Difficult night, heavy trauma/high acuity... vent/insight

  1. 5
    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 few days of reflection, that there are those that are experiencing the worst moments of their lives and my shift, no matter how horrible, cannot compare, and I don't mean to suggest that it does.

    Beginning my shift, I triaged a patient who fell. My first inclination was to put him in the trauma room, but given his minor amount of pain, EMS stated a question of an ankle injury, but it was wrapped and I had not a moment to take it down. Mistake number 1.

    A doc saw the patient within 5 minutes in a hallway space, found an open ankle, likely tib fib. Straight to the OR. Yeah, way to go RN (me). I felt like such a dolt for having misplaced and essentially lower triaged this person. Way to start the shift.

    Literally, and I do mean literally, I triaged EVERY person coming through the bay as an ESI 2 (and not just because I was feeling that I should lean to over-triaging now, out of my fear of now missing something acute). Literally every person was sick/high acuity. Chest pains, abdominal pain (SBO was the seeming c/c for a bit). I was split between triaging in two locations, helping in our trauma bay (where it's an expectation as a backup), having 3 hallway patients, and still trying to maintain sanity.

    Our trauma bays were full to the hilt with MVC's, stabbings, GSW's, you name it.

    It was horrific, to say the least.

    At times like these, it always seems to occur that the least sick patient/family will then chime in about what they need. It is never urgent, and certainly not even a priority given the high acuity of everything. Examples: Patients and families standing in the doorway, giving glaring looks, all with already being informed of the chaos/high volume.

    At one point, I had one patient who I was attending to (belly pain, hx SBO), an ambulance came in with a person who had a hygiene issue everywhere, a lady who wanted a pillow and who wouldn't wait, a lady glaring at me, and another person insisting they needed something (hit the call light 3 times in 10 minutes and I physically couldn't get into the room).

    Everyone was at max capacity, and I do mean max capacity. The hospital doesn't have any floats to send. We are short by two nurses, all of our trauma rooms are full without enough nurses to staff the patients we have, at what point do you just boil over?

    All night I ran and ran. We all did.

    I'm at a crossroads. I do love ER nursing, but given the above scenario, it is not safe. It's not just busy, they are SICK patients who deserve to have more of a nursing presence.

    So I'm at a point where I wonder what to do. I have put in for another shift, since the staffing is better for days and evenings. Staffing is 3:1 for those shifts, but not for nights. Why, I wonder? We are busier on nights but somehow are staffed with less?

    Knowing that management can't give us more (and people have barked up that tree), what is the solution?

    This pace is unimaginable, and I can cope with a lot. I feel I can deal with anything anyone throws at me. I don't get flustered easily, but this past shift was insanity.

    Pending the inevitable Sentinel event, what's the short term solution?

    Anyone have ideas/suggestions? Leaving is not an option, since it's pretty much the only game in town. I'm sure things will blow over and we just have to hang on until summer's over, but honestly, being experienced and feeling over it, how do the newer nurses feel about their future in this climate?

    I feel like I can't abandon ship, because where will the newer nurses be if the experienced ones leave? Safety is my bottom line. For patients, for our nursing license. It's not safe and I fear for bad patient outcomes.
    Joe V, brainkandy87, Dixielee, and 2 others like this.
  2. 14 Comments so far...

  3. 11
    You say leaving is not an option, but this is exactly why I got out. I miss a lot about ED nursing, but I am sooooo much happier now. There is not a nursing shortage, there is a staffing shortage, and until hospitals start pulling their heads out of their behinds and staffing appropriately, I'm outta there. I won't be one of the overburdened nurses who kills a patient because my workload is just plain unsafe.

    Some might see it as "abandoning ship", but I don't. I do not believe it for one second when the administration cries "We're so poor! We need to cut costs!". Baloney. If that were true, they wouldn't still be getting their bonuses. The decision to prioritize profit above patient safety was made by them, not by me, and I refuse to be a part of it by continuing to work under those conditions.

    And you know what? They still haven't filled my position, and I left months ago.
    Last edit by ~*Stargazer*~ on Jul 22, '12
    DizzyLizzyNurse, koi310, itsmejuli, and 8 others like this.
  4. 2
    I am an ED nurse too and this was exactly what I was looking for, I was really worried about the unsafe working conditions of emergency departments in general, after our hellish night last night. I know it's the summer holidays and tidal waves of patients are piling in, but with lots of our staff off sick and the rest burnt out already, we need more staff on nights... simple!!! They are the same if not busier than days, and with a lot less clipboarding. Why don't the big cheeses spend a friday and saturday night seeing what an ED dept is REALLY like???
    Don't get me wrong we're used to rudeness, aggression, glaring looks, complaints but the sheer guilt and sadness of not being able to look after everyone properly was ridiculous. Talk about sweating in the workhouse while the fatcats sleep!
    After 3am we only had one locum (agency) doctor on the floor, who was the ED lead in a trauma team for about two hours, also during the night resus was full, over the course of the night we had a stabbing, fitters.... lots of poorlies, the saddest being a young cardiac arrest the same age as my husband, with a very dignified family, it was heartbreaking.
    I was allocated to minors yet again, my fourth night running, left to just get on with it, and explain to the many walking wounded, drunk, and two abusive ladies, why they haven't been seen for 6/7 hours. What was truly amazing was that some patients had even seen CPR and emergencies rush and in the same breath were incessantly inquiring when they would be seen, and do they have time to go to McDonalds???
    I honestly spent half the night apologising, explaining, placating. And I bet I will be pulled into the office and criticised for giving someone a rolled up blanket instead of a pillow. Even the ward staff left me speechless, one nurse knew full well what was going on in the ED (rumour mill runs fast) yet she still had the audacity to complain when there was no observation chart with the patients notes, the patient had only been with us about an hour and a half, with two sets of his obs recorded on the ED card. I do worry about humanity sometimes.. and I love emergency nursing but.....I'm going to pastures new I'm afraid, I've had enough of being flogged to death, without a sniff of any career development, dumped down minors day after day, watching awful people get promoted, and missing everybody's parties! You can find some other mug ;-)
    Dixielee and MassED like this.
  5. 6
    Quote from lozilla
    I am an ED nurse too and this was exactly what I was looking for, I was really worried about the unsafe working conditions of emergency departments in general, after our hellish night last night. I know it's the summer holidays and tidal waves of patients are piling in, but with lots of our staff off sick and the rest burnt out already, we need more staff on nights... simple!!! They are the same if not busier than days, and with a lot less clipboarding. Why don't the big cheeses spend a friday and saturday night seeing what an ED dept is REALLY like???
    Don't get me wrong we're used to rudeness, aggression, glaring looks, complaints but the sheer guilt and sadness of not being able to look after everyone properly was ridiculous. Talk about sweating in the workhouse while the fatcats sleep!
    After 3am we only had one locum (agency) doctor on the floor, who was the ED lead in a trauma team for about two hours, also during the night resus was full, over the course of the night we had a stabbing, fitters.... lots of poorlies, the saddest being a young cardiac arrest the same age as my husband, with a very dignified family, it was heartbreaking.
    I was allocated to minors yet again, my fourth night running, left to just get on with it, and explain to the many walking wounded, drunk, and two abusive ladies, why they haven't been seen for 6/7 hours. What was truly amazing was that some patients had even seen CPR and emergencies rush and in the same breath were incessantly inquiring when they would be seen, and do they have time to go to McDonalds???
    I honestly spent half the night apologising, explaining, placating. And I bet I will be pulled into the office and criticised for giving someone a rolled up blanket instead of a pillow. Even the ward staff left me speechless, one nurse knew full well what was going on in the ED (rumour mill runs fast) yet she still had the audacity to complain when there was no observation chart with the patients notes, the patient had only been with us about an hour and a half, with two sets of his obs recorded on the ED card. I do worry about humanity sometimes.. and I love emergency nursing but.....I'm going to pastures new I'm afraid, I've had enough of being flogged to death, without a sniff of any career development, dumped down minors day after day, watching awful people get promoted, and missing everybody's parties! You can find some other mug ;-)
    are you in the UK? Or out of the USA, anyway? Sad that it's the same anywhere you go.

    I do feel that ER nursing is a unique experience that is only understood once you walk a mile in our shoes. What gets old all too fast, and something that I have zero tolerance for, is the abuse that we suffer (verbally, emotionally, often physically) from patients/family. I, for one, refuse to take it anymore. I refuse to be flogged by those that do not understand how difficult our job can be.

    My job is a nurse, not a punching bag. I do not take abuse of any kind, and am more than upset when a coworker accepts anything less than courtesy/respect from a patient. I don't mean the patient that IS truly sick, with the concerned family who often gets upset, out of concern. I mean the unnecessary roughness that we experience, simply because we are trying to do our jobs.

    I incessantly remind patients/family of what is going on in our department (communicate, communicate), so they might see that with my explanation we are all busy and there are EMERGENCIES happening around them. The self-involved patients will never understand, but I will continue to attempt to educate them on their position in our ER world.

    After reading your post, it does make me think that it is a management decision (choice) to not add more staff. I have heard "your night numbers do not support more staff" - BAHHAHAAA!! Are they kidding?

    Many of us on our night shift are talking of union. At least there will be a path for grievances. I feel as though management cannot ever make a choice of SAFE staffing and patient care because they have budgetary constraints that DIRECTLY relate to staffing. They have a conflict of interest and unions would be the only way to separate those issues. How can worrying of a bottom line ever contribute to better (SAFER) staffing? It can't.

    I am at a loss. It's bad for our individual health, but collectively, it puts such a smear on ER nursing to have this kind of climate.
  6. 1
    Your story seems to reflect reasons for which I don't care for Primary care nursing. My hospital works on a team nursing principle, generally, and the RNs have their LPNs or Medics to rely on as well as their techs. Between all our medics, techs, and LPN/RNs things move smoothly enough (generally speaking).
    MassED likes this.
  7. 8
    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!"
    Last edit by Dixielee on Jul 22, '12
    cheryl2365, MassED, Esme12, and 5 others like this.
  8. 2
    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?
    MassED and Altra like this.
  9. 2
    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?
    It is all about incident reporting. trust me. I recently had a guy on the ward for 6 SIX!!! weeks waiting on a guardian to be appointed. he was homeless and deemed incompetent of making decisions. He was an alcoholic and a smoker. Would go down to the smoking area and come back drunk!! it was decided by me and my NUM to 1:1 him to stop him drinking.

    I covered my NUM job for a week and had the Div DON in asking why he was being special-ed(coming out of the dept budget even though he was an overflow pt). I had the pt flow exec in asking why he was still here. Nothing was getting done and we were getting spat at and verbally abused every day by this guy who was a medical NOT a surgical pt (surgical ward) Our div DON was fantastic and suggested that we started doing incident reports every time he was verbally abusive or spat or swung for some one. After 25 reports - in 1 week. he was on the medical floor and in 5 days he had a guardian appointed and gone. All the reports were going to the medical div DON as he was her responsibly and our surgical HOU got CC'ed into all of them and kicked up enough of a fuss stating that approx 10 people could of missed out on surgery because of him. It is all about the data. Verbal complaints and ******** will do nothing. Objective data will
    Last edit by Esme12 on Jul 23, '12 : Reason: TOS/profanity
    MassED and corky1272RN like this.
  10. 0
    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
  11. 1
    Quote from opossum
    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
    You hit the nail square on the head with that one! And, imo, it's not just a problem in the ED, it just happens to be more obvious there. Nursing is about constant triage, whether you're triaging care between patients or triaging an individual patient's priorities. The whole cuustomer service mindset has gone way too far imo. It's appropriate and necessary when it involves a patient in decision making and respecting a patient's right to be informed and make choices for themselves. It's another thing entirely when it becomes about a patient being upset about the quality of their food or their pillow not being fluffy enough or their nurse not being in their room 24/7. Entitlement has gone way too far. Edited to add: OP your night sounds just awful! Staffing levels need to change.
    Last edit by jt43 on Jul 23, '12
    MassED likes this.


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