IamA registered nurse in the emergency department, AMA!

My boyfriend used to work in the ER as a scribe before he started medical school. He swore that on nights there was a full moon, weird things would happen. People would, for some reason, be more aggressive/emotional than usual, leading to strange or violent injuries. There was such a correlation, people (doctors, nurses, staff alike) would mark the date of the full moon on the calendar just so they weren't blindsided by an especially busy night. He always tried to get that day off, but of course, it wasn't always up to him.

My aunt, who's also an ER nurse in a different city, apparently swears the same thing. My mom's best friend, another ER nurse in another city, has also been remembered to say the same thing.

Have you noticed any correlation?

Yup! It's actually a really common superstition. I think it's probably all in our heads, but I swear we have the craziest patients, especially psych patients on full moons!

[deleted]

There's a law called EMTALA that requires patients to get the same level of care regardless of insurance status or what insurer they have. My hospital requires you to pay either a co-pay (determined by your insurer) or put down a $250 deposit. This is all done after the patient has seen a provider - either an MD, PA or NP. Registration is not legally allowed to ask for a patient's insurance before they are seen. If the patient cannot pay the copay or deposit, the hospital cannot force them to, and they will be billed later.

26 year old with 3 years of med surg experience here, how much will I hate working in the ER? The idea is so intimidating I'm not sure if I'm willing to gamble the transition.

Tl;DR what are the functional differences that you didnt think of until you started working there?

Oh man, I'm an ED nurse and I would never go back to the floor. On the floor, if you get a fucking asshole patient, they are yours for 12 hours, and they will probably be there when you come back tomorrow too. Multiple doctors round and put in new orders all day, multiple meals, accuchecks, bed changes, baths, med pass for all of your patients scheduled at the same time and they all have 15 meds each. Oh, and did you need something? Have fun paging the doctor 20 times while your patient yells at you for not having the order yet. In the ED, you have that patient for maybe 4 hours. They can't eat or drink until testing is done and then you can throw them the one sandwich you have in stock if they want it. Don't like it, they can order once they get upstairs or get their own food when they leave. No bathing, limited toileting. You get your patient, you assess, draw blood, monitor, and provide meds as needed, then send them on their way. It's great.

100% agree. I don't think I could EVER go back to the floor. The only other area I could see myself in would be trauma ICU, but even that I'm not sure if I'd really enjoy as much as ED.

Maybe I can help... I worked tele for three years before coming down to the ED, love it! It focuses more on the aspects of nursing that i really enjoy, I get to see new things every day, I feel like a much more well rounded nurse.

The ED is intimidating in the scope of patients you see (not sick at all to VERY critical patents, kids to adults, Ortho, Gyn, ID, cards, you see it all to varying degrees) but you also work much closer with the Docs/PAs/NPs than you do on the floor and you're never really alone.

You don't need to know everything yourself, but eventually you will know at least a little bit of everything.

My advice is to see if you can float or shadow down in an ED, get a much better sense of it. It was the best move I've made, I'm ten times happier than I was on the floor.

Yup, I completely agree with your response. I enjoy it so much more than working on the floor. See something new every day :)

Are there any situations that you see on a regular basis that just make you want to say "oh no. Not another one"?

Oh yeah, most definitely. One of the most annoying things I see is that soooo many patients treat the ED like a clinic, coming in for very minor issues that could easily be handled at an urgent care or could wait until a patient sees their primary care provider. It congests the whole department, drastically increases wait times, and makes it much harder for patients with true emergencies to be seen. What bothers me even more is when these patients fail to understand that they are NOT an emergency, and thus will have it WAIT. People refuse to understand when a sick patient is taken from the waiting room to a room before they are. I try to explain to these individuals that the ED does not work on a first-come-first-serve basis, and that the sickest patients are seen FIRST. I can't count the number of times people have yelled at me, cussed me out, or became aggressive due to the wait time - I work in a VERY busy ER. It's the most frustrating thing ever when people who aren't even that sick have such a sense of entitlement and don't give a fuck if someone else is dying and needs medical attention BEFORE them.

How was work this week?

I worked an extra shift this week (I usually only work three 12 hour shifts a week) for overtime pay so I'm pretty exhausted. I work again tonight (I do night shift, 7pm-7am) and this will be my 5th night in a row. I try to do all my days in a row if I can get back on a normal sleep schedule during my days off.

It was pretty busy on and off the last couple of days. Saw a ton of sick kids and my first flu + patient of the season. We also had a lot of high acuity (sicker) patients.

Have you ever seen anything which was too gross for you to handle?

I don't really have a choice to not do anything "gross". I really hate working with sputum and respiratory secretions but I have to suck it up and do it anyways. I usually just put on a mask/face shield if it really grosses me out. I once had to put a nasogastric tube (feeding tube that goes from the nose to the stomach) in a patient who had a small bowel obstruction. He had basically been puking up fecal matter and blood because of the blockage. The smell was probably the most disgusting thing I've ever smelled. He had also vomited all over himself and the ground. But I still had to do it anyways :(

I was reading an H&P once and the dr noted that the pt had saved the sputum she coughed up in a tupperware and brought it in to him. I gagged just reading about it.

Oh dear god! That grosses me out thinking about it too. I had a patient once who brought in a mucus-y stool sample in a wad of toilet paper. Super gross.

I had one of those exact same patients vomit of the side of the bed and INTO MY FUCKING SHOE... That was the day i started keeping a whole second set of clothes in my locker, down to the socks/underwear and shoes

Haha, yeah I keep a set of scrubs in my car, I didn't think about the shoes/socks though. Maybe I'll start keeping some in there too.

What's the worst thing that's ever been shouted at you or another member of staff and what was the reaction?

I can't think of any specific quotes that stick out in my mind, but patients and family members of patients threatening physical violence and death threats are WAY more common than you would think. It's especially scary because even though we have security guards, they are required to use a "hands off" approach. I've come close to being assaulted multiple times and have co-workers who've been kicked in the face, punched, spit on, etc. We also have psychiatric patients who are extremely unpredictable. It's the most dangerous place in the hospital to work, by far.

Hello. UMM security guard here...

We're "hands off" but we will go hands on to keep staff safe in a heartbeat...

Also, Please don't hate us...

I definitely don't hate you guys! I understand that it's policy and probably so that patient's don't file assault charges if they get injured. Some of our guards are amazing and I trust that they would try everything they could to make sure we're safe. It just sucks that they can't do as much as they probably want to.

Have you ever met any celebrities on the clock?if so, could you talk about it?

No, I haven't. I work in the MD suburbs just outside of DC so I wouldn't be too surprised if a politician or someone of a similar caliber came in. I actually used to work as a veterinary technician before I was an RN and had a famous Wizards player bring in one of his dogs to our clinic.

Hey I was a vet tech (LVT) for many years and absolutely loved it. I worked at a large-referral-specialty hospital and I was able to meet several celebrities who needed our services. Not any A-listers or anything but more tv personalities (reality shows and a certain pastor to a mega church). I work in a human hospital now but miss the animals every day. Do you ever miss it?

I actually still do it! I am part-time in the clinic where I used to work full time (before nursing) and I usually work a couple of times a month. I love working with animals (even more than humans!) but they $ and little opportunity for advancement never made it a realistic career option for me.

Even if this nurse has treated a celebrity or any other person for that matter they are not allowed to talk about it. It would be a violation of the health insurance portability and accountability act (HIPAA) and can result in a lot a legal trouble if you do so.

This is true. I can tell stories about my experiences but can't give any names or specific details.

How difficult is it to get a job in nursing?

As you probably know, there's a significant nursing shortage which is only projected to worsen in the near future. It's quite easy to find a job if you have nursing experience already. It's tough for newly graduated RNs out of school to find a job because it's REALLY expensive for hospitals to train brand new nurses and they pose a liability risk to the hospital since they are so inexperienced. Most hospitals have new graduate RN programs with several months of extensive orientation. It makes it even more difficult if you have an associate's degree rather than a bachelor's because there is a huge push for bachelor's to be the entry level degree for RNs even though RNs with associate's and bachelor's practice under the exact same scope of care and can do the exact same job.

Would having personal experience help? I had a daughter who had a brain tumor that ended up making it necessary for her to have a trach, gtube, and ventilator. She had episodes of respiratory failure when she got upset and needed to be bagged by whoever was with her which was almost always me, on top of the regular trach care and tube feeding and whatnot. I was basically her nurse for 3 years without actually going to school. Now the next logical thing seems to be nursing school since I already have so much experience. I know that experience will help me in school because she was such a complex patient but I've wondered if it'll matter when I need to find a job once I'm done.

I'm so sorry to hear about your daughter :( I don't think it would hurt to mention your experience with your daughter, especially once you get an interview. I wouldn't go so far as to put it on your resume, since it's personal experience, but definitely mentioning it during the interview - and giving it as a reason for wanting to get into nursing - would help give you a step up above other candidates with no experience. I would DEFINITELY recommend trying to get a job as a CNA (certified nursing assistant) while you're in school though because having direct patient contact in an acute care setting makes you look much better from the perspective of the hiring manager. In my state, after you finish your first semester of nursing school, you can apply for your CNA license. Good luck!

What's the funniest thing that has happened while you were on shift?

I think probably some of the conversations with the drunk/intoxicated patients. We always get a kick out of messing with them/egging them on if they're really wasted (only works for the happy drunks - not so much the nasty ones). If we have someone in one of the hallway beds near the nursing station, and they're really drunk and they start talking to us we'll engage in conversation and it usually turns out to be pretty funny.

If you know the show, how would you compare your view of doctors in the ER vs. the way things were portrayed on "Nurse Jackie"?

Out of all the "medical" shows I've seen, I think Nurse Jackie comes the closest to reality. I think that's due in part to the writers being nurses and actually working in the medical field. There are definitely still parts of the show that are unrealistic which is frustrating but it's far better than most other shows. I also have heard of some nurses who have gotten addicted to narcotics and fired after they were caught, but I heard it all second hand. It's a little bit difficult for me to compare the hospital Jackie works at to mine because All Saints is a trauma center, whereas the hospital I work for is not.

Have you seen 'Scrubs'? Every doctor I know says that show is the most realistic.

I've seen a few episodes, but its been years so I don't really remember it too much.

Have you ever had a patient who had something stuck up their butt?

I haven't personally had a patient that has happened to. I've heard of a couple of nurses who have, but it's not very common. Though, I have had a couple of patients who've had a retained tampon or condom. It's much easier to get that out than something that is in the rectum! All the MD has to do it use a vaginal speculum and take out the object.

I work registration in the ED and there are actually a good amount of people who come in with stuff stuck up their butt. Usually its a vibrator, but we've also seen shampoo bottle caps, a hairspray cap, a plant stand leg...

Jeez, I guess I lucked out that it doesn't happen at my ED too often!

How many patients have you seen die and which has been the most shocking?

I actually have no idea how many, probably anywhere between 40-70? Working in the ER, we have active codes come in on almost a daily basis. After CPR is initiated, even if we are able to get the patient back, they end up dying shortly after and most of the time if they've coded in the field, they come in DOA and we're never able to get a pulse back.

It's always heartbreaking when we have a pediatric code/death, but we don't get a lot of those because they generally go straight to Children's in DC. Probably the saddest/most shocking death was a 19 year old boy who was found collapsed at home by his parents. When EMS got there he was pulseless so they started CPR. We were never able to revive him. He had no medical problems. His family said that the only thing that he had complained of just shortly before it happened was a toothache. His mom was in so much shock/denial that she was screaming and going completely out of her mind. The family stayed with his body for hours and even hours after he had died, she kept begging everyone to help "wake up" her son. It affected us all that night.

So what did he die of?

Like the other person said, we often don't get to follow up on many of our patients because we really don't have them for more than 12 hours at the max before they're either discharged or transferred to the floor. This patient was a medical examiner case (autopsy) and there would be no way of me finding out at this point what they discovered was the cause of death. I really wish I could find out though.

[deleted]

I'm not a nurse yet, and this won't answer your question, but I'm in nursing school and this type of question has come up, what do you do if you think they are drug seeking, etc. I know it has come up in the medical school too (my friends husband is a 3rd year med student at the same school as me). But across the board for my university, the answer has been to ALWAYS believe someone if they state they are in pain. If they are ordered pain meds, state they are in pain, and the order/timing is appropriate to give the med, then you can give it (unless medically contraindicated).

I'm sorry that people haven't believed you in the past, and hopefully it gets better. I like the motto of believing everyone when they say they are in pain, even if the drug seekers "get what they want" we are still helping those in pain who truly need the help.

I'm not saying that if we suspect someone is seeking that we don't treat their pain. Pain is subjective so we have to assume that the patient is not lying about their pain. Narcotics are NOT always indicated. There are many other kinds of pain medications aside from narcotics that we can offer to patients as well as non-pharmacological interventions (positioning, distraction, heat/ice therapy, etc). Opiates are highly addictive and extremely over-prescribed in the US. The majority of the time, patients DON'T need narcotics to decrease their pain. It's my responsibility as a nurse to do what's in the best interest of the patient, and that includes not enabling patients who are reliant on opiates. I'm also not saying that we never give narcotics to these people. If appropriate, they will be prescribed to the patient.

Also, look at the story in the question above that I replied to. The patient had a history of drug seeking. He got treated for his pain with dilaudid but was upset that I refused to give it to him the way he had asked me to. It's behaviors like this pt had exhibited that send up a red flag. It was obvious that he wanted to get a rush from IV push medications. I told him that it was unsafe and that he could stop breathing if I administered the meds the way he wanted me to. I felt that I was looking out for his best interest and protecting my license.

I apologize for the treatment that you've received because of others. Truth is, there are so many patients who come to the ER because they want pain meds, whether to treat an illness/injury or to treat an addiction. We want to give everyone the benefit of the doubt, but once in a while a patient or two really gets under our skin when we find out that they were putting us on to get a fix. One I remember in particular cheeked his Percs to sell outside the ER. I felt so bad for him and made sure he had his pills right on time...then his ass got dragged up by security and we found all of the pills in his pockets. It's not fair to you that things like this happen and make us jaded. All I can say is be as honest as you can, lay it all out. I'm more willing to believe someone who says, "I have chronic pain and I just had a flare and I just can't handle it." than someone who tries to tell a story. (Or, god forbid, say "The only medication that works is that one that starts with a 'D'")

edit for spelling

Wow, that sucks that you gave him the benefit of the doubt and he tried to play you like that :( It's patients like that who make us skeptical of everybody.

Or when I see that a pt is allergic to nsaids, tylenol, morphine, toradol, etc. I already know where we are headed.... Literally had a patient the other day ask for pain meds and rattle off the aforementioned allergy list and then you, the only medicine that works for me is IV dilaudid (claimed PO didn't work) and that he also needed IV benadryl and IV phenergan because it made him itchy and nauseous. Then tried to tell me I needed to push it straight into his port and then flush it with 10cc afterwards. Doc ordered it in a 50ml bag of NS and PO benadryl. Needless to say he was pissed, haha.

Do your friends ever ask you to "hook them up" with some of the narcotics you work around? and Have you ever stolen anything from a patient's room?

Haha, no, but I don't have those types of friends. And if I did I would question my friendship if they asked me something like that. It's not worth risking my career and my license. And no, I have never stolen anything, period, and definitely would not steal from one of my patients.

Are all nurses (RNs and otherwise) always around blood? Are there jobs in nursing that don't involve giving shots and being in direct contact with patients?

Yes and no. If you work in bedside nursing such as in a hospital, clinic, doctor's office, nursing home, etc. in direct patient care, then you can't avoid it. But if you work in an area such as case management, nursing informatics, or legal nursing then you don't have to work directly with patients - or if you do, then you're not physically touching them. However, 99 times out of 100, these jobs require multiple years of working as a bedside nurse and a more advanced degree before you can obtain that kind of job so that you have a solid understanding of nursing before you can work in a management-type position.

As an EMT, how much of our pt. report do you actually care about? And what extra could be be providing you that we aren't providing?

It depends on how acute they are. If they're not that serious I can get most of the information I need from the triage info/chart and I'm gonna be talking to the patient anyway so just a chief complaint/any super pertinent info is good. If it's a patient coming from a NH or ALF, I can get history and meds, etc from the paperwork. I'm mostly interested in knowing the story, onset of symptoms, mental status at time of arrival vs baseline, meds given in the ambo, if they have a line established, and medical history pertinent to the chief complaint. I also wanna know if family's coming or has been contacting (if coming from NH).

Wow! I want to start off by saying thank you for all that you do! My question does not pertain to your experience working as an RN, but to your journey becoming one. I've taken 2 years of classes preparing for nursing school, but now I can't seem to find the motivation to actually apply. I spent two years as a hospice aide, and I loved the work, but I also realize there's no way I can do this forever. Are the applications as scary as I think they are?

Thank you! I appreciate you saying that. I think you are already a step in the right direction by having experience in health care working with patients. I'm not gonna lie, nursing school is tough and it's a lot of work. I absolutely hated it and many times questioned if wanted to continue to pursue nursing. I'm so glad that I continued though because now I absolutely love it and find it so rewarding. I really feel like I am making an impact and putting some good karma into the world.

Getting into nursing school isn't really the hard part. There are tons of programs out there and I'm sure you'll be able to get into one if you have decent grades and ambition. You just have to make nursing school a priority and really work hard. I'm sure you'll be fine :) Good luck!!!

Why is it that so many nurses DON'T use gloves when taking vials/starting IVs, etc? I'm a firefighter and I NEVER even touch ems equipment without gloves, let alone a patient. I've been doing rounds at an ED as part of my paramedic training and often the nurse who is guiding and helping me with starting lines do not wear gloves. I've seen them touch rashes of unknown origin bare handed and so many other things. Freaks me out. And I'm around many fewer patients on a shift than nurses are.

If I had to put on gloves every time I touched a patient, I would go through, like, 100s of gloves per shift. We can touch a patient without gloves on as long as there's no fluids involved. Obviously if the person is gross or has an obviously contagious disease then I'll wear them and I definitely wear gloves when I start IVs. I wash my hands constantly though. You're always so busy in the ER so you just simply don't have time to put on gloves each and every time you need to touch a patient or get vitals.

For all of us medical students going through our ED rotation, what should we take away from the rotation and what things can we do to make your job easier?

Ask the docs as many questions as you can. Try to be proactive and connect the dots. One of my favorite things about working in the ER is when you have a patient and don't know what's going on so you have to investigate. It's almost like solving a puzzle and the more information you get, the closer you get to a diagnosis.

Probably the best thing you can do to make our lives easier is to just be nice and courteous, not just to the nurses, but all the staff. It really goes a long way when MDs, med students, PAs, NPs, etc don't give off an egotistical "I'm better than you" vibe. I think respect goes a long way. Good luck and I hope you enjoy your rotation!

Why is it that trips to the emergency room always end with me getting a fist full on OxyContin?

I dunno, are you asking for oxy?

I work at a hospital, too.

-Do you use epic? If so.. -Do you sit on your phone all day now that you have epic and let your pca do your work?

The hospital I worked at previously when I did med/surg had Epic and I really liked it. I use Cerner (Firstnet in the ED) now and don't like it as much.

What's your opinion on people who come into the ER because they've had too much to drink? Do you feel they're wasting valuable resources?

Like other poster said, many people who come into the ED don't really even need to be there so I'm used to it. It can sometimes be difficult to determine if someone who's drunk is actually intoxicated or if there's something more serious going on. I had a patient once who was assumed to be drunk and triaged as such, but ended up having no alcohol in his system and his head CT showed a massive hemorrhagic stroke. He came in with garbled speech and confusion. EMS was called to the scene by bystanders who saw him wandering around outside. There are multiple similar instances when we assume that someone is either intoxicated or on drugs when their mental status is altered by something else so we can't just make that assumption and have to treat them accordingly. Even if they are just drunk, they can aspirate on their own vomit, fall and injure themselves, or end up intubated because of their excessive alcohol level.

Have you ever seen / touched a beating heart? If so, what was that like?

I don't work in the OR so I don't get to see any surgeries (except for minor bedside procedures). When I was in nursing school I saw one open heart surgery but they had already cracked the chest and the pt was on bypass so the heart wasn't beating and I left before they started it back up again.

Do you feel like your hospital has adequate equipment for lifting heavy patients?

Have any of your colleagues suffered back injuries?

It's actually funny that you mentioned that, because last night one of my coworkers had a patient who ended up falling because she was morbidly obese (500 lbs) and tried to get up to walk to the bathroom (said she did it at home) and slid down the side of the bed. It took about 8 full grown men to get her back up on the bed. We can get bariatric beds from other parts of the hospital, but they're hard to come by. We also don't have any special equipment in the ED to lift big patients (such as hoyer lifts). After that, pretty much everyone who'd been helping out in that room came out sweating. And yeah I know tons of nurses who complain about back pain, including myself and I'm only in my mid 20s. Thankfully it's nothing serious (I've had an xray done and it was fine) but I worry about it worsening in the future.

As a foreigner: is it really like in movies, that patients are rejected is they don't have insurance?

No. There's a law in the US called EMTALA that requires patients to be taken care of in an emergency setting regardless of insurance status. A good chunk of the patient population where I work is uninsured and many are undocumented immigrants.

My mom's a nurse, do you know her?

Yes. I know all the nurses in the entire world.

Do you currently have a dedicated pharmacist in the er? Whether you do or not, what are your thoughts on having one?

We do, but only from about 1pm-2am which tends to be the busiest time. We have two awesome ED unit pharmacists so I really love it when they're there. I can ask them if I have questions about any of the meds I'm giving or if I have a med to give that needs to be mixed or if I need something from main pharmacy, they will go grab it for me so I don't have to wait for it to be tubed. They also pull meds during our codes. I just wish we had someone 24/7.

Is it difficult always teeling the paramedics they did something wrong? Is it more difficult avoiding them after you find out they were right?

I'm not sure what you're implying.... I respect everyone I work with and would never just straight up tell someone they're wrong... I feel like your bitter from some previous experience

How often do people come in with things stuck in their asses? What's the weirdest thing you've ever witnessed or heard of being pulled out of an ass?

I already answered this question above