PAs in ER

For the past year we have had physician assistants in the emergency room where I work. It hasn't gone well.

They see every kind of patient except mental health patients. Mostly they have worked in the main ER (non urgent care).  I know they work well in some ERs but after working with them for a year, I don't think they belong in the emergency room taking care of non urgent care patients.

In this day and age, ERs have changed.  They are no longer seeing fractures, lacerations and simple illness. We see acutely ill, complicated patients.  The acuity in ERs has gone way up.  I really don't think PAs are up to seeing these kinds of patients. I think they should be seen by docs.  I think patients in the ER expect to be seen by docs.

Physician assistants have a bachelors degree.  I'm sure the classes they take are pre med type classes. They don't have to have a major in a science as I understand it.  They then go to a 2 or 3 year program where they are trained in the "medical model" of medicine.

Two or three years isn't much to be caring for acutely ill, complicated patients. To be honest, they make me nervous as a nurse. I don't trust them like I do the docs.  Working with them feels like working with 1st year residents. You always have to be on your guard with them.  Docs supervise them, but  they are ordering stuff before they talk to the doc.

I think if ERs are going to hire non doctors they would be better off hiring NPs.  NPs have a degree in nursing, they have worked in a medical environment.  The thing is the reimbursement is less for NPs.

This whole thing has made our ER harder to work in.  No one likes it.  It has impacted patient care negatively.

yup

man candy saturdqy

help wanted:

Help wanted:

*someone who can sell ice cubes to an eskimo
*must me masochist
*former experience on garbage truck a plus
*6 months of bouncer experience helpful
*hazardous waste experience required
*waitress/waiter skills
*united nations workers welcome
*biotechnology degree preferred
*must be night owl
*former jugglers will be considered
*ex-zoo attendants encouraged to apply


Join our team of caring professional nurses at Hood Rat Hospital...

the vagabond hipster

You view yourself as some kind of vagabond hipster, hitching from town to town.  Free as a bird, nothing is going to tie you down.  You say you follow bands around the country.  

The thing is you have been here for almost a year.  You have been in jail for not paying bills you have managed to run up.  Even though you are pushing 40, you are some kind of man-child who roller skates in places that get you in trouble.

Today you are found rummaging through a dumpster looking for food, drunk as shit.  Looking for a place to sleep and a meal, you tell the police you need to see a psychiatrist.  You arrive with all your life possessions stuffed into a backpack  someone would use to go on a mountain hike. Tied to the backpack are your 1970's roller skates.

The sad fact is that you are mentally ill and an alcoholic living in a delusional world. Even though we discharge you to a place that could help you, you will refuse the help.  You prefer to live in your delusional world and the thing is, as long as you don't want to hurt yourself or others, you are free to continue doing that.  See you next week...    

dead skunk in the middle of the road

One day a couple of weeks ago, I took my usual route into the ER and I encountered a smell....

It really started before I even got to the ER itself.  Whew what is that?!!

Now as an ER nurse, I am used to bad smells  - GI bleeds, dirty feet, that homeless odor, alcohol and cigarettes, etc.  But this smell topped them all. 

As I walked into the ER it only got worse. It literally smelled like a sewer.  The thing is, it was the sewer.  It seems one of the pipes that drained sewage was having a problem and was backed up or something.  This went on for a couple of hours,  The whole ER smelled like a sewer. 

Did we close down or anything?  Of course not.  We carried on, feeling queezy and our eyes smarting. The thing is the smell was the worst in triage.  It was a "welcome to hood rat hospital, yes that smell is sewage. If you aren't nauseated now, you will be..." situation.

the circle of life

Its the dregs of winter up here in the frozen tundra.

Dregs of winter = January 15-March 15

The show is dirty.
The clouds are grey.
Its colder than a motherf--ker outside.
The inside of my nose feels like the sahara desert.

When the above happens, people stay in the house together
They pass viruses among themselves.
They come to the ER.
They clog up the ER.
The waiting room fills up.
When the waiting room fills up, the staff gets stressed.
When the staff gets stressed, they become irritable.
When the staff becomes irritable, sometimes they snap at each other.
When the staff snaps at each other, the tension rises in the ER.
When the tension rises in the ER, chaos ensues.
When chaos ensues, the staff fells out of control.
When the staff feels out of control,  they go home and drink.
When they go home and drink, they are hungover the next day.
When they are hungover the next day, they move slower.
When they move slower, the patients get irritable.
When the patients get irritable, they act out.
When they act out, the tension rises in the ER.
When the tension rises in the ER, the viscious cycle begins again..

The circle of life in the ER.

i'm tired

man candy saturday

please don't drink the water

There is a phenomenom in this country.  Apparently no one can drink water anymore.  Even people who aren't nauseated can't drink water.

Just about everybody that comes to the ER these days gets an IV whether they need it or not.  They will also get a liter of saline.  Its like a "when you don't know what else to do, give them a liter of saline" type of mentality.  Do you know how many liters of saline are poured into people daily in this country? Thousands. I'm sure it makes the saline liter company very happy.

The days of having someone actually drink a few glasses of water are gone.  I mean the hospital has bought all of these IV catheters, IV fluids, tubing so we have to use them. The amount of saline we waste in the US could fill a river from one end of the country to another.

So if you come to the ER, be prepared to have a couple of needle sticks. You ARE going to get an IV. And damn it we will poke you til we get it. We are good little nurses following orders.


Ridiculous order #657

For 50 points: "Whats wrong with this picture?"

1) Start patient on bipap.

2) Have mental health come and talk to patient.

cuckoo cuckoo

Man I have had some really weird patients lately.

Someone ran out of their room, heading for the door and was tackled by security. Almost hurtled over a bed coming around the corner. After the patient in the bed saw the person running, they got up and ran to the main lobby thinking that some criminal was escaping.

One of my patients through a phone receiver into the wall as hard as they could.

Then there was the person who doing acrobatics on ER cart in a fit of rage. Of course they took their clothes off before the acrobatics began.

I had somebody who was out of it and would literally not sit still. Restraints weren't an option.

People yelling at the top of their lungs because they didn't get admitted/didn't get the narcotic script they wanted, having to be escorted out by security.

People smoking in the bathroom.

Scary ex convicts with a history of violence needing to be restrained.

All this in the last 10 days. Has the world gone nuts?

screw Hippocrates

Lots of ERs have started to post policies about narcotic prescribing.  We have one in our ER. It is in triage next to the triage chairs.  It is a full page, single spaced, in other words, not reader friendly. It says that we do not prescribe narcotics for chronic pain.  We don't refill prescriptions.  You have to have an ID to get a narcotic prescription.

In essence this is what it is: A JOKE.  Our doctors don't follow it. They don't follow a corporate wide policy.  They do give scripts for chronic pain.  They do refill prescriptions.  You don't have to have an ID for a narcotic script.

The argument from doctors would be: it is up to the individual provider to decide what to do.  Its funny, there are nursing policies that we have no choice about following, but apparently doctors are exempt from following them.  They can pick and choose.

Therein lies the basis of the prescription drug abuse epidemic in the US. Gutless doctors.
Doctors who, rather than do the ethical thing, take the easy way out. They don't want to say no and have to deal with the angry patient.  They don't want to have a complaint against them because the patient wasn't happy.  Patient satisfaction and all that garbage.

So it goes on and on. Part of the hippocratic oath states:

"I will follow that method of treatment which according to my ability and judgement, I consider
for the benefit of my patient and abstain from whatever is harmul or mischievous..."

When you overprescribe narcotics so much that prescription drug abuse is an epidemic in this country,  kills thousands every year, are you benefiting your patients?

Hippocrates is rolling over in his grave.

man candy saturday one day late

those steadily depressing low down mind messing working at the ER blues

Sometimes I just get tired of taking care of the down and out, the homeless, the meth heads, heroin users, criminals, etc.  The people who are on the losing end of our society for one reason or the other. I wish their life could be better, but I still get tired of it. As a nurse, I almost feel guilty saying that, but its the truth.

There are days when I feel like I can't take another disheveled, mumbling, smelly person  coming up to the triage window.  You just grow weary of hearing everybodys tales of woe.

These are the people that all of you move to the suburbs to avoid.  I deal with them everyday, all day.  I know that I signed up for this, but it doesn't mean that I don't grown tired sometimes.

and thats the way it is/ode to Walter Cronkite.

Some things I learned yesterday at work.:

It is COOOOOOLLLLLLDDDD where I live.  It is killer cold.  You could die in this shit type cold.

Lest you think that cold would keep the fruit loops away from the ER, you would be mistaken my dear. They will still make their way there with their ridiculous colds, tummy aches, etc.  Even though it is frickin' -50 wind chill.  

Sorry, I refuse to do a rectal temp on a middle aged walking  and talking woman, doctor. You want the rectal temp, you do it.  Bizarre order.

When anything (procedure, policy, any way of doing things) is working, it can't last.  Some one will throw a monkey wrench into that and come up with a way that is so complicated that no one will be able to understand it.

Depending on which doc/NP/PA you get when you come in with the flu, you can get anything from nothing to Dilaudid.  Its a roll of the dice.

You don't have to work IN the sewer to work IN a sewer. One day our ER literally smelled LIKE A SEWER for 2-3 hours due to some kind of problem with one of the pipes.

And thats the way it is, January 6, 2014.

man candy saturday

the boomerang from hell

You present to the triage window carrying on.  Weeping and wailing and claiming you can't breathe, you need to see a doctor: "RIGHT NOW"!!!!!  Here's a clue: If you are able to weep and wail, you can breathe just fine.  Sorry we're full and you have to take your place in the lobby like everyone else...

Of course you are stunned, shocked as it were. My GOD, HAVE WE NO SHAME!!  You go protesting, to the lobby where you get on the phone and proceed to loudly trash our ER and hospital, throwing in a couple of "Motherf---kers" into the mix.  Eventually you leave. Yeah!!

Oh but you aren't done.  Of course you aren't.  Here you come 30 minutes later in an ambulance.  Back you come to triage.  You are once again stunned, shocked as it were.  You are once again triaged sent back out to the lobby for a repeat performance.  Only this time the natives are not so accomodating, they give you the evil eye, daring you to get on your phone again...

You eventually leave..again..maybe this time you'll call the ambulance to take you to another hospital.

Buzz Lightyear like you've never seen him before

I saw this on the the internet.  It is actually from 3 years ago.  A man came into an ER
with yes, you guessed it, a Buzz Lightyear up his butt.  Buzz has wings and apparently
they were "deployed".  Ouch.  I remember my son had one of these figures growing up.
If I remember correctly it had flashing lights and may have talked....hmmmm...I wonder if it was
still doing that on arrival to the ER.

                   HAPPY NEW YEAR from your local ER!