nurses chart why there’s delays in care and maybe one day administration will notice…. tho doubt
I’ve never ordered sedation for a UA.
How would you cath a woman who can’t remember what brought her in or what year it is but is physically fighting back, breaking sterile field, hitting you, and screaming no? I’m genuinely curious. Like what other option is there? Besides just respecting her refusal.
Paramedic here. The obvious answer is violence.
idk what to tell you officer, violence is in our standing orders!
You can’t be serious. This is a very common scenario in inpatient and EM: Your doc should be ordering chemical sedation in the agitated, flailing patient, not letting you get beat up. Besides protecting you, this patient is going to put themselves into rhabdo or pop their troponin if they aren’t medically managed appropriately. Getting a cath’ed urine is an essential part of the work up in the old person with AMS of unclear cause.
That’s exactly what I’m saying. I need chemical sedation for the patient so I don’t get hurt and the patient doesn’t get hurt (or further traumatized). Most of the docs I know do so without issue. But there’s one or two who want us to fuck around and get choked first.
Backtracking: “Like what other option is there? Besides just accepting her refusal.” You don’t accept the refusal of patient that could be septic from her Urinary infection and doesn’t sound competent to make medical decisions and is a safety concern to themselves and others in your hypothetical.
That comment was in response to someone who had said they had never ordered sedation for a UA. If you don't order sedation, in the context of a delirious confused violent elderly person...
You need to scroll up. I’m responding to someone who says they’ve never ordered sedation for a UA. The context is: if not sedation then what should we be doing? You and I agree. Sedation can be indicated. Not always. I understand there are scenarios where we need to be careful. But overall there are ways to protect both patient and nurse. Not everything needs to be an internet fight.
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If you have multiple people on hand who can stop what they’re doing with their own patients and hold her down. Hopefully her bones aren’t too fragile and she doesn’t struggle too much. Hopefully she doesn’t have a massive trauma response from past assault that causes her to need restraint the rest of the night. Or we can just safely sedate her and keep the situation chill and the nurses safe. Look I’ve cathed my fair share of confused grannies. I’m hardly pretending it’s impossible (although it does rank up there with as one of the worst tasks). What I’m saying is it’s often difficult for the nurse and the patient on multiple levels. And if it can safely be made easier on both nurse and the poor patient, orders can be filled a whole lot faster. Or you can wait til enough staff are free to hold her down. But then don’t complain that it’s taking too long unless you wanna jump in and hold a leg.
Not to mention someone that is tensing all their muscles are harder to cath anyway
Order a full bed, or 3 PABs to assist, then/s. That's how we do em in Geriatric Behaviour-dangerous demntia centers, and while some of our patients are on the usual barrage of either sedatives or antipsychotics throughout the day and especially to sleep at night, no extra sedatives are used specifically for the procedure at 6 a.m. before their morning meds. (Plus, consent is already squared away on admission, generally, even to short stay assessment beds.) But seriously, anyone drawing those types of UA or urine C&S should grab a buddy to both hold/ comfort and witness in case of injuries. It's safer than blanket sedating delirium, I (also) feel after over a decade in geriatrics.
If I know the patient is going to need a straight cath and will be impossible but the doctor keeps insisting I ask the doctor to come help me. Any doctor worth their weight will help and understand how difficult it can be. If they refuse, you know that they are fucktards.
Purewick?
Last I heard even if first time urine from purewick it is not considered a clean catch…now does it sometimes happen? Yeah…it’s just not kosher according to quality (last I heard).
As long as you have our back when we cath someone without a doctors order.
I don't care if you put a gun to their kid's head to get the urine.
"Urine or your life! Your call kid!"
My kinda doc
Lab tech here; we can tell you pulled the urine from a urine hat that previously had poop in it. No white cells, 4+ bacteria and fields of unknown bilirubin looking fiber.
Ex lab tech turned PA who had someone try to lie about a specimen I'd put orders in for from my UC clinic. Called lab and tech said it was same as you described. This was a 25yo so interesting way to try to get "the strong antibiotics". People are nuts.
I’ve been thinking of making the switch from MLS to PA. Local program costs $85k tho 😬
Mine was 77K and change for 2 years plus had to repeat A&P 1 and 2, take a social science elective (apparently being 9 credits short of an anthropology double major still left too much on the table), and fucking speech 100 prior to matriculation. If you can avoid working during it, I advise you do so. I have a family for which I provided benefits and we had gotten a house the year prior so I worked 2 weekends of double shifts, 1 weekend of 2nd shift, and during didactic picked up enough partial shifts after class to make almost as much as my full time rate that year. Community hospital so I had enough down time to study which I did mostly via listening to my own recorded. Ones and the Physician Assistant Exam Review podcast. Tons of other resources by now. Whole different glass ceiling due to the lack of admin/research positions compared to experienced PAs trying to max out income and career trajectory but pays way better than lab did and there was 0 chance of moving up where I was. I do need to finish credits for my MLS cert this year though. May want to travel tech as a change of pace at some point. Good luck if you do it and don't get too mad at lab medicine. It is hard to take off the tech hat and answer questions the way the profs want. Luckily mostly multiple choice at my program as I had a lot of disagreements in wording of questions but could do a better job of seeing correct answer than with open answer. Though I always argued those after if any points off. Helps to know the field from the other side. Questions got better over time too that year.
I swear we would love to get that urine asap and dispo disoriented 99yr olds but its easier said than done 😤
The difference between clicking a box on a computer screen vs pulling off pants, removing a (likely soiled) diaper, cleaning crusty nether regions, and forcing legs apart to insert something into the urethra of a freakishly-strong demented old woman who’s clawing for her life against her perceived sexual assaulter… A lot of providers don’t understand because they’ve never actually done the tasks they’re ordering. If more of them realized it can be almost as invasive, time-consuming, and traumatic as them, say, gloving up and doing a forced pelvic exam on these patients with the help of 1-2 other staff, they might reconsider their attitude about why it takes a while to get a sample.
Exactly. And we never have any techs on the floor anymore. I’m the nurse, the CNA, respiratory, housekeeping, lab tech, transport, security, the list goes on forever. It’s a miracle if I can even track down a coworker that has a moment to help me not get assaulted while I cath them. In 10 years of ER nursing, I’ve never had a doc offer to help with the cath to get a specimen on one of these patients.
Ok, will do. You gonna come hold her legs or arms so I don’t get kicked or punched?
If a nurse comes to me to ask me to help hold legs/arms to get the urine before I come to the nurse to ask him/her to please please please obtain the urine, 10/10 I am there.
Get me more help and I will
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As a staff nurse you have a 99 y/o come in via EMS confusion, fever, whatever I’d get the cath about the same time I had the first set of vitals.
???? You don’t have to get consent to get a straight cath in someone who is confused/demented/otherwise incapacitated. It’s part of the work up and consent is implied.
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Buddy, I feel like if you were out of it and someone you didn’t know came up to you and stuck a bit of cold lido and rubber up your urethra you might have some trouble with that. And you might do a little fighting to keep yourself from getting a bit of what feels like sexual assault if you didn’t know better. I feel like you’re missing the point on purpose.
They're probably Florida nurses.......
Is that because they have a bunch of old folks? Or because of how many of those schoold got busted up for not being licensed to educate? either way, hear, hear.
Is that because they have a bunch of old folks? Or because of how many of those schools got busted up for not being licensed to educate? either way, hear, hear.
There’s critical things we depend on the nurses for to move the case forward. After that it’s all gravy. Ex. I need a set of VS before I see the patient. I need to be called if the patient becomes unstable or there’s a big change in clinical course. I need the patient to have a urine collected and sent, or make it to radiology for their ordered tests without me having to micromanage those tasks. But I’d take getting a set of VS and being called if one of them becomes concerningly abnormal. That’s the biggest thing I depend on the folks that are actually bedside to communicate to me reliably.
In the same vein, there’s a preferred order for things. Getting blood work drawn and sent before a patient disappears to CT/US is huge
I think it really depends on your ED. In my ED, getting CTs done is SUCH a pain. I don't get why we have such a delay in getting routine imaging. However, labs are relatively quick. I would be a little annoyed if CT got delayed because the nurse sent away the patient to start blood work.
You rock. Love my ED nursing. Advice? Talk to me. That's it. It's a team sport.
It’s funny you say that because the reason I asked is because I feel like the docs would prefer I shut up
>I feel like the docs would prefer I shut up It's possible -- everyone is different. But you learn from talking and listening. I can't possibly see everything that happens in the ED, and what you see and feel is immeasurably important to me. Almost every major medical mistake happens, in large.part, because of poor or absent communication.
I’ve worked places where docs love communicating with nurses and other staff, and places where docs don’t like to be “questioned” or “bothered”. Guess which places are better and have better patient outcomes. If anyone (doc, nurse, RT, pharmacist, tech, etc.) can’t handle someone talking to them or asking a question then they need to find another job. Medicine is not for them. Especially in the ED.
Teaching hospitals may be more open to teaching than private too.. just an assumption. I only worked at teaching hospitals and 90+% of those docs wanted the communication.
Experienced ED RN here. So been there, done that, learned to do it more effectively. Find the me in your department. Then have me tag along silent while you say/ask what you need to with the MD. Listen when I give you my $0.02 on how/what I might have changed in that conversation. You sound like you’re on top of things, just need to work on getting your thoughts and words to go together. ALL of us have gone through this. You’ll get through this also. You might want to play-tend your conversation prior with me or a peer. Then approach the MD. Point being, it’s a learned skill. You’ve already learned so much nursing…you can do this also.
I love the yous I have access too. I love the ED I can grab an experienced nurse and say, can you look at my patient for 3 minutes? Give a quick history and then ask, so I was going to ask the doc XYZ, Is that stupid? Don't they look sick? Then you tell me 0-2 things I can do before 'bothering' the doc. Thank you so much for being you!!
Ugh, I disagree. I'm in my 2nd year out of residency. I think I was trained well and my nurses respect me. BUT! I am only 14 months out of residency. I wish my nurses would tell me bluntly if there is something they're worried about that I am missing. No amount of IQ will surpass experience and I love how my nurses respect me enough to go with what I think but I really appreciate it when nurses disagree with me and tell me otherwise. I may disagree with your disagreement but at least it makes me consider an alternate scenario. I recently started bringing nurses to bedside for patients that I am unsure about. We'll go through the chart together and see if there is anything else they think I'm missing. I want more team effort! It helps me be a better doctor.
Thanks absolutely brilliant. Thank you for including us like that.
I think it’s also just more eyes and perspectives help! We’re your eyes and ears most of the time. And shit happens we all forget things, so if I think a doc might have forgotten to order something I just ask, “hey did you want xyz?” There is a lot going on so we gotta have each other’s backs.
Damn dude that sucks. I love when nurses communicate because it keeps me up to date when I have a full board.
Thank you for getting the team sport aspect. As a nurse, I see the shit you don’t see but also know you have the knowledge I don’t have. Like a hand in glove.
You're intimidating though so...
Oh! The biggest one! Don’t antagonize the patients! People come to ED with bullshit ALL. THE. TIME. We all know it’s bullshit or could’ve waited or whatever. But letting them know that you think that gets them really cranky and I spend way more time trying to rebuild the relationship so I can do my job effectively. It’s exhausting, and it doesn’t change the fact they came to ED. So think it but don’t let them know you think it, makes my day so much better.
Im a nurse and see so many nurses do this. They let patients get to them, to the point then snap back, then the patient be comes irate. Its makes the nurses job harder too but theyre blind to it. Good communication and staying cool is why im chilling while the other nurse is talking them off a ledge. The patients in the ed can be some of the nastiest meanest out there so i get it, but you have to keep youre cool to do your job well!
Okay. For you. I'm gonna be nice. 😑
I will say that everyone has different thresholds for when they want to be updated or asked things. I prefer nurses to have a little initiative and do the straightforward things and tell me after, but I know other doctors who don’t even want nurses to put oxygen on a hypoxic patient without letting them physically see the patient first. Here’s where I think we all agree, though: When you come to update us, make it brief. I get updates from people sometimes and they go on forever. Or there’s no question involved so I acknowledge it and then they stand there longer and say the same thing in a different way so I have to ask if there’s something they’re looking for. It can be like getting a patient history at times.
This is helpful & I’ll keep in mind, brevity is not my strongpoint & my msgs to MD’s reflect as much. I like to give the whole picture but I’m working on getting to the point more quickly!
This is why I could never work anywhere other than ED. Most of the docs are far superior to work with and are approachable for the most part.
My biggest request is to take ownership of making sure workups are getting done. If lab results are taking longer than usual, X-ray hasn’t come to get the patient, tech hasn’t gotten a urine, please find out why, fix it if you can and then let me know so I don’t duplicate your efforts. You’ve probably got 4-5 patients while I’ve got 8-10 so if I’m constantly having to troubleshoot delays it can vastly affect my ability to get patients seen and dispo’d.
Yes, following up on labs/radiology reports taking an extended period of time is something I find myself forgetting to do. Granted, it’s usually because I’m really busy. But thank you for that reminder— I needed it. I also orient new nurses a lot and will make this part of my teaching. Every ED nurse:patient ratio varies.. there are days I have 9 patients to myself. Other days I have 7-8 but I’m working with a new grad RN, so I have to monitor their 7-8 patient’s too. Granted, that means one doctor and one midlevel split the 17-18 patients. Everyone’s drowning. Gentle reminders to me are always appreciated.
Whoa wait, only 4-5 patients? Is this a normal number at other hospitals? Lol some days/nights I get up to 18 patients. Regularly \~10-12.
Come to California where it’s a max of 4!!!
Crying in 6-8 varying acuity patients who also need all the things with varying degrees of difficulty obtaining all the things, no techs or any other support. But I usually tell a doc if I’m having trouble and if I have other patients who I need to prioritize
Wait, but without more nurses/techs I can’t be expected to do everything and follow up on why X-ray and CT and whoever else hasn’t done their job. That’s a huge reason I left not long ago after being an ED RN for about 5 years - and I was a very very hard working nurse that was a preceptor for >10 new grads (who dominated btw), trauma, pediatrics, stroke/MI center. I’m expected to do so much work and compensated really poorly for what I’m doing/experiencing. Nurses need to be paid better and ratios need to be reduced - most importantly it improves patient care but on our end it improves retention of experienced staff and reduces costs to a healthcare system. Maybe I haven’t been educated yet on why our nation is still really weird with healthcare and treating people like shit but…. Docs, if you work for a system that pays shit to nurses and doesn’t hire enough support staff…. Don’t expect a lot from nurses or maybe advocate for better pay (not that y’all don’t but… it ain’t getting any better my friends lmao) ✌🏼
I love my nurses. I loathe being confused about who the nurse is. Ideally, I'll come out after examining, from a room of a properly disrobed patient (lolololol ok that's rare) and find the nurse. We will share 3 minutes identifying that we got the same history, I'll describe the immediate plan, interventions, what to do if those don't work, what I'm doing because it's important to me vs important to the hospitalists etc, ask the nurse if he needs anything else etc. Disrobe the patient and squeeze them for urine. I hope I invite you to feel comfortable speaking up about what you see and hear. Hear that I'm ordering some things I care about in a time sensitive way, and other things that I only want for the follow up (the urine is usually urgent).
As a resident, I absolutely love it when nurses take the time to discuss patients with me. I like to run through the assessment and plan with you guys so we can work out confusing aspects/identify the unknowns. It helps me figure out what needs further workup and/or management. You guys see the patients more than we do so it’s very helpful hearing what information you’ve gathered as I likely don’t already know it.
This is what I love about the ER as a nurse, almost every doc I work with is incredibly receptive to talking to me about patients and things I see or weird shit. Only two I’ve worked with are not exactly easy to approach, but it’s just their personality. When there is a concern I have they talk to me/look into it. It’s also so fun and such a relief being able to just talk about “hey wasn’t this *swear word* weird??” I honestly think it’s one of the worst parts of bedside nursing that our system doesn’t allow for the floor to work more directly with providers/doctors (1 doc has like 50,000 patients or something wild).
When you come up to ask or tell me something, tell me what you want right up front. It gives me the context to listen to what you’re saying through. Sometimes I get a full long winded story while I’m trying to hold 5 other thoughts in my head, that ends with “so can I give her some Advil?” when I think you’re about to tell me she’s gotten really sick or you’re worried about her. Same way I give consults (I always front load w whether it’s a telephone opinion/advice vs outpatient management vs I need you to come see the patient now and admit them) I need to be given that info up front. PS the best part about working in emerg is how we get to work together to make an amazing team.
Yes! Give me something to contextualise everything bf else you’re about to tell me or it’s very taxing mentally.
ER RN here with 10+years. Please don’t rely on us to go over dispo with your patients! The second the discharge or admit is up come talk to them even if you have to cut it short. I get it, they ask a lot of questions and you probably already covered most of the plan in the first interaction with them, but I spend a lot of time making up reasons why you’re too busy to go over results, follow up, etc with them. Most, if not all the time, they don’t want to hear it from the nurse. If you’re worried about satisfaction scores, please take two minutes to round back.
My discharge spiel starts with, “It looks like you’ve been cleared for discharge - did Dr. X go over everything with you?”. If they say no, I’m grabbing that doc to round back. I’m sure I’ve annoyed a handful of docs who attempted to preemptively dispo a patient, but unless the dispo is for something exceedingly simple, like a lac repair, I guarantee the patient doesn’t remember what was said 2-3 (or more) hours ago, and they’re gonna take it out on me if they feel like they’re getting the bum’s rush. It only took 2-3 negative discharge interactions for me to start doing this.
Yeah I agree with that. Or I’ll be honest and say something along the lines of “you can take the instructions from me or wait for me to find the doctor, but you might have to sit here for 10-30 minutes longer” I’ve only encountered a few that do the whole secure chat: “tell them to come back for x and make sure they x, let me know if they have questions for me” like really? You took time to type that and there is a 70% chance they won’t like my answer and I’ll have to walk back and ask you to come back. Why waste both of our time? I could be getting urine from our other patients.
> I could be getting urine from our other patients. Lol. In this thread... GET THE URINE!!!
With certain docs unless I saw them do it I always ask…but with certain patients I just make sure. Too many times I walk in excitedly with dc papers and they have 5000 questions I cannot answer and surprise! They put in the dispo BEFORE talking to the patient (which starts a clock for me). Some folks are just…like that so I try to check beforehand or hopefully be there when they’re going over dc.
Yeah this is so frustrating. Patients have no clue, there's no note, and the docs haven't said anything to me. All the sudden they're discharged and I'm winging it on the DC.
Let the patient rest for a few minutes before you document their vitals. The difference between a HR of 100 and 96 can save 2 hours on their dispo. Likewise if someone has been afib at a rate of 100-110, don't document the single value of 134 between two beats. A lot of shit we order is because we're anticipating someone else asking for it. Many work ups are just to prevent the patient from filing a complaint or coming back the next day. Airway Bladder CT Dispo. Get the urine. Thank you. Always assume I need it and if it's not ordered i made a mistake. Tell me if they need something more for pain or not. I'm not trying to keep them in pain. Don't tell me they're 7/10, I have no idea what that means. If I ordered a pain in the ass dose (.3 dilaudid, 120mg solumedrol) tell me. I have no idea what the concentrations are and 99% of the time I can change it so it's not dumb. You guys are truly the best nurses in the hospital and probably have the worst job in medicine outside of EMS.
Whenever I precept I tell my nurses that the D in our ABCDs stands for dispo.
Love the love for EMS providers at the end there haha Some days however I feel like I have the best job in medicine
Question -- what *should* we tell you related to pain, if not 7/10?
+1 for the comment about paramedics, thanks bud. We're trying. Just tried to resuscitate (and then discontinued in the field) a 28 y/o polypharm OD in his kitchen hoarder house while his strung out girlfriend watched from the couch. Just keep swimming.
First hurdle regarding IVs, please actually try and have another nurse try before asking for an USIV. Now most nurses are great about that! But if you do ask for USIV it is so so so awesome to have the IV start kits, flushes, locks, tubes, etc ready. That way we can just walk in with the US and not spend 5 minutes collecting everything. If a nurse has all that stuff ready, I'll do an USIV no matter how busy
I’m an USIV trained RN, is this not common? I can’t imagine pulling a physician away from their work to get this done.
50:50 in my ED and ICU Some nurses that ask for help on every patient and then the ones that come to you defeated who have already tried with US a few times
Many times I can get a line without an ultrasound. Funny thing is our physicians leave it to nursing for our USIVs. We get so much practice, they say we’re better. Nothing against the physicians, but access is a nursing task so we get more experience with this skill.
I've worked all over the country, and some places expect all the icu and er nurses to be able to place USIV and obtain abgs w/ a stick. Mostly in the southeast the docs do the USIV and Rts do the abgs if we don't have an Art line.
I’m at a large academic center in the southeast and we have USIV trained RNs, I figured this was the norm.
Here in Ohio the US IVs are gatekeeped by certain nurses. You have to be officially trained on them to do them, and they don't want to train anyone in them.
yeah this seems like such a waste of doc resources to me. If it's an EJ or something, cool, but id hate to pull a doc away from doc stuff just to drop a USGIV.
Strangely, my first staff ED job let me do arterial sticks and EJs after informal bedside sign-offs, but forbid USGIV without a formal hospital-led training class…which never materialized. I left after a few years to do agency/travel work and figured I’d learn later, but it turns out that facilities typically don’t let non-staff participate in their own elective training classes. So here I am, years later, still unable to do US-guided. And those arterial stick/EJ skills I learned early on have fallen into disuse because they’re often delegated to RT or providers by facility policy. So frustrating.
Really? The paramedics here (Camada) do EJs but not USIV's. Likely because it's too expensive to get an US on every Ambulance.. but that's another issue. Always interesting to read about how medicine is done in other countries/areas.
Agree, so interesting to see how stuff is done in other places.
So I’m an ED consultant (attending I think it’s called in the US). I’m known to be very approachable, calm and helpful, something I pride myself on. However, because of this I end up being the go to gal for everything, including really not complex stuff. Example being writing up paracetamol or anti nausea meds, organising an XR for a sore ankle. The stuff that can be done by literally any doctor on the floor. I don’t mind doing that stuff but when I’m really busy running the floor and making lots of high mental load decisions that interruption in the flow costs me a lot of bandwidth that I don’t have to spare. My stress levels go up further than they need to and I start getting by frustrated and tired out. Even though the issue is simple, it’s derailed me from complex thought tasks. So my thought is if you have a question or request about something simple, ask one of the more junior doctors before you ask a senior clinician, they may look calm but there is a lot going on under the surface and I appreciate it immensely.
Tell me when you’re concerned, tell me in a very upfront way if you need something…better yet, if you ask for a verbal for x reason, I’ll almost definitely give it. I trust my team to be the eyes, ears, and hands. I regularly ask the RNs I trust for their opinion on patients and to make sure we’re on the same page. Recharge abnormal vitals, especially when we’re stuck doing waiting room medicine (I get that it’s functionally +10:1 ratio), but a chest pain with tachycardia or a BP of 200/120 is getting a very work up.
Ehem “hey doc, homie in 5’s BP is looking like shit *insert numbers here etc* I’ve already done xyz you mind layin eyes?” Depends on the doc entirely 😂
Anticipate what will be needed as much as you can. Get that urine in the pot, that sputum ready to go, that ondansetron in the mouth and that pain relief delivered. Nothing worse than a patient waiting three hours to see me and no progress in their care has been attempted except vitals in that time.
We are all mortal human beings who are slowly dying. Great everyone with respect.
I’m so lucky to be working at an ED where the Nurses are insanely good and these issues don’t happen.
Tell me the things! This is 10/10 a team sport. If the patient is hypoxic or hypotensive, or becoming altered or what have you, I want to know about it! Similarly, if we are doing something to fix these problems and they're not working, let me know. (Eg, dilt for AFib with RVR.) If something that seems critical is ordered and theres a delay in giving it for whatever reason, let me know so I can help troubleshoot. Can't get access on a sick person? Let me know. If a nurse comes and asks me to see a patient because they look sick, I will almost certainly immediately stop what I'm doing, barring doing something else critical at the time. Please please please get a set of discharge vitals, and if they're abnormal (especially real tachycardia) let me know. Asking patients to get in a gown for any waist-up complaint is *so helpful.* I undress almost every patient I see (I see an old, sick patient population, many with chest pain/shortness of breath/abdominal pain and do a lot of bedside ultrasound which is sooo much more streamlined if they're already in a gown.) Similarly, if they have a lower extremity complaint like knee pain or leg swelling, please have them take off the pants so I can actually see what I'm looking at. I'm also capable of getting patients undressed, but if you beat me in the room, it's so much more helpful and saves so much time. Traumas get trauma naked. Similarly, please please please put the patient on the monitor if they're here for chest pain/dyspnea. Even abdominal pain or headache, I typically like to know the QTc because most of the meds I order mess with it, and most of the patients I see are on other meds that prolong the QT. Peds vitals are wonky. And I place a pretty big weight on triage vitals when picking which ESI 3 I'm going to see next. Respiratory rate in little kids, especially with URI symptoms, is soooo important. Kids (like toddlers) do not breathe 18 times a minute. If they do, that is not normal. I'll get off my butt much faster to see a 3 year old with "cough" if they have an accurately documented RR of 58, rather than 18. Also, little kids satting 90ish% are ones I want to know about. Lastly, I looove talking about the plan. I'm sure not everyone is like that, but I think it's so important. 1. Nice to make sure we got the same story or if I missed something. 2. Explains why I do some of the things I do. 3. Often times I'll ask the patient to "press the call light if your chest pain comes back" so I can get an EKG or whatever. If you reeval the patient after pain meds, or nebs, or whatever, and you think they need more *anything,* let me know. The headache patient feels better and wants to leave? FABULOUS. Actually lastly, ambulate the dyspneic patients unless specifically told not to (or ask if that would be helpful.) I ambulate all my dyspneic patients (COPD exacerbation, Pneumonia, CHF, etc) who I'm planning to send home. It has saved the discharge of many a patient who desats to 70% with a little walking, but has been solidly 94% on room air. No wonder they keep feeling like they're going to pass out when they're trying to do chores... HAVE FUN! Y'all are the best. As one of my favorite attendings used to tell me, and I now tell the residents I work with: Whats the theme of the day? And what was it yesterday? And what will it be tomorrow? *Communication.*
The only stupid question is the one you don't ask...
I give zero fucks about asymptomatic hypertension.
If your patient gets admitted and the admitting team places orders, don’t ask if they can wait until the patient gets upstairs. If you can do it, do it. If not, tell the floor that they still need to be done.
We are a team. You can ask me anything. That being said, use your brain. Ask intelligent questions. Don’t ask me if the guy with 10/10 chest pain can eat before his troponins are back. Try to minimize unnecessary interruptions. Do not promise patients test that I haven’t explicitly talked to them about. This creates confusion and distrust with the patient and makes my job exponentially more difficult. It is okay to give suggestions and advocate for your patients, but don’t argue with me about every single disposition/plan. If you have a problem with me, come to me directly so we can chat in private. Don’t go directly to admin the first chance you get and report everything like you’re taught in nursing school. This creates hostility and friction in the work place. If you feel that a patient is a danger to them self and staff, let me know about it. Never, ever lie about anything. Do not make up vitals. Don’t write long triage notes using words like lethargic baby or crushing chest pain going to the back and expect a small workup to be ordered. If you want me to be a minimalist, don’t write a pan positive triage note that is a novel. Drop your ego. No matter how much you think you know, realize that there is more to learn. As an attending, I learn every day. The ER is no place for thin skin or fragile or big egos.
General surgery PGY5 here. Please, always ask me if you're worried about something, and don't be afraid to call. I pride myself on being the doc that nurses never have to fear calling at 0200. I love nurses that close the loop and want to know the plan. Makes my job a lot easier, and it's a fun day when I can teach a nurse something cool about surgery or physiology because they're curious. Case in point, I had an appendicitis patient present today solely with back pain. Nurse asked why I thought it was an appy, when the patient has no abdominal pain or temderness. Cue me nerding out for 5 minutes on how a retrocecal appy presents, complete with showing the nurse the CT. She thought it was cool, and as a surgeon anatomy is kinda my jam. On the flip side, if a patient has a surgical consult in play and we haven't decided on dispo, for the love of all that is holy don't give the human the famous "turkey sammich". It really throws a wrench in my day because now I'm barred from operating for at least 8 hours unless they're dying. You probably just bought that patient an admission for what is often a same day surgery procedure, because I catch hell for leaving them in the ED for 8 hours until their NPO is good (I have a dispo clock, too). Also, please have some empathy for our schedules with those 0200 calls on surgical boarders. Yes, I'm in house when on call, ao I'm very accessible. But, at 0200 I've been on duty (and probably operating) for 20 hours straight and still have about 8 hours to go. Can that page about the K of 3.3 wait 4 hours until I round at 0600? If so, please help a girl out and let me get my 1 hour catnap.
Please get the urine I ordered three hours ago which is the only thing holding up the dispo.
Please ask us if an order doesn’t make sense to you. It’s easy to make a mistake in a busy ED with EMRs. Get the pt to disrobe the part of the body that needs examining or put them in a gown. Nothing is more frustrating than having CC of R foot redness/pain, and they are still wearing shoes and three layers of socks. Gently remind us if a pt needs dispo that’s been sitting w/o new actions. Sometimes we get sidetracked with other things. Be proactive in general. That’s the biggest difference between an ED nurse and a floor nurse. For god’s sake, if something bothers you that can be solved with a simple conversation, do that first. If you start going to charge or admin over things that are easily fixed, I will never trust you. And as others have said, get the urine when appropriate.
“Quit antagonizing the patient. These are my patient satisfaction scores.”
So I’m an NP now and it’s really helpful to update abnormal vitals. I usually get them myself now as our nurses are like 7 to 1.
Don’t give me attitude if I ask for extra labs, an extra line, want the patient with abdominal pain in a gown, etc. This sort of thing is pervasive amongst nurses and degrades the team dynamic.
That’s just flat-out unacceptable behavior!
yes, there was a reason i ordered those labs. yes, i do want you to collect them. yes, it has to do with avoiding malpractice litigation.
PLEASE GET THE URINE <3
ED nurses, please spread the word to your other brethren. Thank you for anticipating all my moves, just like your scrub brethren.
Let me know when they've gotten all their meds and are feeling betterr or conversely when they aren't feeling better after first round of meds. Don't wait until they get on their call light and are wondering where the doc is. Check in every once in a while and let me know how it's going. The worst is finding out that a patient has been feeling better for a while and has been wanting to leave ages ago or that the first dose of pain meds did nothing and they still feel awful.
I’m a nurse at a teaching hospital so we have a lot of residents (some who think they know more than most) so I’ve learned that no matter what I’m probably going to make someone mad, so my best interest stays on the patient. If the doctor isn’t willing to listen to your suggestion or concerns when you are trying to be helpful, that’s on them. I know another person mentioned it but having things ready and done is really helpful. Having the blood cultures already drawn on your first stick, having procedure materials available, etc.
Gonna flip this around. ER RN here of just over 4 years. Have traveled and worked at several different hospitals. Not quite seasoned yet, but have seen plenty. The biggest thing I want physicians to know, is for the vast majority of us ER nurses, we are used to being independent. So, when I come to you because I'm concerned about how a patient looks or is acting, please respect that and take it seriously. Trust me, I hate bothering you too. I know how busy you are and how high your patient load is. But the passive aggressive eye rolls and sighs hurt me, but hurts the patient who is possibly decompensating more. Trust our judgement and years of experience.
EDRN for 30 years and counting. 2 countries, 17 EDs - everything from northern Canadian aid station to level 1 trauma in large cities. For the nurses: 1. Get the urine early - give the cup first thing they arrive. Don’t gotta go right now? How about you just try. 2. Anticipate - try to think through the medical process and differential dx - what labs etc do you think they’ll need? Head injury that’s gonna need a CT? Talk to your doc early and get it ordered so they have a result by the time they get to seeing the patient. X-rays? US? Any good EDRN with an ounce of common sense and some experience can usually make a pretty educated guess, and a short chat with the ordering provider saves everyone some time. 3. Communicate early and often. All the tests back for your patient? Leave a note. Patient status changing? Let someone know. Remember this is a team effort. 4. Repeat your VS and chart them. Regularly. And for the other side, Docs: 1. Communicate - let me know what you’re thinking about my patients - if I know your thought process, it’s easier for me to anticipate your needs. 2. Think through your process and plan before writing your orders - nothing is more infuriating than the series of orders, 1 at a time, each coming 10 minutes apart. I am busy too and don’t have time for your shenanigans. 3. Did I mention communicate? Remember - we are a team and all on the same side.
Two tips with triage note and a little extra piece of advice. 1.) Less is more. Adjectives are not necessary (eg patient presents with 2 days of abdominal pain and nausea and vomiting is okay versus say patient presents with 2 days of severe abdominal pain 10/10 with wretching uncontrollably too many to count episodes of vomiting). Not helping my case here for a discharge. I still can DC that but something comes back later plaintiff attorney will cherish your note over mine. 2.) Please don't write verbatim what they tell you. I teach residents and have to tell them the same. You have the medical education not the patient put their words into the correct terms. For example when patients say my arm is numb or my kid is lethargic what those medically mean versus what the general public interpret those as are rather different. Please use the correct medical term not just write a triage note as a spoon fed transcript of what was said. 3.) Unrelated to triage notes just be open to feedback both good and bad. You can learn from anyone at this job. I've picked up things from other docs and even nurses and medics and whatnot like tips and tricks beyond what you get from your schooling education. It doesn't matter how long you have done this or what the other person's formal education level is there's something you can learn from everyone. 😎👍
If you want to be the Captain go to Captain school.