Thursday, March 8, 2012

Report Follies

2030 on a typically cray Monday night, calling report on a 60 something lady who was here for chest pain:
Hood Nurse: Yeah, so I'm giving you Mrs. Smith, she's a 65 year old lady being admitted by Dr. Spazz for chest pain. She had one episode of burning to her epigastric area that was unrelieved by antacids, we gave her some Morphine here and the pain hasn't returned since. She should be a pretty easy admission, she's overall a pretty simple healthy patient, her enzymes are all negative, but the doctor wanted her to stay for a stress test just because of her age and because she's a diabetic.
Floor Nurse: Wait! She's a diabetic! Well, what was her last blood sugar?
Hood Nurse: Um, hold on, let me look at her labs from earlier. Looks like it was 63 on her metabolic panel, but she said she hadn't eaten all day and was complaining of being hungry so we gave her a sandwich right after that.
Floor Nurse: 63! That's too low! You need to recheck it!
Hood Nurse: Um, I mean, like I said she was fasting and then she was fed. It wasn't critically low by any means, and it was addressed.
Floor Nurse: Well, you still need to recheck it.
Hood Nurse: Look, this patient is stable, she has no complaints even slightly resembling those of hypoglycemia, in fact, she's been discussing the next Dancing With the Stars cast very passionately with me for the last hour or so, obviously she's okay.
Floor Nurse: Well, I'm not taking that patient until you check her blood sugar again.
Hood Nurse: Yeaaah. I'm not going to do that. It's not an emergency. I'm gonna go ahead and use some judgement and assessment skills and say she's fine. If a blood sugar of 63 just before eating a sandwich is that much of an issue for you, you can go ahead and check it when she comes upstairs or you can call the house supervisor on me if you feel like this is a legitimate issue worth refusing a patient over.
Floor Nurse: Well, whatever. It's your license.
Hood Nurse: Yup. Any other questions?
Floor Nurse: No. (click)

What, you're not even gonna stay on the phone to get the vital signs and ask me if the patient is alert and oriented or if she has any skin issues? Yeah, sorry, on another day I might have obliged, but when there's 50 sick people in the waiting room and I have three other patients that need shit, you're not going to bamboozle me into doing your HS blood sugar. I guess I'm just a bitch that way.


  1. Ah with report. I get this kind of crap all the time, after calling 3 other times & being told for an HOUR that the nurse is in an isolation room. Yeah...SOMEONE needs to take report because he have patients in the rafters at this point.

  2. I get that most of the time when giving report to psych.
    "Well, his last blood pressure was 162/92, I just medicated him with lisinopril..."
    "162/92!!!?! Does that sound like a stable blood pressure to you? I'm not taking this patient until the BP drops."
    "I'm sorry, are you not a nurse...?"

    1. Ugh, our nurses pull the same crap. I tried to send a patient to the IMU yesterday with a BP of 170/95 and the nurse tried telling me no. "He's not stable enough." Bitch, please, you're in the IMU. If he's not in danger of crashing on the elevator ride up, he's stable enough for you.

  3. Thats why I love one of our new rules. Unless it's an ICU patient, we can call the floor and tell the secretary to tell the nurse to review the chart. They get 20 minutes to review it and then I page for transport to take the patient upstairs. I hardly ever call report just because the floor nurses are so psycho about stupid stuff. I like the other comment about BP, get that one allllll the time. I guess in the ER you get used to seeing BPs like 230/120 with a stable pt, we just don't spring into action over that one, sorry. And no, floor nurse, I won't be asking for a prn BP medication for you from the ER doctor. That's what your admitting physician is for.

  4. We had the same problem when I worked in admissions (sub unit of emergency). Finally we began writing report, faxing or tubing it to the floor, and calling the unit secretary to say that it had been sent. End of obligation. It was FAR more efficient, because it was a given that the patient would be transported 10-15 minutes after report was sent. If there are questions, call. End of story. Prior to that change, there was endless game playing and other stupidity.

  5. Sounds like our postpartum nurses. They can't (won't) do blood transfusions, postpartum magnesium sulfate, anyone with a BP of 140/90 or higher, the slightest bit of "extra" postpartum bleeding, or anything outside of totally normal. Seriously people!? You are nurses, are you not? L&D is not the holding spot for every single little irregularity. It is freaking LABOR and DELIVERY. We labor them, deliver them, do a brief recovery, and bring them to POSTPARTUM. We need the beds for the five other women LABORING in the waiting room or in the hall.

  6. For every story I've heard from an ER nurse about a bitchy/psycho ward nurse, I've got one about an ER nurse that sent me:
    -a pt with a HR of 35
    -BP of 210/100
    -a hallway pt (like, would have a stretcher in the hallway as a ward bed) that was a double amputee.
    -hallway patient with abdo pain NYD. Turns out it WAS diagnosed, as a SBO and the pt had IV, replacement IV and NG to suction. None of which we could accomodate in the hallway
    -pt with a blood sugar of 45. Pt was alert, talking.
    This is only a few. I could go on. If it were me, I'd probably ask you to do another blood sugar as well, not because I was trying to get out of doing an HS blood sugar, but because it's what I would do in that situation. I don't think that ward nurse was very polite about it, and probably could have handled it better. Perhaps if you had done it, the next time you called up with report the ward nurse would be a little nicer?
    Best, safest patient care startes with respecting ALL the roles that nurses have. You obviously have no respect for the ward nurses, so why should they have any for you?

  7. Not a medical professional....

    Is the patient about to die? No? Then not the emergency department's problem. Fin.

  8. God. I should have done an over/under on how long it would take some butthurt commenter to talk about all the dangerous shit ER nurses have sent them in their career. Look. Obviously in the history of nursing, inappropriate shit has been sent to floor by ER nurses. I don't send unstable patients to the floor because I'm not a stupid, dangerous asshole. However, I'm sure some stupid dangerous asshole has in the past. Trust me, those of us who are decent ER nurses don't like working with these types of people anymore than you like taking report from them. But that I "obviously have no respect for ward nurses?" Bitch, please. I have endless respect for GOOD floor nurses. They have an approach to care that is something I am literally incapable of- the attention to detail and patience required to do that job is something that is absolutely not in me.
    But I don't have respect for any nurse-floor, ER or otherwise, who doesn't listen to me when I'm trying to tell them about their patient and wants to freak out and act foolish over some trivial bullshit and waste everyone's time. I most likely would have done it were it not stated in the form of a demand just for the sake of being nice. But if it's stated in the form of a demand while suggesting I'm an unsafe nurse? Check your own damn blood sugar.

    1. I'm sorry. I over reacted. I'm sure you are a good nurse with respect for the ward nurse and to imply otherwise was incredibly rude of me, I know I'd be pissed is someone assumed that of me from one post. Although I could blame it on a dozen things, the fact is my comment was not appropriate. All I was trying to point out is that bitchy/dumb/stupid nurses don't just exist on the ward like everyone seems to be all to willing to point out.

    2. It's cool. True enough. And I think your observation about respect is spot-on. A lot of the conflicts we get giving report I think have to do with us stereotyping based on being burned in the past. The nurses on our floor always assume we are going to send them inappropriate crap with a bunch of stuff sneakily left undone, because other idiots have done it in the past. And we often assume they're going to not listen and just ask a bunch of accusatory and stupid questions because a lot of them do. I think the two potentiate one another, which is why I usually try to be nice when I call report. To a certain extent that is. I've learned the hard way, mostly in my own setting, not to be too nice.

  9. OK someone enlighten a nursing student here... what is this I'm not taking a patient until" stuff about. I'm confused.

    1. Hahaha. Floor nurses don't understand the difference between "stabilization" and "completing and comprehensively curing all medical problems prior to arrival to the floor".

      My favorite is the Type II diabetic amputee or whatever with a blood sugar of 260. "Did you give INSULIN??? WHY NOT?!?!?!"

      It's like, I'm sure this ain't Amputee Andy's first hyperglycemia rodeo, and there are oodles of waiting people in the lobby who need his bed. YOU fix his blood sugar; I'll line, lab, assess, give meds to, collect a medication list from, straight cath, and ambulate the weak old lady in the lobby with the UTI and fever while you're doing that.

    2. As a floor/stepdown nurse I usually take the report and take the patient. What I get is what I get. I usually don't care if a finding is not addressed unless it is directly related to the reason for the admission.

      One of the rare times that I argued with the ED nurse, the patient had presented as a destabilized psych patient. An hour or so after arrival his labs came back (for some reason that I don't know, or that is only known to the ED doc- they ran Cardiac enzymes.)

      When the enzymes came back moderately elevated, they got a set of vitals and found out that his pressure was 225/110. It was still well over 200 systolic when the nurse called report several hours later.

      When I asked about the pressure I was told that they don't treat chronic conditions in the ED.

      OK- but this guy is having an MI.....?

      ED nurse- Well the doc didn't order anything.

      Did you ask?

      ED- I don't write the orders, that's not my place.

      Nurses do advocate...never mind, just send him up so that I can get it taken care of.

      She huffed and puffed about my attitude for a minute, and about how his pressure wasn't relevant, but I just wanted him out of the ED and into my bed so that I could start controlling his pressure. For all I knew his elevated enzymes were entirely caused by untreated malignant hypertension.

      Did not treating his pressures for the 4-5 hours that he sat in the ED while they knew about them make a difference in his outcome? No. But in this case it was a matter of stabilization.

      I admit that this is one example. Most of the time you guys rock. Hell, I used to work with roughly half of the nurses that are in our ED now. I had a hand in orienting several, and one of them oriented me when I came to the hospital. But if one side of the coin is going to write a post complaining about lazy, good for nothing nurses- you can count on a few stories coming back from the other side.

      Believe me, we know which nurses you are talking about. We have to work side by side with them every day. If you think that they are a pain in the ass over the phone, try counting on them for a hand, or expecting them to get their own shit done on a day to day basis.

  10. My favorite is when you get to deal with the whole "WTF why are you sending me a patient with a blood sugar of 220 and not addressing it? You can't do that... etc. etc." and the admitting physician is still down in the ER seeing other patients. I've spoke with them, then added a note in the chart, "hospitalist notified regarding floor nurse and patient blood sugar. New orders will be noted on the floor." :) && then the patient is sent.

  11. People are always trying to throw the damn license thing around. Like what are they license monitors or license police? Oh no the sugar dropped to 50 and then got fixed....alert license monitors. Bull Shit. I am just suprised this floor nurse spoke such good english.

    Miss you

    ER Doc

    1. Yeah, I always thought the patients were supposed to be the license monitors by threatening to report all the negligent RNs that failed to fulfill the duty of giving them the amount of Dilau-da they request! What's with this lateral violence shit?
      Come back to us! We all miss you so much. The non-whiny physician alliance has become very weak. I'd go with you, but I can't be moving out in the country and distilling my own corn whiskey. I'll screw it up and go blind for sure.

    2. Haha, im not out in the country! I have a shift on 21 and 28 BE THERE

    3. I am seriously considering picking up the 21st, which says a lot about how much I miss you because I am totally fucking over this god-forsaken shit hole at the moment.

  12. I feel your pain. I work in the delivery room and giving report to postpartum is painful. They refuse report and Admissions 30min before and after change of shift. I wish I could tell women who come in fully dilated at 3:25 and tell them sorry its change if shift, close your legs and hold it until 3:45 while we give report to the next girls coming in. If her prenatal labs arent entered on the fax we send them for report, they ask you to check to computer before u send the pt cuz u know their secretary cant look it up. Ahhh and the best part if the IV infiltrates when the pt finally gets to them they WILL call back and ask you to come restart when it was working perfectly fine when the pt left the unit. Like seriously!!! We went to the same nursing school, passed the same exam to get ur license. You can start ur own fucking IV now that the pt is ur responsibility. But obviously not all of them are that terrible but its a constant battle with them.

  13. You call report to the floor?

    We get a page, telling us that we're going to get a patient. I get told by the secretary or the charge that I'm getting them, if I'm lucky. If I'm REALLY lucky, I have 5 minutes to look at their ER chart online before they get here. I don't refuse to take anyone, but do question if they're like, wicked inappropriate for our floor (M/S, Oncology) i.e. pregnant, an overdose/suicide attempt, or written for another floor (such as cardiac tele, critical care- it's happened).

    We just suck it up and take the patient. The only thing I ever want to know that I sometimes can't figure out (due to our computer system) is if an antibiotic was started or not on the neutropenic patients.

  14. I refuse to work in a hospital that allows tubed or fax report. Dangerous, IMHO. Report is a license to license handoff, and you know if I look at a chart and have questions, the ER nurse I need is unavailable. Not fair to the RN or the patient. Professional respect and responsibility have to exist on both sides. I was floating to short stay discharge area the other day (shudder!! Not my thing!) and was given report from PACU. 220/102, up from 130's preop, surgeon not notified, in pain, only pain meds ordered were clearly on allergy list, not tolerating anything PO but I can give nothing IV in this setting, and I'm supposed to get her ready for discharge home within the hour. So seriously not ok. Mutual respect, and universal floggings mandatory for the lazy bums in ALL settings that make it hard for the rest of us to trust each other.

  15. where i work, we get report on the computer. occasionally, an er nurse will call if they have very specific concerns of if there's been a major change...i don't mind getting report via the computer...and we don't have the option of refusing a pt, though we may try to get the pt rebooked to a more appropriate unit, but that has to do w/beds, not nursing

    what i hate, hate, hate is that while we get booked with a pt & the report is entered into the computer, we don't get a call when the pt is being transported. sometimes it will be hours after we've been booked & received report before the pt comes. it seems like we always get booked around 3, and then the pt will show up 4 hours later, just in time for change of shift & then it gets all hectic & least a heads up so we're prepared to take the pt at change of shift would be awesome...but this problem sounds specific to my hospital..ugh

  16. Thanks for the clarification :)

  17. I know this was written a while ago. And I am a baby nurse so I'm hoping to get some clarification. I work on a med/surg telemetry unit. I do find sometimes things like blood sugars and elevated pressures aren't always addressed in the ED. If I see a blood sugar is 230 or 60, I ask the nurse if they will speak to the Doc to see if they want this addressed. Simply because, the ED nurse is in the same place as the doc. In my mind, I feel like it's easier to walk up to the doc and say, "Hey, labs came back, blood sugar is 230, do you want the nurse upstairs to cover the patient for the evening?" Or, "Blood pressure is still 180/90, do you want to give a one time dose of norvasc?" Rather than me receiving this patient, calling the doctor while he may be in the middle of admitting a patient, emergency, etc. and asking these questions that can be taken care of much more quickly in the ED.

    I do not mind covering a patient with insulin, or giving a cardiac med. However, i'd like to know that these issues/non-issues have been brought to the docs attention and whether or not they want interventions to be done at that time. Ed nurse, "This patients BP is 180/90, Doc says no interventions at this time."

    Just recently I had a patient sent to me with a blood sugar 250. He had no insulin ordered at all. I asked the nurse, "can you please just ask the Doc if he wants me to cover him? And if he does, to please put in an order for insulin."

    Another time I had a patient, ETOH with BP 180's over 90's. No PRN dose of any BP med. I asked the ED nurse, "I see the blood pressure is high, do you mind asking the Doc if they plan on ordering a PRN dose of anything?"

    What are your thoughts?

    Newbie Nurse :)

    1. It really depends on the situation. A blood sugar of 250 honestly does not even register on my radar anymore. Most in and out ed patients won't be treated unless it's a critical value, say 400+, particularly if they're like most of our people- type 2 with chronic poor control, well hydrates and non toxic- their every day values. Bp over 180 I usually try to address. I think the misconception is that the doctor is right there. Most ed docs have handed off care to the admitting HOURS before they have a bed on the floor, and if you ask them for anything for a patient no longer under their care, they get pissed and won't help. The admitting docs are occassionally close by, and I'm happy to ask if they are, but usually it involves me paging the same doctor you'd be paging, so if it's not a pressing issue it doesn't sit well with my supervisor if they're taking up a bed a new patient could be occupying. Hope that helps. Now where the admitting doctors go, god only knows.