March 31, 2006, 1:06 pm

The Key To A Smooth Running ER? Nurses!

There is a person in this photograph who suffers from a rare, dare I say extinct affliction.


It’s an actual photo of “Flat Cap Syndrome”.

Flat Cap Syndrome developed when the brim of one’s nursing cap was larger than the fold behind it.

Some say that the victims were responsible for choosing to go to a School of Nursing identified by those caps.

Don’t blame the victim.

Maybe it was the only School that she was accepted to.

Maybe…..maybe she didn’t know….

By the time I graduated, designs in nursing caps had pretty much made Flat Cap Syndrome a thing of the past.

My cap was never flat, and to this day it stands proudly in its case in the den closet in pristine condition.

(Disclosure: it’s in pristine condition because I just bought it off of eBay.

I have to get the green and gold ribbons on it and then I have to get the courage to wear it to work because my co-workers will have a field day with me.

If all of a sudden there is no more Emergiblog, it’s because they killed me with ridicule.

Call the authorities.)


Some of the advantages of working in different facilities are the exposure to different styles of nursing, different opportunities, different patient populations and differing protocols regarding what nurses are able to do on their own.

I’m not talking about using nurses instead of doctors, a la the problems that Dr. Crippen at NHS Blog Doctor describes, I’m talking about protocols that allow nurses, using certain criteria established by the ER physicians, to initiate care prior to the doctor seeing the patient.

Sounds like a great way to facilitate patient flow and satisfaction, right?

It is!

The best ERs that I have worked in are the ones that, per protocol, allow the RNs to do what they do best.

Conversely, the worst ERs I’ve worked in allowed the nurses to do nothing without an order.

  • When I worked at “World Renown Medical Center With Hard To Get Into Medical School”, this was the case. The nurses could not make a move without an order.
    • Why?
    • It was a teaching facility. How could the interns/residents learn to order appropriately if the nurse did it first? And forget verbal orders, if some resident gave an order you grabbed the nearest order sheet and made them write it. So often you’d have five or six different order sheets going.
    • Why?
    • Because if there was a descrepancy between what was said and what was done, guess whose derriere would be on the line? Right, the nurse’s. Remember the old saying about how excrement flows downhill? It’s true.
    • And the wait to get into a room? Hours. We’re talking 5-7 hours at times. You could be vomiting, have a 5-day migraine with photophobia, writhing on the floor with right flank pain secondary to a kidney stone and you would STILL be sitting in the ER with all the feverish, coughing bronchitis patients. And don’t think asthma would get you a front row seat, either. If your O2 sat was normal, have a seat like everyone else.
    • Why?
    • Because the beds never turned over. Because one nurse would be responsible for six monitored patients plus the psych isolation room across the hall. Because….
    • … first the “Pulmonary Team” had to see the patient, then they would decide this was a cardiac problem and you’d wait a few hours for the “Cardiac Team” who would discover that the patient wasn’t on that service after all and a different “Team” would come in an hour later, only to discover that said patient couldn’t be admitted there anyway, but then the patient would vomit blood which meant that they were too sick to transfer and you had to wait for the “GI Team” to come down and finally admit the patient.
    • Not to mention every single pediatric patient in the clinic area getting conscious sedation for their boo-boos.

Get the picture?

Then we have example number two.

  • Small community hospital, one that I will call “Mini County Hospital”. Sat right in the middle of a very ethnically diverse, lower-income area of a suburb that could be called the Meth Capital of the SF Bay Area. Many patients. Many clinical, non-emergent patients. Some very emergent patients.
    • The nurses were not allowed to do anything. Nada. Kaput.
    • Why?
    • Because the department had a wide mix of nursing experience, from new grads to newly designated dinosaurs like me, and there were no protocols because they could not depend on all the nurses to have the same level of competency.
    • So one day, Nurse Experience (me), brings in a patient with chest pain, starts a line while the tech does the EKG and within five minutes hands the doctor the EKG and the orders for CBC, Chemistry Panel, Cardiac Enzymes and portable chest to the unit clerk. No problem, right? Wrong.
      • I was curtly asked, “Who the hell told you to order those labs?”.
      • I looked at Dr. Who Was In Training Pants When I Graduated From Nursing School and said that they were the standard labs ordered for a chest pain patient suspected of having a cardiac problem.
      • “You are not covered to order these labs!
      • I said , “Are you telling me that after (then) 24 years experience in nursing, that I cannot at least get a cardiac workup started?
      • That was exactly what he was telling me. I had three times the experience and was old enough to be his…..older sister, but it didn’t matter. The nursing expectations went to the lowest common denominator, that of a new grad.
    • Which meant the patients in the waiting room waited, sometimes 8 hours for the same reasons stated above. The nurses could not facilitate patient movement. Because we worked with relatively new doctors, every child who vomited even once got an IV and a bolus. Most got septic workups.

Now let’s contrast this with an ER that runs quite smoothly, which happens to be where I am now and plan to retire from when I’m so old I can’t stand up straight.

  • This ER has nursing protocols. Detailed, well written protocols. Here’s what happens when you come into this ER:
    • For example, you come in and your chief complaint is nausea, vomiting, diarrhea for three days with fever and you are extremely dizzy when upright. I’m your nurse.
      • Before the doc shows up I will have orthostatic vital signs, an IV in, bloods drawn, a bolus of Normal Saline initiated (unless you are elderly or have heart trouble) ,at least a CBC and Chem 14 ordered (with additional blood in case more tests are added) and you can expect me to ask for and collect a UA and an stool specimen, which may or may not be needed, but they will be collected just in case.
    • Or you are an elderly male who looks 8 months pregnant and hasn’t urinated for 2 days except for a little bit here and there. You can barely walk, you are in so much pain. If I’m your nurse you will have a catheter in before you can say “ouch”, assuming your prostate co-operates.
    • Your wait on a bad day in our waiting room may be three hours max.
    • Why?

Because the Registered Nurses in my department are covered by extensive ER protocols and we work with doctors who respect our judgement and know we would not order outside of our protocols.

My attitude is that by the time that doctor walks in to see the patient, everything he/she needs has been at least considered. I am able to do much more than described above, but it often isn’t necessary because the doctors see the patients so quickly, they are usually right behind me.

(Yeah, I have a great job, which I appreciate all the more because I’ve had some bad ones.)

So the Emergency Departments that give nurses the most autonomy via protocols wind up being the ones that really need it the least. And they wind up being the ones with the highest patient satisfaction ratings.

A little ironic…

Doncha think?


Addendum: Dr. Who Was In Training Pants When I Graduated From Nursing School turned out to be one of the neatest persons I have ever met and he is a fantastic doctor. He was the one I missed most acutely when I left for my current job. Go figure.


  • Charity Doc

    April 1, 2006 at 10:00 am

    Why is that doc in the picture wearing a head lamp when examining a child? We have a similar gear in our ENT room, but it’s OOOH..fiberoptic…AAAH, hightech. To be honest, I’ve never used it, nor have seen it used by anyone, ENT docs included.

    As to set ED protocols…I love them and have written many of them over the years for places that I’ve worked at. How else would I be able see patients fast enough in an ED of 70,000/yr. census and single coverage after midnight (ususally though, 1AM)?

    I ain’t no fool, the nurses run the ED. The good ones makes me feel that I am, but the truth is all too well known….The nurses can make your experience HELL if you’re not careful. I cannot think of any other field where there’s a tighter symbiotic relationship between nurses and docs than the Emergency Dept. We got each other’s back We are a team with one goal in mind…to get patients where they need to be. And simplistically, there are only 3 places that they can go to once seen in the ED.
    1. Home
    2. Upstairs
    3. Morgue

    But then some moron broke the rule and established an observation unit (also called the clinical decision unit), the mother of all dumping ground, that I dare not tell any of the consultants about because once they find out it exists, there goes the party.

  • Your job/current ED sounds like the ideal set-up. As we’ve been training it has become clear that we are taught that we must have a doctor’s order for everything.

    It seems more efficient to have the standing orders in case of N/V, urinary retention/distended bladder, etc.


  • overactive-imagination

    April 1, 2006 at 1:13 pm

    Hi Kim,
    If you get a minute…could you e-mail me. If you don’t mind answering some questions regarding the differences in “titles”. For example ADN, Rn with an AS (or BSN) is there a difference. And I keep reading about “pinning ceremonies” on student nurse blogs, why are they getting pinned instead of going to “graduation”. Thanks

  • Linda

    April 1, 2006 at 1:15 pm

    Great post. You always give me a lot to think about for when I graduate and get a real job.

  • Anonymous

    April 2, 2006 at 12:03 am

    I’m a volunteer in a very well-respected ER, and I noticed that things do tend to move very quickly, even on busy nights, because of the physician assistants and nurses. For example, a short while ago, a baseball player came into the minor treatment area with a black nail from contact with an 80mph pitch. He waited in the waiting room for about an hour, I called him directly to his room, bypassing triage, and watched him get his nail drained by the physician assistant. (That was when the charge nurse yelled a little bit, but expressed gratitude for trying to keep things moving.) I’ve also brought people to their rooms in the serious treatment area and immediately been followed in by a nurse and a tech with a blood cart (I think; like I said, I’m a volunteer, I’m in no way medically qualified).

    So, yeah. I agree. Things move quickly because of nurses… after all, there are, like, ten of them, as opposed to three doctors (at my hospital, anyway).

  • Colin

    April 2, 2006 at 12:05 am

    I love your writing. And your outlook. My few experiences as a patient in E.R.’s have been quite good.

    Once I did get frustrated when the clerk asked my birthdate. Of course, I can’t speak, and I was in such pain I could barely stand up. My wife told the clerk my birthdate, and the clerk said she had to hear it from me. So I had to write down my birthdate. I’m sure there was some rationale for that, but I can’t imagine what it was. If I had been unconscious, would they have treated me?

    Once we got past that, we were in the very competent hands of a nurse, and very soon thereafter a doctor. As soon as it was possible (a few tests had to get done first), the morphine started, and I was loving life again. Dx: kidney stones X 7, one ripping its way through and six lurking behind.

    Lesson: drink lots of water. Always. And if you can’t drink, get a PEG tube quick.

  • Anonymous

    April 3, 2006 at 7:41 pm

    It does make all the difference in the world having ER protocols. I don’t think I could work anywhere else with the restriction of getting an order for everything. It would drive me insane!! I also enjoy the comraderie shared with all ER staff, you won’t find that in any other area of healthcare.

  • Anonymous

    April 4, 2006 at 7:55 am

    OK, you’re going to hate me for this, but…

    I like nurses. I really do. And I would certainly rather be cared for by a nurse, than by nobody at all.


    When I go to a hospital, or an ER, it’s because I’m sick. And experienced or not, nurses aren’t doctors. They simply don’t have the training. So while on the one hand I like the idea of your doing everything ‘for the doctor’, so they only need to sign off, I wonder whether that has a tendency to make the MD think less of the patient.

    You are clearly an excellent nurse. You know a lot about medical care. But if there was some reason NOT to infuse saline, or NOT to do a procedure, are you sure you’d recognize it?

  • Kim

    April 4, 2006 at 3:34 pm

    Hi Anon,

    LOL – I don’t hate you, trust me.
    Remember, the nurses are NOT diagnosing, only starting the process so the doctor has information when he/she comes to see you, (1) thereby cutting (hopefully)the time you have to wait in the ER and (2) hopefully helping your symptoms before they get there.

    Anyone out of the ordinary, so to speak, doesn’t get the protocols. For instance, Mr. Urine Retention: if he had blood in what little urine he was passing or recent prostate surgery or bladder surgery or had other symptoms in addition to an obviously distended bladder, nope he doesn’t get the cath ’till the doc says okay.

    Same with elderly folk or people who have congestive heart failure – no fluids unless ordered by the doctor.

    And it you can’t give me a history of your past illness, no protocols until seen by the doctor (except for an IV and blood draw).

    Never diagnosis! Remember, those protocols that are written only to get care started, were written by ER physicians, based on a patient’s presenting chief complaint and symptoms with many caveats as to when they are NOT to be used.

    So, we aren’t doing “for” the doctors at all, protocols are designed “for”the patient, to facilitate care.

    The nurses work with the docs, not instead of them : )

  • Brad

    April 4, 2006 at 7:10 pm

    Great post! Inefficiency seems to be one of the banes of modern health care. If only there were more EDs like yours…

  • Barbados Butterfly

    April 5, 2006 at 3:15 am

    Kim – I’m totally with you on this.

    I’ve worked with some fantastic nurses whose diagnostic and management skills are streets ahead of doctors, particularly interns and residents. They make life/work so much easier.

    Then there are the nurses who are taught that they aren’t allowed to do anything. Sigh. I had a nurse phone me in the operating theatre the other day to tell me that I needed to come to the ward to speak to a patient’s family because they were all concerned that we were planning to perform an operation on her. (We weren’t, as her small bowel obstruction was settling with conservative management; I’d explained this to the elderly woman but she didn’t retain or comprehend the info.) I explained that I couldn’t come to talk to the woman’s family during an operating list and asked the nurse to relay information regarding her management. Namely, that we weren’t planning surgery because the bowel obstruction was getting better. The nurse said that she couldn’t tell the family anything. Apparently she’s been instructed never to tell family members any medical information because she “might get it wrong and then people would get mad”.

    IMHO, a system that prevents nurses relaying clear instructions/ information to patients and family members is a warped system. As is a system that prevents experienced and intelligent nurses from starting treatment. Whether you are a nurse or a doctor you can make a mistake. Providing that there are appropriate guidelines and clinical support, I don’t mind who starts the IV, puts in the urinary catheter or gives a bolus of glucose to an unconscious diabetic with an unrecordable blood sugar measurement.

  • adventures in disaster

    April 5, 2006 at 10:43 pm

    I love protocals. In every Er and CvICU I have worked we have had pages and pages of them and it is wonderful.
    I cannot tell you how reassuring they are when a patient is doing poorly, it gives us the ability to react quickly while waiting for the doc.

    I think the publid is weirdly misinformed about todays highly skilled nurses. They may not realize it is the nurse who recognizes and treats life threatening emergencies..if we waited for the doc to get out of bed and drive to the hospital they would be long dead.

    A note about your nursing cap. You may have to get permission from infection control before wearing one..they are banned around here as they are known bacteria and viral carriers. Think about how many times you will “fix” your cap to your head in one day. You will have to find some way to disinfect that cap daily.
    I hope they don’t make fun of you too badly but consider wrapping the cap in a plastic cover of some kind to keep it from becoming a mini plague carrier.

  • Kim

    April 6, 2006 at 1:20 am

    Hi Adventures,

    Here’s my deal about my cap.

    I wash my hands between patients so I don’t pass germs along and I don’t spread infection.

    I also wash my hands before touching my cap in any way. So, if it is enough to stop the spread of infection between patients, it should be sufficient to stop the spread of germs to my cap.

    Now, as far as fixing the cap goes, it practically stays on without any pins as I have so much hairspray and gel (Billy Idol, anyone?) in my hair that the darn cap ADHERES to it! LOL!

    I have never ONCE had to re-adjust my cap once it is on. It just sticks. And in the ER, it doesn’t get hit by trapezes or other things.

    I honestly forget it is on. Until I take it off and have a nice case of “hat head”.

    Looks pretty funny after I’ve been wearing it for awhile….

  • pixelrn

    April 6, 2006 at 10:34 am

    At my beloved GHOAT we are protocol driven and I positively love it. I wouldn’t want it any other way. It is the most efficient way to ensure that the patient gets the care they need, without delay.

    As for that “teaching facility” excuse, come on. GHOAT is also a “World Renowned Medical Center With Hard To Get Into Medical School” But if a hospital isn’t placing patient care as its first priority then something is seriously wrong. I mean, what exactly are you supposed to do on July 1st? Sit back and let all the new interns figure it out for themselves? Not very conducive to learning, if you ask me.

  • The Medical Immigrant

    April 8, 2006 at 1:45 am

    I’m not in the US, but I want to say, as a medical student, soon to be intern, THANK YOU so much to the experienced nurses who teach us so much, help us through those first months, and understand how scary it is for us.

    Whether you know it or not, we will remember you for all of our lives as those who helped us through those first steps.

About Me

My name is Kim, and I'm a nurse in the San Francisco Bay area. I've been a nurse for 33 years; I graduated in 1978 with my ADN. My experience is predominately Emergency and Critical Care, and I have also worked in Psychiatry and Pediatrics. I made the decision to be a nurse back in 1966 at the age of nine...

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