October, 2007 Archive

October 30, 2007, 2:57 pm

Emergency Nursing: A Pictorial Essay


I can just imagine the dialog for this photo:

“Why Bob, that Doctor Jones is just wonderful! He wrote this prescription for fifteen hundred tablets of Valium!”

Bob says, “Why that’s wonderful, dear!”

Bob thinks, “Oh, thank god! Now maybe she’ll get off my back and I can read my newspaper in peace!”

Better living through chemistry!


The life of an emergency department nurse is often chaotic and stressful. If “a picture is worth a thousand words”, let me take a moment to actually show you what a typical shift in a community ER might look like.

Disclaimer: those depicted in the following photographs shall remain nameless to comply with current HIPAA regulations regarding patient confidentiality.



Any visit to the emergency department begins with triage.

Here, we have a patient with a chief complaint of pain, nausea and feeling as though he is “full of air”.

The patient’s wife reports increasing incidents of the patient hiding behind chairs and flinging feces in her direction, thereby causing increased stress in the home.

It is important to note that although the patient is smiling, he reports pain to be a 10/10. Nurses must be careful to take the patient’s word and not make value judgments based on outward signs of pain or a lack thereof.

On arrival to the room, the patient immediately asked for something to eat. This is not an unusual situation, as 98.6% of all nauseated patients become hungry on arrival.

A banana was given.



Communication is the heart of collaboration.

Here, our intrepid emergency department nurse pleasantly explains to a primary care physician the purpose of the medication reconciliation form.

Dr. Primary is astounded at the amount of work the nurses do to make his job of ordering easier. He vows to make sure he completes the form in the future. Another ER success story!

I’m sure holding Dr. Primary by the back of the neck had nothing to do with it…



CPR certification is one of the more important requirements of emergency department nursing.

Here, we see one of the ER staff working diligently, practicing chest compressions on a colleague.

Uh oh! It seems that someone has forgotten the “R” of CPR and now their colleague is exhibiting decerebrate posturing.

No problem! It takes more than profound anoxia to keep an ER nurse down!

Our posturing partner finished the shift and managed to make it home before calling in brain-damaged.

The nurse was, however, counseled for not breathing on the job.



Technology plays an important part in emergency department medical records.

Computers have made it easier to read blogs on the job access patient’s medical records, thereby improving continuity of care.

Here we have Dr. PuterGuy and our hard-working ER nurse perusing the previous history of one of the patients in the department.


It seems this patient has a family history of feces flinging.



Ah, cameraderie! How would ER nurses survive without it?

It’s your coworkers who have your back, help you when you are swamped, fill-in for you when you are sick, take the feces-slinging patient when you’ve had enough and basically make coming to work a joy.

They also hold you up when you are sleeping at 0500, as is obviously happening with our hard-working ER nurse.



This concludes our pictorial look at a day in the life of an ER nurse.

In conclusion, when things get hairy, the department is bursting at the seams and you don’t think you can take another step or read another order…

…don’t forget to hug your administrative assistant/unit clerk.

They’re the ones who actually run the department, anyway.


No emergency nurses were harmed in the making of this pictorial.

All photos taken with an iPhone, which was not mine. Because I don’t have one. Yet.

This is dedicated to all the ER nurses who think the night shift doesn’t do anything. I hope this dispels any of those unfounded notions!

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October 23, 2007, 9:05 am

Prognosticate With Grand Rounds!

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I can foresee a relaxing morning of quiet reading!

It’s time once again for Grand Rounds, this time hosted by the intrepid contributors of Pallimed: A Hospice and Palliative Care Blog, where many in the medical blogosphere did not hesitate to participate in the “Prognosticate” theme of the week.

I predict that a splendid time is guaranteed for all!



Our favorite Mother Jones is taking the reins for the next Change of Shift, coming up a week from Thursday at Nurse Ratched’s Place. Head over to Blog Carnival with your best by-for-or-about nursing posts or send them directly to nurseratcheds place at yahoo dot com. Either way, I predict that many of you will send in submissions!


Digiposter — Jeff Scott Soto

Have you been sitting around wondering “Gee, I’d like to see a live rock concert webcast. I must have to go somewhere and vote for it. But where do I go?”

You have?

You might need a life!

But I have just the thing for you! If you click on the widget and vote for Jeff, you will be able to rest easily, knowing that you did your part.

Oh, and “Mistiejourney”? Uh, that’s me. It’s my alter ego on all the rock boards and forums.

Even though Journey and I have gone our…wait for it…separate ways…it’s hard to shake a screen name you’ve had for thirteen years. It becomes part of your identity.

Geeze, maybe I need a life.


Boy, talk about shifting gears, I have to go write a five page rough draft of my critical argument paper. The topic?

Terri Schiavo.

There’s a topic that will yank me back to reality real fast.

Wish me luck.

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October 21, 2007, 2:04 pm

You Don’t Really Wanna Mess With Me Tonight


I’m not sure how mad the doctor is in this film, but it’s Basil Rathbone!!!!

I love Basil Rathbone!

There has never been a better Sherlock Holmes on the screen.

Hands down!

Suave and sinister! My kinda guy!


Medication reconciliation forms.

Every time I fill one out I have every four-letter-word known to man run through my brain and then I invent some new ones.

And last night it got worse.

Pardon my language, but I am pissed off. Royally.


Let me do a quick recap of what we are required to do, as nurses, on the medication reconciliation form:

  • We are required to write down precisely what the patient tells us, even if we know it is the wrong dosage! If the patient says they take 25 mg of Ativan every four hours, we have to write “Ativan, 25 mg” on the reconciliation form.
  • If the patient hands us a list of their medications and instead of “Furosemide”, they have written “Furobedide” we have to write it exactly as it is printed on the list!

Now, the paper that we so painstakingly fill out in our ER is then taken upstairs with the patients that are admitted and all the admitting doctor has to do is look at it and check off the box if they want it ordered in the hospital.

Did you get that? We nurses write the orders out in their entirety and all the doctors have to do is CHECK A FREAKING BOX.

Sorry, I’ll try not to shout.

What this means is that (1) the patient is actually writing their own orders based on what they tell the nurse on admission when (2) the admitting physician should be responsible for finding out exactly what the patient is taking and write their own orders!


So what’s new, you say? Same old stuff we’ve (I’ve) been writing about ad nauseum for the last year? Yadda, yadda, yadda?


I walked into work last night to find a note on the bulletin board (this is the preferred method of communication where I work) telling us that Dr. Q found a dosage error on a medication reconciliation sheet that would have “sent a patient to ICU” and that we nurses in the ER needed to be more careful.

<commence seething>

It gets better. Attached as an afterthought was a post-it note stating Dr. Q also thought that the floor nurses should go over in detail everything that is written in the ER after the patient gets up to the floor. Oh….and he appreciates all our hard work.

<full seethe ahead>

I left a choice note on his note and I am too old and too cynical to give a damn about the repercussions.


So this week’s theme for Grand Rounds is prognostication.

I foresaw this trouble looooong before now. The way we are required to fill out the medication reconciliation sheet is a safety hazard. It has been, it is now, and it will continue to be.

It is the rare patient who knows exactly what they take, how much they take or why the hell they even take it!

But this is what their orders are being based on.

Even if they come in with two full pages of medications, single spaced and printed off a computer, when I verify the meds with them there will be 3-4 changes and at least three that have been discontinued.

So now the ER is getting criticism while doing something the doctor should be doing to begin with, but that is not the worst part.


The system is set up so that any discrepancy, any dosage error, any transcription error (we aren’t allowed to xerox the patient’s list) – any adverse reaction/incident….can be blamed on a nurse for writing it “wrong”.

Yet they require us to write it “as is”.

The system is set up to fail. Somewhere, somehow, someone is going to be hurt. And I’m not exaggerating when I say it will be the nurse whose signature is on the bottom of that form that will take the fall.

So, Dr. Q, before you come down and spread your eminent wisdom to those careless emergency department nurses, why don’t you find out why that dosage landed on your patient’s form, realize that you should be ultimately responsible for what is ordered and then thank us for doing your job.

Don’t criticize us on one hand and then patronize us with your appreciation of how hard we work.

You don’t have a clue, buddy.

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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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