Friday, October 9, 2009

I'm not taking that patient!

Ugh. I think there is always somewhat of a conflict between the ER nurses and the floor nurses. Some of the floors I get on with great, but there is one in particular that seems to freak out if all the patient's vital signs are not within normal limits. I get where they're coming from part of the time- I have had a few patients that I tried to send them that later had to be admitted to ICU- but other times I swear this one particular floor is either a) medically stupid, or b) just plain lazy. I will admit ER nurses tend to be flippant about vitals where I work. a 180/90 blood pressure is perfectly fine for me- our patients are generally hurting and stressed and their vitals are going to be out of whack, whatever.
Before I get into some of these stories, let me first point out that I'm talking about a telemetry floor- meaning they specifically see patients with cardiac issues- so you'd think they would understand basic cardiac pathophysiology. Maybe not.
My hospital is close to a nursing home, so most of our patients have CHF, or congestive heart failure- meaning, in summary, they've had some damage to the heart, so it doesn't work as efficiently and has to pump faster, and the patient is more prone to getting overloaded on fluids, so we're really careful about giving them too much.
The first patient they freaked about was being admitted for fever due to a urinary tract infection- so her heart was already elevated from that- plus she was in late CHF, so her heart rate was 130. It had been that way they whole time- she was completely stable- that was just where she lived. I told the nurse this when I called report. It wasn't sinking in-
"The heart rate's 130!"
"Yes. But there's a medical reason for it."
"But it's 130! Aren't you going to call the doctor?"
"The doctor knows. He was down here lookig at her when he wrote the orders for her to go to your floor. The heart rate isn't going to change."
"You need to call the doctor!"
"You need to call the doctor. I'm not calling him about information he already knows."
That turkey called the house supervisor on me! I explained the situation to her and she immediately sent the patient to the floor. One explainable, out of normal limit vital sign does not an ICU patient make!

I swear they've gotten even worse since. Yesterday we had a similar issue- an elderly man with CHF who had fainted due to dehydration. We gave him a liter of saline fast to get him rehydrated, but we started him on a slower rate of fluids as not to overload him. The blood pressure was 95/52 when we called report- technically normal and completely explainable by his condition. The nurse upstairs did. not. get it.
"That is a low blood pressure!"
"Uh, yeah. But there's a reason why, and it should continue to improve."
"But it's low!"
"Yes. But we don't want to fill him up with fluids too aggressively because of the CHF. "
"But it's really low. What if it drops?"
"Why would it drop? If it drops call the doctor! Do you understand how this works?"
I was literally hitting myself in the head with the phone by the end of the conversation.

Forget completely about the med floors- I swear they aren't allowed to have any sick people up there. Some of it makes sense- they can't give cardiac drugs IV push since their patients aren't on continous monitoring- but the stuff they refuse to accept is freaking ridiculous. I sent them a patient with a 180/90 blood pressure who I had been holding in the ER all night for his blood sugar so they wouldn't have to fill an ICU bed. The admitting doc would have let me send him up a lot earlier but I wanted to get his sugar down the where the meters could actually read it so the floor nurses wouldn't have to send blood to lab. I even started a second IV for them- if EMS starts the first they have to remove it and start a second of their own, unless we do it in the ER.
So the whole night I dealt with time consuming hourly blood sugar crap, I was ready for him to be OUT. His pressure had been high earlier in the night and I knew they wouldn't take him, so I called the doctor and got a ton of orders- including two oral blood pressure meds and and IV meds for the gaps in between. He ordered them all at once, but I wasn't comfortable dumping all three in him at once so I held one and gave it right before he went up- I'd also stopped the insulin drip, started the sliding scale orders, and checked a blood sugar. She did not seem to get that they medicine was going to bring the pressure down soon, so I mentioned that she had order for IV meds, too.
"I can't give that. Can't you call the doctor and get the order changed?"
"You can call the doctor and get the order changed."
"Aren't you going to check another blood sugar?"
"We check an hour after we give insulin. I just gave it."
"But it's been 15 minutes, hasn't it?"
"Do you seriously want me to check it 15 minutes later? That makes absolutely no sense. No."

Ugh. the thing that makes me the craziest about that shit is that they have techs to do that! We have ourselves, and other sick patients! I understand stabalizing people, but please! Not everything is going to be fixed by the time the patient gets admitted. That's why they get admitted.


  1. Lol...yeah, I don't think floor nurses & ER nurses will ever see eye to eye. It's like discussing politics or religion = a no-win situation.

    The blood pressures I could deal with (since when is 95 systolic considered too low??) The heart's abnormal for someone to live in the 130's on a telemetry floor unless they have lazy doctors. And if they were on a medical floor...a rapid response would be called immediately. You're right...I don't think they are allowed to have sick patients on the medical

    And the a perfect world techs would do their job. Sooooo very different in reality though. They seem to think that because we know "how" to do it, that we "should" do it rather than have them to do their job. Ahhh...isn't nursing fun?????

  2. This is true- I remember far too well what some of the techs were like when I worked on a surgical floor in my last semester of nursing school- screwing around on Ebay while the nurses scrambled to take vitals and give meds.
    I think our hospital especially tends to make my reaction to any out of whack vitals pretty casual- our docs regularly discharge patients with 200 systolic pressures- and get pissed when we mention it to them. We have so many patients who can't afford or don't take their meds that we see super high blood pressures and 450 sugars and just kind of shrug, since it's pretty much that person's norm.
    I have no clue why doctors are so hestitant to admit patients to ICU! I actually had to pretty much tell one to do it the other night- she was trying to get me to give like, 8 different BP meds to a guy who came it with a 300/150 pressure and send him to a telemetry floor. Hell to the no. I told her I needed a nicardipine drip and ICU orders and I got it, snap.
    So yeah, I feel your pain a lot of the time- I think we just get so jaded down here that unless someone is actively dying, we decide they aren't sick.

  3. Almost as bad as jailers when a prisoner comes in and sneezes. They panic and refuse to accept him and force us to take him to a hospital where he/she will spend the next few hours on the taxpayer dime only to find out there is nothing wrong!

  4. hmmm. 180/90 BP generally we as phone triage RNs tell them to make an appt with their MD unless they were symptomatic (dizziness,headache,vision probs,etc)-then go to ER. Also to take their BP several times and if out of normal range a couple times...then see MD-not ER. With low bps...well, suffice it to say, unless they pass out or are dizzy or very dehydrated...we never send them in.... :)
    I used to do ward nursing...usually had no probs with ER RN admissions.... ;)
    Sounds like u are a very good ER RN! Good work!