I am a Registered Nurse in an Emergency Room! AMA!
I have just over 10 years experience working in an Emergency Department (6 years as an EMT, 4+ years as a male RN). I'll answer all of your questions about patient care and the inner workings of the healthcare field in the USA, debunk myths, and tell you all the ways that TV misrepresents how things really are. Nothing is taboo besides giving up specific patient information. So ask me anything.
Proof (while protecting any possible association with patients) https://ibb.co/Kx5WNN6
Yeah, we can get pretty insensitive and inappropriate at times. If the ambulance crew brings a CPR in progress to us, but the patient has no chance of reviving, we'll say they were pounding on a corpse.
If a patient stinks, we say they're diagnosed with acute shower deficit.
For obvious drug seekers, we say they have hypodilaudidism (dilaudid is a narcotic and a favorite request from drug seekers)
Other times, we're just insensitive assholes when privately discussing patients. When dealing with a morbidly obese patient complaining of leg pain with no injury, i went to the ER doc and said "so what could possibly be causing leg pain in a 400 pound patient? I think we have a medical mystery here. Like a case from House... will we ever crack this diagnosis?" It's shitty, but just being able to laugh at the surreal or ridiculous keeps us going
For a while I considered going into nursing myself, as a guy. What are some of the challenges working as a male nurse as opposed to a female nurse? One guy I knew went into nursing but found it incredibly challenging and quit shortly thereafter. I wasn't a close friend and never got to ask him why.
Do male nurses get treated differently by other nurses, patients or doctors?
Nursing it's one of the few careers where being a straight white male is a huge detriment. There is a constant vaguely hostile feeling from some older nurses and doctors . There's the pretty common questions of why are you a nurse? As if wanting a well-paying job where I can help people isn't reason enough.
During nursing school clinicals my instructors would go into a room before me and almost apologetically tell the patient that there was a male student nurse helping out today, and ask them if it would be okay with them if I took care of them. The female students did not get that treatment.
Once I graduated and started working as a nurse, there was a house rule, but not an official policy that a male nurse needs a female chaperone when doing a catheter on a female patient. There was not a similar rule for females doing a catheter on a male patient.
Working in an emergency department, or the ICU kind of take some of the heat off because there are a lot of male nurses in those departments. But if I wanted to switch over to labor and delivery, there would be a lot of obstacles to get through. Obstacles that women do not have to go through at all
The chaperone rules protects you as much as it protects that patient, honestly. But it should go both ways. I’m a female former nurse and always had at least a CNA in the room with me for anything involving the genitals on either sex because honestly, it’s just smart.
I always have an extra person in there for the help and the CYA aspect. But they didn't want guys doing female caths at all and then only with a female chaperone.
Do you ever try to fight the sexist culture or do you just put up with it? If the former, then any stories?
Nothing earth shattering really. In Nursing School, I started racing my clinical instructors into the rooms on my Labor and Delivery rotations. If I could get in first and just introduce myself as a nursing student instead of a MALE nursing student, then the patients were usually cool with accepting my care.
At work, I just ignore the "female nurses only" rules and started doing anything I was qualified to do in spite of my penis. I'd still get a tech to help with catheters, but I don't ask a female nurse to do the task for me.
What was the toughest situation you were able to save a patient from?
Septic patients are notoriously difficult to treat, especially once they progress past a certain point. One in particular stands out though. Elderly man from a bad nursing home was sent to us complaining of weakness, abdominal pain and fever (pretty standard so far). On arrival, he was breathing way too fast, cool, clammy, heart rate through the roof and blood pressure in the toilet.
We started the sepsis workup and treatments right away, but it was almost too late. We were dumping IV fluids into him but his blood pressure wouldn't stabilize. I just managed to hang pressors (very dangerous meds designed to constrict blood vessels and bring the blood pressure up) when he stopped breathing. At that point, we had to manually ventilate him and hope his heart didn't quit, then put a tube in his airway (which requires us to stop ventilating him for that procedure). By the time i got him to the ICU, I had six different medications going into five separate IV access points, and had to have him on a ventilator just so his breathing wouldn't get out. I honestly didn't expect him to survive the night oh, but I later heard that he had a full recovery and discharged a couple weeks later.
Shout out to respiratory therapists for their role in ventilating, tubing and life support management.
Agreed. Every code is barely controlled chaos, the success of which depends on the entire team.
That’s awesome, and congrats. Was pneumonia a concern for you when intubating or as a nurse was that not as concerning because you figured this is the only way to save his life?
I’m a nursing student in my first semester and critical thinking skills are being taught and it is very difficult to “think like a nurse.”
At that point, we just assumed he had pneumonia as well. Can't fix a guy who doesn't have an airway, so in went the tube and ALL the antibiotics.
Elderly man living in a nursing home. Sigh... When I got that stage I hope someone will not do all that to resuscitate me.
Get your DNR in order
How do you leave it all at work and not have nightmares when you have seen how awful humans can be to each other?
It used to bother me a lot more than it does now. I just realized at some point that no matter what I see, I can't take it personally. People are terrible, but can also be pretty amazing. Basically, as long as I do as much as I can for as long as I can, then I can't really affect the outcome much more than that.
It's an unfortunate side effect of being in this business for any length of time, but I'm definitely saltier than I used to be, and even though I will always treat a patient to the best of my abilities, some of them don't get the optimistic, gullible nurse that they wish they did.
When most of what you deal with are drug abusers, non-emergencies, or just people who generally can't cope with life, you start to really latch onto the genuine emergencies and people who actually need to be there. I really focus on those people in my mind, and don't let the others take up too much headspace.
How do you cope with the uncertainty of how a shift is going to go? Some nights, barely a soul comes in, only boredom. Other nights are nightmares of traffic accident polytrauma, bowel ischemia, myocardial infarction and being understaffed. Doesn't this get tougher as you age?
Short answer: alcohol and caffeine Long answer: those of us in this field tend to work hard, and play hard. When we're at work, we're totally present and committed, so while the slow nights can be nice, the nights where we're busy with genuinely sick patients who we can actually help are pretty great too.
When we're not at work, we play, tend our hobbies, drink too much, and generally recharge for the next duty run. It's that kind of clear separation that keeps us going
Why ER? Why not ICU, surgical nursing, or any other specialties?
First off, when I was fresh out of nursing school I did do two years of cardiac nursing, so I do have a good comparison to draw from.
Basically, I like the pace of the ER and the flow. Especially when compared to bedside nursing on the floors. The mindset required to take care of four to six patients for an entire 12 hour shift is something that I have but do not prefer over taking care of anywhere from 2 to 20 patients in that 12 hours. The pace is much faster, the nursing skills at least in a Hands-On sense are much more in-depth and necessary, and the light touch work such as sitting with a patient for 30 minutes and listening to them talk about their life is not required in the ER.
My wife is a nurse on a cardiac floor, and I always tell her that when it comes to actual nursing patient care, she has me beat hands down. I always get the credit for being a great nurse because I can start IVs and make splints and hang four drips at a time, but the actual soft touch parts arr what the patients remember and are the reasons that floor nurses get thank you cards and er's rarely do
Do you feel that cardiac nursing helped prepare you for ER? I’m a new grad nurse on a cardiac/telemetry unit and I have my eyes set on the ER :)
Any semi-acute experience is going to help you transition over. I was already in the ED and wanted to diversify my resume, so took a PDR cardiac job. I did two years then went back to ED exclusively.
Does it bug the crap out of you to watch shows like ER or a Grey’s Anatomy that have doctors and nurses sleeping with each other, unprotected sex and having supply room trysts? Does it irk you that people think this is a day in the life of a healthcare professional?
It doesn't really bother me, so much as amuse me. Anyone who works in a hospital knows that nothing about that place is sexy, and the idea of fucking in the supply room is just nasty. Not in a good way. The general public's misconceptions can be fun to mess with though if I can keep a straight face.
Have you been in a situation during your career that made you question your decision to be a nurse?
All the time. For every instance of heroically helping with directly saving a life, there are a dozen instances of being elbow deep in the yeasty folds of a bedridden patient trying and praying that you can get a straw-sized tube into the urethra so she quits peeing the bed. When you're wiping the ass of a patient with c-diff diarrhea, you truly learn how long you can hold your breath and can't help but wonder how your life would be different if you had just stayed a computer tech in a cubicle.
How come when you call report to the ICU, you never know anything about the patient other than their current vitals and H&P?
j/k!! We love our ED nurses!!
Well we're really busy tangling all those cords and lines for you. You can't expect us to ask about their home life when we're wrapping the Vanco line around the ET Tube.
How do you keep mental stability when people die?
First of all, you just can't take patient deaths personally. Ideally you're doing your best, so if someone dies it shouldn't be your fault. That being said, you can't help but think about some of them. Especially the kids. During any medical training, they talk about the importance of debriefing with peers and other professionals after traumatic events. In more than 10 years the only debriefing I've ever gone to was for a six year old who died in a car wreck. That one stuck with me for a while
What is the most stupid or infuriating person/incident you've encountered?
That's an extremely tough question to answer. Hard to narrow it down to just one. Some of the worst are those who know how to game the system. EMTALA is a law that basically states that when a patient presents to the ED, we have to evaluate them for emergent issues.
With that said, one patient does come to mind. A homeless male came in by ambulance with a complaint of altered mental status. He was clearly drunk, so we were letting him "metabolize too freedom" meaning when he was awake enough to walk (usually preceded by a request for a sandwich), we could let him go. Well he wasn't too excited about leaving the warm bed and started getting verbally abusive, so we had security escort him away.
An hour later, he came back complaining of chest pain. A chest pain workup on someone who doesn't have a heart issue, takes about 2 hours. So we did that song and dance, then discharged him again. He became verbally abusive again, threatened physical abuse again, So security was called again and he was escorted away.
Another hour passed and he came back saying he was suicidal now. If someone says that they are suicidal, then they are a mandatory hold until they can be evaluated by a mental health professional. After a certain point of the night, the MHP won't be in until the next morning, which means the person has to be held in the ER all night until they can be evaluated.
So, my point is the guy knew all the right things to say so that we would have to do certain workups, run certain tests, and eventually hold him all night. Bear in mind that there was nothing actually medically wrong with this guy, he just didn't want to stay in the homeless shelter that night. So he abused the system, got what he wanted, and didn't have to pay a dime for it, because it comes out of taxpayer money anyway. And bear in mind that while we are working on him, we are spending time away from patients who genuinely need help
If you're in the US, my understanding is that unpaid medical bills aren't paid by taxes, they're paid by raising costs for people who can pay, sort of like how shoplifting causes retail stores to raise prices.
So yes, technically paid by taxpayers, but not in the way that phrase implies
Yeah I'm more talking about the Medicaid abusers. Medicaid is a great program that I'm more than happy to pay my share of taxes into. But when it's abused, I can't help but feel the sting.
Ever have a case where you were convinced someone was faking and whoops they weren't?
Likewise, have you ever had a faker so good that they fooled you?
I've never thought someone was a faker and been wrong on anything serious. Fake seizures are ridiculously easy to spot and disprove, but pain fakers are tougher since pain is subjective and impossible to prove. That being said, the pain fakers/drug seekers have gotten to me and every time it just jades me a little more. Which is unfortunate for those in a genuine pain crisis, because they don't deserve and haven't earned my skepticism.
How prevalent is drug use among nurses and doctors?
I can't say for sure. I know it's an issue, but not any more than other high stress jobs. At least at my facility, we're all subject to random drug tests, and that's enough to keep most of us just using the legal vices.
I work as a respiratory therapist, usually in an ER or ICU setting. Am also a male, and I do come across some of the issues you’ve stated above about being male.
My question is how do you deal with patients that TRY to make it personal? I’m talking about the old lady who is obviously sick and cranky, and is taking it out on you by berating you and insulting your skills as a nurse. I recently had an encounter like this, and was on hour 10 of a 12 hour shift. It took everything I had to maintain my composure, but ultimately just gave her her breathing treatment and left without escalating. I’d imagine it would be harder to just walk away being her nurse.
Yeah people get bitchy, but it's just one of the things we have to deal with. If they're verbally abusive, I set boundaries and tell them it's not appropriate. If they keep it up, I get security involved. If it's just general cranky people, I do my job and get out of the room as quick as possible with as few things said as possible.
As a male RN in training myself through uni, i find it difficult to do my assessments (writing). And get low to poor grades. Having to repeat a few courses due to that.
I feel totally great, sceptically confident and natural on the ward floors for placements and scored 92% in my last practical assessment. Got some very lovely detailed positive feedback for that practical assessment.
Whats some tips for having the drive to get through the super sludgy part of uni and what is the major differences coming out of uni as a newgrad?
My advice would be to just jump through the hoops and don't argue with your instructors. They really don't care about your opinions and all you'll do is turn them against you. Every part of nursing school is just a hoop to jump through so you can get a job in the field and earn pretty decent money. Keep your mouth shut, jump through the hoops and get paid.
edit: And being a new grad, just consider it an extension of school for the first year. Take advice, internalize it, but don't argue it. Take the shit assignments without complaint. Ask for help and guidance, and advice. Once you get your feet under you, it's best to be remembered as someone who is humble and eager to work than a know-it-all new grad.
Are the hours as bad as some people make it seem? Or is that just a select few medical facilities giving everyone a bad rep?
I personally love the hours. Three 12 hour shifts per week is much preferable to five 8's. I think what people complain about is just the length of a 12 hour shift feels like it goes on forever sometimes. Do two weeks of work back to back 6 days on, 8 days off, and you can really feel like you're losing your mind.
Why did you pick the RN path instead of becoming a paramedic and staying in EMS? It seems like the EMT -> RN path is very common, or at least highly desired, and I've wondered why.
You seem too young, but I'll ask anyway if you've ever watched E.R., and if so, what do you think is the most inaccurate depictions from that show? What are the main influences in your life that led you to work in emergency medicine?
Initially I was going to go for paramedic, but after working as a tech in the ER for a couple years, the nurse is all kind of talked me into going into nursing. I had also not met many happy paramedics mostly because they get paid half of what a nurse does for doing similar work with an identical patient population. All of that kind of pushed me toward nursing instead.
I didn't really have any major influences to get me into EMS. I more just stumbled into it by taking first aid classes and then first responder classes, and I just liked them so much that I went for my EMT, which got me a job in the emergency department. Then the nurses talked me into going into nursing and here i am
As far as the show ER, a lot of their lingo and jargon the spot on though often times in the wrong place like they'll say "I need 50 ccs of ringers lactate stat" those words are all right, but the context is off. Ringers lactate are basic IV fluids that for an adult we given boluses of 500 to a thousand cc's at a time. We Infuse that over half an hour pretty commonly. So an ER doctor would never ask for 50 ccs. And it wouldn't be given as a push, but as a drip or bolus.
Other than that, every medical case on a show is adequately dramatic and complicated. Most of what we deal with in real life is pretty mundane
If you're honest with yourself is the primary reason you're in this career at all $$$?
That's kind of true for everyone though isn't it? If we could all get paid to do what we want, we'd all be naked on a beach with a drink in our hands right now.
If it was just about money, i would have stayed a computer tech and worked in a cubicle for similar money. Truly though, I genuinely like this field and the work (most days). The fact that i can get a better than living wage from my college degree is icing on the cake.
As far as getting treatment and cures, Do you believe mental illness is just as important as physical? Do they correlate in any way?
Mental health is hugely correlated with physical. This country still views mental health as a matter of will instead of a chemical imbalance so the resources are pretty limited. Add in to the fact that someone in a mental health crisis is going to take up the ER resources of three other patients and you start to see how it wears down caregivers and jades patients.
How much schooling is needed to become a nurse?
9-10 semesters...4-5 years depending on your credit load per semester and if you take summer/winter classes.
What country do you work in and how is it working there? Would you move to another country if they offered better pay?
I'm in the USA and not in the best paying region. I like where i live, and if i wanted, i could move somewhere else for a 50% raise at least. As it stands, i earn better than living wage in a place that i love, so more money isn't a huge incentive to move at this point in my life
What are you career plans for the next few years? Are you looking to become an NP (and where), move into administrative work, research/academic, continue to ride the variety of the ED, or something else entirely?
I'll go for NP eventually, but I'm gonna stick around the ED for a few years yet.
I'm always envious of the career options nurses have, especially ones like yourself who I feel have the drive and knowledge to really push themselves. Good luck in all of your future endeavors!
Thanks. It's really a great field.
Do you ever disagree with the doctor? I once took someone to the emergency room and everyone there was great - until the doctor came in and it was clear that they were the biggest asshole on the planet and placed their need to be a dick above their desire to actually help us. We had to go to another emergency room. I just remember the nurse (I think he was a nurse) having this expression on his face like he knew the doctor was crazy but wasn't allowed to say anything.
Yeah we disagree occasionally, but never work it out in front of the patient. I have apologized for doctors behavior before though
HOW often to hospital workers hook up? is it common for doctors and nurses to "mingle"?
It happens a lot, though not at the hospital as seen on tv. We're all a certain level of depraved that "the normals" have trouble dealing with sometimes, so we tend to hang together quite a bit. When i was a tech, i hooked up with several nurses from other departments, but when i became a nurse, i got married almost right away, so can't speak to docs and nurses getting together.
If you became the national person that can determine one healthcare policy or act..what would you chose for everyone in the US to train or be knowledgeable about? (aside from universal healthcare)
Mental health issues (assuming there is infrastructure in place to make mental health a priority in this country). Barring that, I'd like the public to know what qualifies for an ER visit. Really cut down on the toe pain complaints.
Why are we letting new grads start in the ER? For pt safty, should we not start them on the floor to gain the concepts of nursing? I like baptism by fire but not when peoples lives are at stake.
It's tough to get into the ER as a new grad. I was a special case since I'd worked in the department for five years before. Even with that experience, I was in over my head every now and then. For someone to start there with no previous experience can be a bad idea for sure.
I’ve heard pretty rough stories of people in the ER from motorcycle accidents. Have you seen any yourself? Any words you would say to people who ride?
Yeah I saw a guy who hit a car that turned in front of him. He went over the handlebars, broke both arms and legs and just peeled his face off...he didn't make it. Advice: Wear a helmet and always assume that cars can't see you. If it's you vs. them, you'll lose.
Any horror stories that happened while you’re working ?
Too many to count. They usually involve dead kids or violent psych patients. Opposite ends of the spectrum on my empathy but equally draining.
Not sure what you mean by spooky. If you're talking supernatural stuff, not that i recall
As marijuana has become more acceptable and widely used, have you seen many cases of cannabinoid hyperemesis syndrome in the ER?
Happens all the time. The hardest part of treating them is convincing them that it's their weed that caused it.
Hi,Thank you for your work! I (embarrassingly)have to call ambulance nearly once a year,Last year with suspicion of TIA. I know I have tendencies of hypochondria.I worry too much. But as over 50 years old,I encounter unexpected symptoms recently.
I don’t know which is which until I ask Doctors.(Edit:So I call non-emergency medical number first,and they refer me emergency..)
Some nurses and doctors treats me very kind,also there are not kind people.I’m not faking illness.(Actually hospitalized 5days for Ischemic Colitis.2years before,most recently) You meet my type of people in ER,for sure,how do you figure out “It’s serious or not”?
(Edit:I live in Japan,ambulances are not pricey but I don’t abuse.I consult non-emergency medical number first)
The serious vs. Not serious assessment begins as soon as you walk through the door. An experienced nurse will be able to tell pretty much at a glance if you're sick or not. Some baseline vitals are going to help with that as well. If you look like you're sick, you kind of get fast-tracked to the back. From there we'll do all the lab work and studies to verify.
But from the sounds of it, someone like you who seeks non-emergent help first isn't the kind of person we consider a problem. The kind of people that we glance at and roll our eyes, and just trudge through our jobs for are the types who show up several times a month, come in for non-emergent complaints all the time, and just generally abuse the emergency system.
Recently, one of our frequent fliers came in because she had vomited twice in one day. No abdominal pain, no bloody vomit, no dizziness or other problems. Just threw up twice and is vitally stable. That is the epitome of a non emergent, unnecessary ER visit
Do your team really stick to your job scope? I mean doctors diagnose and gives management plan, nurses carry out management plan and jobs dont overlap. I am not sure hows your working culture in your country because its a norm in my country that junior doctors are bullied to do almost anything under the sun including taking blood, setting up ivs, sending blood to lab, taking vitals, setting ryles tube, urinary catheter sometime changing bed sheets.
There's some overlap within scope. For instance, the nurses can place certain orders if a patient meets criteria. The docs tend to stick to their jobs, but there's a bit of overlap among nurses and techs where either can start an iv, make a splint or clean a room
Is it true that nurses eat their young? As in, a lot of hazing is directed towards new nurses from senior staff, with the mentality of "if they can't take this, they shouldn't be in this profession."
That's what my friend told me when she first started.
Kind of depends on the facility and department. I've heard it can be a problem, but i only experienced it rarely and in pretty mild forms. I know people who got bullied so hard they quit entirely though, so it's case by case
With all the beeping, how do you determine an emergency from what seems like a lot of false alarms?
The last time I was in the ER, I had telemetry, and the monitor (the computer screen behind me) kept saying the lead was coming off. It was losing contact every other second and kept beeping. When I used the call button, they told me they weren't worried about it.
So many things beeping.
Do you think things are missed? Or do you guys know which beeps are important?
And how much do you rely on family members to tell you if someone is worsening? I have kind of a weird family situation that I don't even understand myself where the ER is kryptonite to them so when I have had to go, I've had to go alone which is really hard. I sometimes think that the staff in the hospital might count on a family member being there to alert them to something since the monitors seem sort of like car alarms—they go off so often that people don't pay attention to them.
Also, is there ever a time in the ER when there are too many doctors or nurses working? In my experience, it seems like there are always too few so that at the end of the visit (if you're being discharged) you get 1-2 minutes with the ER doctor and he/she can just unilaterally end it by walking out the door because they have other patients. One time when they were listening to my chest to take deep breaths they said I needed to breathe faster because they had other patients to get to. But I have this thing where I have unusually large lungs and hypoventilation. If I do deep and fast, I nearly pass out. I get that the ER is for the worst of the worst, but in reality there are a lot of people there for less than the worst of the worst. With how much money ERs must bring in for hospitals, it always seems like there's just too few doctors.
Also, have you ever seen a patient discharged by a doctor when in your opinion they should have been admitted?
The last time I was there, as I was leaving my pulse on standing went to the 140s and stayed there and BP was 150/100. I was out of breath and had to leave by wheelchair. The triage nurse who took me in looked worried. The other nurse went to ask the doctor if he still thought it was OK for me to leave with my stats and he did but didn't come back. Obviously they can't disagree with the doctor openly, but I got the sense that they perhaps did.
Alarm fatigue is a real thing. Thankfully the real serious alarms have a different sound because we all just kind of tune out the usual beeps and boops.
Family can be helpful or a total hindrance depending on their knowledge of the flow of the ED.
Overstaffing only exists to senior leadership. They have no concept of what it means to have to plan for a what-if scenario and expect us to run on a skeleton crew, which just isn't safe.
We've got a good group of Docs at my ER, so I don't see someone discharged that often who I would have kept. I can pretty well predict when a patient will bounce back though whether it's medically necessary or not.
I’m a male going through nursing school. I love the program and I’m always proud of how well I know my health assessment. However, school is just so much and we’re always talking about getting sued which is sometimes feel discouraging . My question is while you were in nursing school have you ever sometimes felt like giving up?
Only every day. Look to the prize. And look at what happens to all the people you know with useless degrees. Stay strong and jump through the hoops
4+ years as a male RN
Did your coworkers treat you differently after your gender reassignment?
Ha! funny thing is you don't have to give a gender differentiation when you're an EMT. It only matters when you're a "Male Nurse"
Probably because you're idea of respect is different from reality.
Do you find yourself and co-workers making more glib jokes and I guess gallows humor to help you cope with the nature of the job? I know many cops and EMTs often do this as a sort of mechanism to distract from the heaviness they can experience.
So to that point, got any good instances of this kind of humor?
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