ER - How to stay calm

sreynolds · Sep 29, 2015

I'm still relatively new to the ER as well, with only 4 months under my belt. Previously, I worked on a very busy cardiac/stroke step down floor. I always have a tech, but there is only one that I can depend on to always help and have my back. I have learned to ASK FOR HELP when I need it. When something has come up, and I've asked why no one came to my rescue when it was clear to see I was drowning, the response was always, why didn't you ask? While it's frustrating, because I feel like I don't have TIME to even realize what I'm needing help with sometimes (I.e. Being stuck in a critically ill patients room for an extended amount of time or dealing with a trauma alert or resuscitation), I've come to learn that everyone else is just as busy too and they don't have time to stop and look and see who has a lot of "to dos" flashing on the computer. Once I started asking for help from my team mates, it really helped. Also accepting that you are only one person and you can only do so much will greatly reduce your stress level in these situations. I also started jumping in when I was caught up, to help my team mates out without being prompted. I will go in and start a line and hook a patient up to the monitor while my coworker works on triage for new EMS patients, for example. Going out of your way to anticipate the needs of my coworkers has helped me get lots of "street credit" and they are more willing to come to my rescue when I'm in a pickle.

I try to chart by exception. A lot of my team members will put a note in every hour or so, but I literally only chart when there is something that NEEDS to be charted. If everything is fine, or within normal limits, I don't make a note. It's assumed everything is fine. You are charting off on meds and labs etc, so you are showing you are with your patient. Making a note stating they are "resting quietly in bed, no needs/concerns voiced at this time, vitals stable" is redundant and too time consuming. So only chart on abnormals.

Also, I've learned to prioritize better and stock my rooms at the beginning of my shift with things that might slow me down and keep me from staying on track. I make sure my rooms have urinals, bedpans, 3ml syringes, blunt tip needles, extra electrodes, urine specimen cups, gauze, alcohol prep pads, extra flushes, plenty of blood tubes, and I stack extra blankets up in the corner of each room, along with washcloths, towels, an extra gown, and a nemesis basin. That way I don't get stopped for mundane things, like my mom is cold, can you bring more blankets, or my husband has to pee NOW, and there's no tech around to go fetch a urinal.

The last bit of advice I'll give, is do everything you can do while doing triage in the room. I've learned which doctors order what, and I know which chief complaints will need a line started. I throw in a line and get blood FIRST THING for every chest pain, SOB, dizziness/weakness, syncope, blood in remains/stool, and abdominal pain. This has saved me so many steps, because no matter if I get slammed with 2 patients at the same time, I know I already have a line and sent blood down on my other two patients so I have time to jump on my new patients and get them going.

Good luck and always remember to relax. It's not always easy to keep calm when **** is literally hitting all the fans in all your rooms at exactly the same time, but when I get stressed it literally doesn't help me work any faster

Lev, MSN, RN, NP · Sep 30, 2015

Great advice. That really helped and it was nice to see that I'm not the only on in the same boat. I will try to utilize my techs more. It just happens that sometimes they don't do what you asked them and then you're stuck doing things that you really don't have time for. I do try to help out my coworkers as much as I can and they are very grateful when I do help because I do not leave things undone. If I help you, it will be a good job. However, I really don't have as much time as I would like because I am usually so so busy with my own patients.

sreynolds · Sep 30, 2015

I should have been more specific....when I ask for help from my coworkers, I ask fellow nurses. I gave up asking for help from my techs pretty quick. There is only 1 tech that really does her job, and I rarely get her assigned to my pod. I find myself doing EVERYTHING for my patients, so I'm essentially the nurse and the tech. I get my patients hooked up to the monitors, I get my own EKGs, I help my patients to the bathroom, I draw my own labs, literally everything. I've come to accept this...so when a tech walks out of the break room where there is apparently a tech pow wow going on, and they actually help me, it's a HUGE help because it was unexpected. I feel I'm a better nurse because of it. Like I can look at the lazy techs we have and say, no I'm good, I have it. Go eat your breakfast before it gets cold. Our nurses are great though and we usually have a resource nurse floating around.

Lev, MSN, RN, NP · Sep 30, 2015

Lol that sounds like a lot of our techs too.

twozer0, NP · Sep 30, 2015

The longer you spend in the ER the easier stressful situations become. Eventually you'll be watching Jeopardy as you do chest compression's! I'll take the rapist for 500 Trebek. Mr Connery, thats Therapist! Don't let the stress burn you out, try and find ways to satirize some of your day!

MassED, BSN, RN · Oct 8, 2015

when you're busy, if you can jot down a time and a short idea/intervention - you can always go back and addend your note when you have more time. Sometimes if it's written on a piece of paper, if that's easier, then go back and enter your notes. Such as: 1300 to xray, 1530 urine sent, 1630 waiting for CT results. 1700 medicated for pain. Then add more to those later. Don't feel bad about treating your sicker patients first. Your less acute patients will either learn this from you or someone else. You can pop your head in and say "this is what is going on, this is what we are doing, I'm in the next room with a sick patient and will be back in approximately 20 minutes for xy and z." At least you have updated them and then you can see your sicker patients before getting back to the less sick ones. It's all a matter of time management. Some never get the hang of this. If I have an ankle pain, or wrist pain, or something that I know won't require more than a Tylenol or Motrin, I may not asses them until I discharge them (like a true fast track patient) and this is just how it goes. If it's not an emergency, tell your brain that this is o.k. Don't feel bad about it. If it were a true emergency patient, you'd be in there, so let that guilt go and don't let others tell you what your priorities are (unless you just got a new patient you didn't know about). Good luck. Keep your ears and eyes open.

buckeyeRNED · Oct 10, 2015

Anticipate what is needed as much as possible... line/labs/EKG. Ask for help.

I try to not make more than one trip places... if they ordered multiple things on a patient I'll try to get them all done in one visit... if multiple patients need things from the stock room I'll get them all at once... if I'm triaging a non-critical patient I'll do a quick assessment on them so I chart it in the computer at the same time. Take a look at your work flow, and see what you can condense. If IV meds are ordered do you start the line, and then go to the pyxis and return to the patient's room? Or do you pull your meds ahead of time so you only have to make one trip?

Also, remember to prioritize, and then don't stress about the things that aren't a priority. If you have to get blood cultures and hang ATB on a septic patient, the orthostatics and toradol and charting on your other patients can wait.

Chinpop · Oct 14, 2015

I pride myself on being self sufficient in the Emergency room. However, sometimes I just ain't got time to do an EKG or apply a sugar tong splint after a conscious sedation.

It's inevitable to feel overwhelmed at times in the emergency department. When it happens, take a step back in your mind, ACCEPT the situation for what it is, and begin to prioritize. If your less sick patients have to wait a bit for you to get back to them in order for you to take care of your more sick patients, so be it.

Notes should always be short and sweet. Remember KISS? It means way more here than anywhere else. Be direct, state what you mean to state, and keep it simple, stupid.

In one of the ED's I work in, we are always two RN's short or more, see around 160K people per year, get plenty of trauma and to put icing on the cake we are overloaded with psych patients due to a recent change in state law and funding.

Could complain, but they pay me to do what I can where I can in order to maintain a safe environment and document like I was trained to.

Lev, MSN, RN, NP · Oct 28, 2015

I wrote this post a month ago, and I can say that things are a little better. For one, I started delegating more. The boarder situation is getting worse and worse and with all those floor orders being put in, I need all the help I can get. Sometimes I feel like a commander when I'm delegating to a tech, but at the end of the day we are here for the patients and they need help with stuff. I make it clear that I do not shy away from tech duties by doing them constantly. However, there are some techs that I just can't depend on, so those days it's sink or swim or should I say tread?

I'm a lot more comfortable with just general stuff. I think being calm among the chaos is a skill and a decision you have to make. Every ER has those people who make it more stressful for others because they are always rushing things. They have to realize, that until I see that patient and carry out those orders, the patient doesn't move anywhere. So if they were waiting for 5 hours in the waiting room, they are going to wait another hour in my room and be more frustrated. I'm just learning to ignore the people who think they are making things go faster. It's really about doing one thing a time, one patient at a time at any given moment. You cannot be in two places at once. You have to focus on the present moment, prioritize, and ignore the other pressing tasks until you finish with the pressing task you are doing now. It's hard when you want to duplicate yourself but don't go there. Just focus on the present.

Bobjohnny · Oct 30, 2015

Anticipate what is needed as much as possible... line/labs/EKG. Ask for help.
I try to not make more than one trip places... if they ordered multiple things on a patient I'll try to get them all done in one visit...

In the same grain, if you have residents, don't be in a hurry to run to a room as soon as they put an order in. Especially lower level residents, because you will likely have another order or two in within the next few minutes. It seems that without fail I'll go to a room and then they'll add two more orders & then the attending will see the patient and add another one.

chansen · Nov 2, 2015

The concept of multi-tasking is flawed. It takes away mental or physical energy from whatever task is most important. Forget the word multi-tasking exists. It can impair performance.

Have a mental routine before your shift. If you're religious, pray. If you meditate, meditate. If you have a song that pumps you up, listen to it. Think about what a shift normally entails where you work, focus on what you're going to do to have a strong day. Switch your brain into "I'm at work mode."

Always deal with your critical patients first and foremost, which goes without saying, but otherwise, do time-limiting or tasks you hate first. Can't stand accessing a PowerPort and you have a patient with one? Go do it first. Someone needs a straight cath for a urine specimen and they're here for an abdominal complaint? Just get it done. Thinking about the things that you have to do that you don't like to do will give you anxiety and take away your ability to completely focus on the task at hand.

Cluster every single thing you can. If you are going into a room, take everything you're going to need, get them situated, get vitals cycling, address anything you can while you're available, because you don't know what's coming through the door next and you don't know when you're going to be back in that room. It's easier to say, "can you peak in on Mr. Jones in 22 and just make sure he's still breathing and his cuff and pulse-oximeter are still hooked up?" to a tech, then it is to realize you haven't been in the room in two hours and you have no vitals and no idea how he's doing.

Learn what's important to chart, and what isn't. Some folks chart everything down to "tucked blanket around patient's feet for comfort." I'm not that guy. Same with assessments on non-critical folks. If you use a 5-level ESI system, anyone who isn't a 1 or a 2 gets 1-2 systems covered with an assessment. ESI 1s get every system. ESI 2s get multi based on complaint and linked concerns.

When you have a dirty room, or an empty room, make sure your essential equipment and supplies are ready. Nobody wants to be That Guyâ„¢ that has a sick patient and there's no ambu bag, or the suction isn't working, or there's no christmas tree on your O2 regulator. It's good habit anytime you're in a room to look around at the critical equipment and fix that problem anytime you come back to that room.

Lastly, learn to let things go. You want to feel like you can do everything. All at once. For all your patients, and those of your peers. But you can't. Remember this mantra: You can't control what happens to you, but you can control how you react to it.

Additional reading re: multitasking.

Multitasking and the neuroethics of distraction by William P. Cheshire from Ethics & Medicine: An International Journal of Bioethics, March 1, 2015.

Stop multitasking: Doing it all accomplishes nothing by Catherine M. Seeber from Journal of Financial Planning, May 1, 2015.

Choice in multitasking: How delays in the primary task turn a rational into an irrational multitasker by Ioanna Katidioti and Niels A. Taatgen from Human Factors, June 1, 2014.