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

[MassED]

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.

[MassED, BSN, RN]

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!

[MassED, BSN, RN]

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.

[Dixielee, BSN, RN]

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.