4th week at ED.. it's hell, we should be called gods of labor

[tarotale]

Wow, ED is where it is at! I am on my 4th week of internship, of which the 2 were didactic. Originally as a MS nurse, I can't hide my shock at how much crap one nurse is responsible of at the ED. I am close to getting crazy at this place. I knew ED was busy, but MAN, there really is NO TIME to chart, let alone sit down.

exemplary scenario: old, confused, febrile 80y/o pt with dung caked all over her perineal area, her bp 70/40, obvious sepsis, having to get blood cultures, ivs, lab works, notifying docs, etc etc... and I haven't even asked anything to the family about her hx or assessed her properly yet, then another EMS stretcher rolls in next door, this time numbness/tingling, not as critical but having to do all the work plus ekg, then another doc gives stat ekg order for a pt in other room whose K+ comes back 6.5. I haven't updated vitals on anyone yet, got a pt to discharge, UAs pending which I totally forgot about until my preceptor reminded me, and my bladder is about to burst.

At this point, I am telling my preceptor "how the hell can you do all this?" Oh ya, I haven't charted anything yet. There is no help either. The charting system sucks( meditech.. piece of crap). It's so busy and fast pace that I forget things unless preceptor reminds me. I am so darn scared when I am by myself that I will kill someone or forget to report something or just get backed and behind, that I will start missing tons of things.

I remember sitting on my rear on obs floor when I wasn't busy, just chilling after 2100 meds. Here, I am running around and brain sparking all 12 hours. Maybe it's just anxiety of being overwhelmed at new place, but I don't think there is any department busier than ED.

If you have quick tips on how you survived, and how you managed to remember things, and just ER tips, throw it at me, cuz I need them. Thanks, and dang we rock.

[tarotale]

I have not used Meditech....but are you able to associate the patient to the room that way vitals will automatically download when you click the time in the computer?

and I have determined that maybe it's a sign of a facility that try to be cheap butts, cuz meditech is grossly outdated.

in each pod there are two nursing stations, and funnily enough, only one desk has monitor to see remotely those auto vitals at nursing station. if you are unlucky one assigned to side that doesn't have the monitor, then ya you need to get up and observe vs, and that stinks. every minute saved in ER is a minute that you will desperately need when doo doo hits the ceiling I learned!

we do hook them up on monitor and auto time interval q 30 min, but at this point, it's even hard to chart those as I have hard time even keeping up with q2hr vitals. I do try my best to chart as I go, but when everyone is expected to chart even stupid details like "IV start time and stop time" when simply that can be found on the eMar (which is double charting)... the charting system really doesn't help one bit. I would say out of 10 times, maybe about only 3 or 4 times we would get help, or at least as it seems. I am actually night shift and I hope once I move into it, there will be more help? My preceptor and I always pop into rooms that get EMS whether they are ours or not just to help out, but I don't see that happening from others all the time it seems. The challenge seems pretty clear.

Listen, I'm going to try to be gentle but simultaneously blunt... if it angers you, you have my apologies because that is not my intent but...

auto time interval q 30 min... it's even hard to chart those as I have hard time even keeping up with q2hr vital

So it's hard... you'd better figure it out pretty quickly because it's also vital (which came out spontaneously before I recognized that we're talking about vital signs)... I promise you, if you don't get the hang of regular vitals, you're going to get hung out to dry when a patient *was* stable on your fly-by 10 minutes ago and then crumps immediately after... you know that you were monitoring them closely and it was just one of those things but your charting says that you were ignoring them... this isn't a place you want to be and all your protestations will fall on deaf ears...

I do try my best to chart as I go, but...

When your introductory clause is followed by "but," you're on shaky ground... the word "but" is shortened from "rebut" which is to say, "the preceding is what I say... here's what I actually think, though"... or it's a shortened version of "butt" which is what you'll feel like when your patient crumps and your charting is not up-to-date.

Even abbreviated and simple notes, which take very little time, can give you some back-up when you say, "hey, I was monitoring the patient, we were crazy busy, I didn't have time for the thorough charting but I saw them 10 minutes beforfe and they were awake, alert, oriented."

To quote Yoda: "Do, or do not... there is no try."

~~~

Help on the NOC shift... maybe... our NOC crew seems a little tighter than the day crew, primarily, I think, because it tends to be newer people. However, NOC crew also runs lighter and when the crapola hits, sometimes there's simply no bandwidth to provide help.

~~~

One other admonition: Avoid the tendency to criticize the system... some of the saltier ones (Navy/Marine term describing those who've been at it for a long time) might have the attitude that you haven't yet earned the right to complain.

~~~

Take comfort in the knowledge that you will get faster and more knowledgeable. Success in the busy ED relies on moment-by-moment reassessment and reprioritization.

[tarotale]

Listen, I'm going to try to be gentle but simultaneously blunt... if it angers you, you have my apologies because that is not my intent but...

So it's hard... you'd better figure it out pretty quickly because it's also vital (which came out spontaneously before I recognized that we're talking about vital signs)... I promise you, if you don't get the hang of regular vitals, you're going to get hung out to dry when a patient *was* stable on your fly-by 10 minutes ago and then crumps immediately after... you know that you were monitoring them closely and it was just one of those things but your charting says that you were ignoring them... this isn't a place you want to be and all your protestations will fall on deaf ears...

When your introductory clause is followed by "but," you're on shaky ground... the word "but" is shortened from "rebut" which is to say, "the preceding is what I say... here's what I actually think, though"... or it's a shortened version of "butt" which is what you'll feel like when your patient crumps and your charting is not up-to-date.

Even abbreviated and simple notes, which take very little time, can give you some back-up when you say, "hey, I was monitoring the patient, we were crazy busy, I didn't have time for the thorough charting but I saw them 10 minutes beforfe and they were awake, alert, oriented."

To quote Yoda: "Do, or do not... there is no try."

~~~

Help on the NOC shift... maybe... our NOC crew seems a little tighter than the day crew, primarily, I think, because it tends to be newer people. However, NOC crew also runs lighter and when the crapola hits, sometimes there's simply no bandwidth to provide help.

~~~

One other admonition: Avoid the tendency to criticize the system... some of the saltier ones (Navy/Marine term describing those who've been at it for a long time) might have the attitude that you haven't yet earned the right to complain.

~~~

Take comfort in the knowledge that you will get faster and more knowledgeable. Success in the busy ED relies on moment-by-moment reassessment and reprioritization.

Good advice for newbie thanks. I know it will take awhile to get it but I will get there hopefully in a year

[applesxoranges, BSN, RN]

Having good support is everything. Without ancillary support, your job can get 100 times harder. At my old job where I was the ancillary staff, I usually did a lot work such as I had about 75% of the patients IVs started and blood drawn (easier to keep track because we had handhelds), transportation, and helped out with cleaning up patients with the RN. Here I am the only one because I cannot find my paramedic ever because she does not carry her phone (I found the phone in the box where the phones are kept). Not to mention we have five patients with no sense of balance for acuity and all of the triage stuff has to be done by the RN because the medics feel like they don't have to do the back half. The charting system sucks because it pulls from the triage data and won't update so when the doctors do their stuff, it has to be done beforehand.

So good ancillary staff is a must. At my old job, we had a phleb 1 pm to 1 am, a paramedic 7pm to 7 am, a patient care tech 8 pm to 3 am (used to be 9 to 5). Now we have paramedics that we cannot find that work weird hours. It wouldn't be so bad if we had four patients to an RN like they used to but when you have to do everything including blood work and sometimes transportation, it sucks.

Sometimes other nurses will pitch in when they can. I had a paramedic the other night who played on her phone as another RN came into start an IV. Why didn't she come in? Because the other RN couldn't get it so she knew she wouldn't.

When I filled in as a paramedic, I understand why the charge for the night was excited because I made an effort to look at boards and to get stuff done. I took patients up, cleaned rooms, tried to get IVs, made sure people knew my number, asked and offered to help frequently.

[tarotale]

Having good support is everything. Without ancillary support, your job can get 100 times harder. At my old job where I was the ancillary staff, I usually did a lot work such as I had about 75% of the patients IVs started and blood drawn (easier to keep track because we had handhelds), transportation, and helped out with cleaning up patients with the RN. Here I am the only one because I cannot find my paramedic ever because she does not carry her phone (I found the phone in the box where the phones are kept). Not to mention we have five patients with no sense of balance for acuity and all of the triage stuff has to be done by the RN because the medics feel like they don't have to do the back half. The charting system sucks because it pulls from the triage data and won't update so when the doctors do their stuff, it has to be done beforehand.

So good ancillary staff is a must. At my old job, we had a phleb 1 pm to 1 am, a paramedic 7pm to 7 am, a patient care tech 8 pm to 3 am (used to be 9 to 5). Now we have paramedics that we cannot find that work weird hours. It wouldn't be so bad if we had four patients to an RN like they used to but when you have to do everything including blood work and sometimes transportation, it sucks.

Sometimes other nurses will pitch in when they can. I had a paramedic the other night who played on her phone as another RN came into start an IV. Why didn't she come in? Because the other RN couldn't get it so she knew she wouldn't.

When I filled in as a paramedic, I understand why the charge for the night was excited because I made an effort to look at boards and to get stuff done. I took patients up, cleaned rooms, tried to get IVs, made sure people knew my number, asked and offered to help frequently.

that will be infuriating to see others play around when rns are working so hard! I know I am new in ED so can't really talk over people but if I had gotten some salt in me (for reference, see poster above :)) I would've gotten on to that medic for being lazy jack.

Our ED is really busy and the support seems to be lacking esp when dung hits the ceiling b/c medics are being pulled here and there all the time (I barely see my medics) so technically I think 95% of works are being done by RNs. Our manager just did some interviews for RNs and medics, so I hope to God we get some help! When that EMS keeps rolling in and I got other stuff to do, or triage keeps throwing people in your rooms without doing triage charting, I'm seriously disturbed.

BTW, obviously you worked in other ERs before, so what do you think makes the ED which hires more ancillary and support staff like techs and medis? Is it Magnet status, or just the hospital culture? Rich hospitals and system with $$$??? Thanks and Let me know!

[RedInScrubs, ASN, RN]

I totally admire ER nurses, bless their crazy souls. I could not do what you all do.

Only thing I wish I could change is their busyness getting in the way of calling up and giving report BEFORE sending up a patient up to the floor.. Like I don't enjoy walking in a room after being handed a slip with nothing but a name on it, asking the patient why they're here, and then run and get a stat blood glucose because the patient says "My blood sugar was low. They made me come here." I also don't like getting a big ol' 32 when I take their blood sugar, because they've been sitting there for a half hour and no one called up report, so I have to call down.

Be kind. Give report, no matter how busy you are, ER angels of awesomeness.

[tarotale]

I totally admire ER nurses, bless their crazy souls. I could not do what you all do.

Only thing I wish I could change is their busyness getting in the way of calling up and giving report BEFORE sending up a patient up to the floor.. Like I don't enjoy walking in a room after being handed a slip with nothing but a name on it, asking the patient why they're here, and then run and get a stat blood glucose because the patient says "My blood sugar was low. They made me come here." I also don't like getting a big ol' 32 when I take their blood sugar, because they've been sitting there for a half hour and no one called up report, so I have to call down.

Be kind. Give report, no matter how busy you are, ER angels of awesomeness.

I totally can vouch for you since I have been a floor nurse myself... I have always been really understanding type to ER nurses when I was at MS because I knew they were exceptionally busy department, so no med rec done, pt came with little bit of stool or pee pee (as long as not code brown), little things not done here and there, it was fine, ya but that bs of 32 sounds pretty bad lol.

One thing I noticed down here at ED was that it is so busy that even pertinent things like checking blood sugar gets pushed back to other priorities. If the pt is stable and shows no complaints of hypoglycemia, but I know she has DM and needs to check, but got other important crap to take care of, that sugar check goes far behind the list. The critical thinking and prioritization is few of if not the most important skills at ED (sense of humor and alcoholism maybe equally third place haha). I remember I at least had time to do things on the floor... actually there were lots of times; there are busy moments in floor definitely and I remember they can wreck our brains, but I see that at ED, it's busy ALL THE TIME, so much that I have to write down on my paper that I need to chart whatever I did lol (rarely get to sit down after assx or interventions).

I think ED makes one of the best nurses, not to put down ms or floors, but I have been a floor nurse, and the intensity, prioritization, work load, stress level, skills, critical care management, thinking, etc is just cannot be on the same level. Redinscrub I don't see any reason you can't do ED. I mean ya there are people who for some reason just can't follow up with the work load and quit, but that's rare; that's why they call ER sink or swim. You should try it out here. Be good to your ER nurses, I love it when floor nurses are nice to me :)

I could not do what you all do.

Likewise.

Only thing I wish I could change is their busyness getting in the way of calling up and giving report BEFORE sending up a patient up to the floor.

Some places, it's the norm... other places, like mine, ain't gonna happen.

I also don't like getting a big ol' 32 when I take their blood sugar

That's not a matter of report, that's a matter of deficient nursing care on the part of the ED nurse.

no one called up report, so I have to call down.

This has been hashed over on other threads but that's just not how it goes where we are... and in our case, there's a summary report on EMR that can tell you what you need to know better than I can tell you.

Sending an unstable patient up to the floor, and bg=32 counts, ain't OK... no way, no how...

Unless there's an exceptional circumstance, I don't give report -- but I do expect my patient not to get anything for 30 minutes after they arrive so I assess and intervene accordingly. If the patient ain't ready to roll, they're not going -- despite my charge nurse busting my cajones to get 'em OTF.

[sandyfeet]

Couple of tips...

Does meditech have something like 'acronym expansion'? I use SCM and will use the acronym $discharged that the system writes out as "Patient AOx4, respirations even and unlabored. Patient states pain level tolerable to leave facility at this time" and use that on my discharge note. Little things like this save only seconds, but over 12 hours it adds up!

When I first started, it was hard for me to get a patient history unless I was standing still and looking the patient right in the eyes. BIG time sucker. Now I get history while hooking them up to the monitor. If they are vomiting I get history while starting the IV. You get the idea. Before I leave the room I make sure to chart and then I might say "I just want to clarify, you said your symptoms started yesterday?" or something to that nature.

When you are new and have a preceptor, other nurses usually won't help you out for two reasons. One, you already have two nurses to cover one patient load, so you technically already have "help". Two, when you are new is the time to struggle, figure out your rhythm, figure out your resources. You can't start out relying on other people's help. All of this does not include Level 2 ESI or higher. If your co-workers are not helping you during acute strokes or full arrests there is something wrong.

It gets better but these are the rough times!

[RN_rescue_ninja]

Delegate to techs as much as possible within reason. Also, unless there's no other logical option, getting two trucks back to back like that is not cool. I'd be speaking to someone about that...

[uRNmyway, ASN, RN]

Is it weird that this makes me jealous? Lol... I've been thinking lately that I should start applying for ED positions, I often work so darn hard as it is, I can't help but feel I might as well have the glory and excitement of ED to go with it.

OP, I'm sure it will get easier when you get used to it. Just try to chart as you go, like others said, making sure to CYA is really important.