A28 year old female patient presents to your emergency room. Her “friend” drove her to the hospital. It’s a cold, windy, snowy night. And no this isn’t a murder mystery 😃. The friend drags her in the door, and drops her in the chair at the registration desk, tosses her purse on the floor and mumbles something about moving the car, and then disappears. The registration clerk, sticks her head in the door and hollers for help. You bring stretcher to door and list the patient to the stretcher, with a little help, she a bit overweight.
You roll into the trauma bay, doing all the things, you’ve been trained to do. Airway, breathing, circulation, disability and expose.
A -Airway. Pt’s airway patent
Breathing – BBS, low tidal volume, rate 8
Circulation – no palp, radial pulse, weak shallow carotids, BP 74/P
Disability. Unresponsive to painful stimuli, GCS 3
Exposé – pt’s clothes cut of, no signs of trauma.
Pt has no gag reflex, oral airway placed and pt respiration assisted with BVM. In the mean time staff is going throu her purse and find.
1. A suicide note
2. An empty bottle of metoprolol with someone else’s name on it.
3. An empty bottle of verapamil
4. An empty bottle of 10/500 Lortabs filled yesterday afternoon, again with someone else’s name on it. (90 dispensed)
5. One empty bottle of elavil, 90 day supply, this was actually the patients prescription.
You have 2 nurses, 1 PA, 5 beds, a co -ocated paramedic unit. The paramedic on duty stuck his head in the door and said the weather is to bad, the heel opted is grounded and the interstate is closed. Not transport available. This is a 25 bed critical access hospital. Both RN’s are CEN’s.
Sound a bit far fetched? Sorry this is a real patient and real scenario. In this case one RN was also a CCRN with ICU and flight experience.
Total time in ED For this patient 26 hours till interstate was open and pt was able to make 2 hour transport to tertiary care facility.
The purpose of this blog and this scenario is to focus on the critical care education that is needed by ED nurses in today’s environment. It’s not enough to know what to do, but we have to know why we do it and how it works.
Ok now back to the scenario.
In this case we already know she is going to make us work to hard.
The PA wasn’t credentialiad for central lines, so all treatment was done with PIV’s.
By the time we were done, she had 8 IV’s, including a large bore EJ.
Bicard Drip, Insulin drip, Glucogon drip. (For some reason there was a full box of glucogon in the pharmacy, I think someone had ment to order a box and mistakenly ordered a case), Pressors, and fluids running. Pt intubated, on vent (no resp therapy) foley, NG tube. Since the there was possibility of ER, we perfeormed aggreasive bowel decontamination,
The knowlege of the 2 nurses, with their specialty certifications as an indication of their knowldge or one of the primary reaons the patient was discharged from the hospital. All to often an ED nurses education ends with the minumum level of information to get the job done. ED nurses have a broad scope of knowledge and skills, but adding critical care education adds depth. The depth that can make the difference in our patients outcome.