Difficult night, heavy trauma/high acuity... vent/insight - page 2

by MassED 5,216 Views | 14 Comments Guide

Hi All, very busy time of year in a level 1 ER. Being summer, huge volumes of tourists = a tough time for all. As per typical, I have changed some scenarios/events to protect privacy. I would like to first write after a... Read More


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    I actually feel a sense of relief and a bit of anxiety reading everyone's posts: seems the ED situation is on the same downward spiral everywhere. I've been in emergency nursing for about 5 years now and every time we have "the night of horror" - thinking it's the worst shift in our careers - another night comes along to claim the #1 spot. In all fairness to my current employer, this is by far the best ED I've been in thus far in terms of having an awesome team, adequate supplies, and a supportive/involved nurse manager. The biggest thing we hear about though is patient satisfaction scores because of its relevance to reimbursement now. Budgets are tighter, the sick patients are sicker, pts/families are more demanding, and there is a never ending tidal wave of inappropriate ED usage. Last night patients/families were all so upset and angry (guess who? the level 4's and 5's)...The nursing supervisor actually had to get involved because - as we have all the trauma bays full, 5 rigs en route (2 of which were priority 1's), a STEMI and a sepsis alert via triage, all the hall beds full - a guy was raising heck about his girlfriend not getting "treated" immediatedly for constipation!!! I have nothing to offer as far as solutions go...we dig in our heels, forget the meaning of the words 'lunch' and 'bathroom', and do the best we can. We file complaints and have meetings etc but I truly believe that when lack of reimbursement due to consistantly low patient satisfaction scores starts to hurt administration's bottom line, some changes will be forthcoming (ie K+MgSO4 above: objective data). Of all the specialties I've worked in over the past 17 years, I love the ED the most but it also frequently makes me seriously consider a complete change of careers. We are certainly in the trenches so to speak...my respect goes out - as well as my prayers- to all my fellow ED nurses. I'm proud to be a part of the team and know, no matter how bad it gets, we make a difference in someone's life every single day. Maybe together, as a specialty, we can all work toward a REAL healthcare reform solution.
    MassED likes this.
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    Quote from Dixielee
    What a great thread that speaks to me! I, too, have been an ED nurse for many, many years and know that my time in ED is coming to a close soon. I don't think this is just a summer problem and it will end in a few months. I think it is here for the long haul for a number of reasons. The economy in general is in shreds. Everyone is tightening their belt just for survival. Gas costs are up, food costs are up, taxes are up, so it is no surprise that health care costs are up, reimbursements are down, and cuts are being made at every level.

    I work in a very busy ED 120,000+ per year. We are in better shape than others I have seen on this forum in terms of staffing. I really DO believe our ED management is doing the very best they can. They are not above coming in on holidays, nights or just horrible shifts to help out. They don't take patients, but will transport, start lines, make runs to the lab, and order pizza for us! But it is still very quickly taking it's toll on everyone.

    At peak times, we have 2 triage nurses, 2 triage techs and a "greeter" nurse who does a quick screen to decide if the patient is appropriate for fast track, needs to go to the main ED quickly without triage, or can safely be triaged and wait for a room to open. We have 4-5 hour waits every evening with 40 or so in the waiting room at one time. These are the ones who are too sick for fast track but not sick enough for the main ED immediately, so they are our level 3 patients...urgent.

    At any given time we have 8-10 trucks inbound with the sick and injured, or 1-2 helicopters on the way in or out. We are a regional trauma center so we get transfers from all local hospitals within a 100 mile radius. It never, ever ends.

    The floors or ICU can say, "Stop, we have no more beds". We never have that luxury, and being a referral center, we can never go on ambulance divert. The psych issues are becoming more and more of a problem and a danger to staff and other patients. We can't get psych patients transferred many times for days or a week. We have to staff extra police and security just for them, plus additional staff as sitters because of the danger they present. We are seeing more and more homeless with huge medical, psych and of course social issues. We can't send them anywhere, so we are the end of the line for many of them, their last resource, and we are stuck.

    Then, you have the "real" ED patients, i.e. MI's, traumas, strokes, general medical, orthopedic or surgical patients. Even with a 3:1 ratio on the acute care side with no available floats, it is a scary place to work. When you are tied up with a critical ICU patient who is not going to surgery or cath lab, you can't get out of the room to even admit your MI patient, or your new drug overdose. Oh, and your "stable" drunk hall patient who is there to sleep it off, but doesn't! He wanders in and out of patient rooms looking for something to eat.

    Then the mother of the bratty febrile kid gets mad at you because you won't blow up gloves for the kid to play with! AGGGGGG! Lunch?? OK, in my 12 bed pod, I have my 4 patients, 4 patients of the nurse who went to lunch, and the 3 patients for the nurse who had to go to special procedures with her critical patient. Then they ask you to hold the charge phone while the charge nurse goes to a meeting!!

    No, I don't think this is a passing problem that will be resolved anytime in the foreseeable future. What will healthcare "reform" bring? More nurses, less patients?? I don't think so. I pray for those going into the profession, I pray for those of us still in it and mostly, I pray for our patients, current and future who are getting less than they need.

    After 38 years of acute care, primarily ED nursing, I'm ready to sit in a cubicle in an air conditioned environment, be around people who bathe everyday, and talk to people on the phone about their insurance coverage and if their particular ailment is covered. I will miss the patients, the other staff who share the "we're all in this together" battlefield attitude, the great ED stories, the adrenaline rush and the exhilaration of making an immediate difference in someone's life. I will miss the gratitude of the child who was afraid, but I was able to soothe their fears, the little old lady who recently lost her husband and came to the ED after a fall who gives me a kiss on my hand for taking care of her wounds, the raucous pizza dinners in the break room with those who understand, but I just can't do this much longer.

    To all those new, fresh faced new grads who read these forums and ask, "Am I cut out for the ED?" I can only answer, "I certainly do hope so!"
    You've been in the ED for 38 years? Geeez, I know I won't last that long at this pace. No way. I don't think anyone could. I think for some, leaving the ER would bring a fear of boredom, perhaps? I think, "Boredom? Bring it on!" I can deal with that, so can my feet, my knees, and my BACK. Most of all, my brain and psyche can deal with that. Boredom doesn't lead to burnout, but verbal/physical/emotional abuse, lack of pee breaks and food breaks sure do!!
    Last edit by MassED on Jul 23, '12
    Dixielee likes this.
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    Quote from hiddencatRN
    It seems like staffing is a major issue. Are there just not nurses willing to work nights or do they not want to staff well? What would happen if EVERYONE working nights just started filling out incident reports EVERY time care was delayed due to volume/short staffing? Like, it takes you an hour to get in to a minor patient to give motrin or something? In the incident report you can indicate that you were in xyz rooms handling whatever priority. Your risk management department might take notice of staffing issues and lawsuit risk if you all do enough of them en masse. Draw attention to the potential sentinel events.And you say staff has tried to address understaffing with the bosses...but how high up the chain have you gone? Hospital CEO? Local media? I guess what you need to decide is how much of a fight you want to put up versus how much you'd rather wash your hands of it. Ultimately, I'm not sure how much you'd accomplish alone, but if everyone else is ready to revolt, who knows?
    I think this is why so many of us are talking union. Not that it is the answer, but we're grasping at this point. For me to remember every bit of what I'm running around doing to actually write up an incident report would be a miracle. I need a real time low jack to track what I'm doing and what room I'm going to, then at the end of the night shift, I could go back and recall what time I was where, etc. That's actually a really good idea, now that I think of it. Hmmm. I have to actually psyche myself up to get my game face/game mood on just to think about going to work right now. I go to the store thinking of what can I snack on without a break, what drinks will give me energy and give me a bit to look forward to. Isn't that ridiculous? Coffee is a treat halfway through my shift, and you have to find your silver lining somewhere!
    Dixielee likes this.
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    Quote from opossum
    These posts sound like my night last week in the ED - I'm a per diem "float" (don't get me started...) who is now cross-training for the ED after doing mostly ICU and Med-Surg. I've been working as a nurse for a little over a year and I always thought I wanted to do ED nursing. Now...I'm not so sure.

    One night last week was just too much for me - we went on ambulance diversion, we were simply packed. Most of the patients in my zone were not critical, just urgent - painful gout attack, broken nose, CP w/normal EKG and troponins....I felt like I was doing damage control the whole night and just got it from both ends. How do we advocate for patients who haven't seen in a doc in 4hrs because there is a cardiac arrest that just came in?

    How do we explain the concept of triage to less-critical patients in the Almighty Customer Service mindset? I just don't think it's possible, and I'm not sure I want to be a part of it anymore
    That's just it. We DO educate on how we triage (or I do, anyway), and when our trauma rooms are full tilt, I tell my patients WHY they are waiting. I explain that there's an emergency that is requiring ALL of our doctors right now, and that is why the wait. Of course, you always get the "how long?" I tell them, that's just it, it's an emergency room, and if an ambulance comes in, or somebody comes in that is emergent, everyone else is bumped. That's just how it works. People may get mad, and they do, but I don't have patience for those that don't understand, even after I have painfully explained in simple terms. Some people never do understand (or want to understand), and it's usually those that have urgent care type complaints who could be seen by their PCP or urgent care and chose not to. I make sure I have AMA or LWOBS forms for them to sign, should they choose, and always explain that to them that they don't have to stay, that they are not being held against their will. Those that are truly sick and need to see a doctor OFTEN (not always, well the family may not be understanding) are the most understanding.
    opossum likes this.
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    Quoted MassED: You've been in the ED for 38 years? Geeez, I know I won't last that long at this pace. No way. I don't think anyone could. I think for some, leaving the ER would bring a fear of boredom, perhaps? I think, "Boredom? Bring it on!" I can deal with that, so can my feet, my knees, and my BACK. Most of all, my brain and psyche can deal with that. Boredom doesn't lead to burnout, but verbal/physical/emotional abuse, lack of pee breaks and food breaks sure do!!

    I think working ED has actually kept me healthier because I am sure I have been exposed to everything in the book! It is now to the point where I fear for my patient's safety because of the workload and I fear for my own safety because of the increase in violent behavior of patients.

    As far as lunch.....I can't tell you how many meals on the run have consisted of chicken strips and tater tots because they are portable and fit in your pocket!! I know, gross, but you do what you have to

    Best of luck to all of us as we carry on, doing the best we can.
    MassED, opossum, and corky1272RN like this.


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