Scared & Confused

I've just recently transferred to the ED. The experienced nurses said they didn't truly feel comfortable for almost a year. Find one experienced nurse each shift and use them as a resource. You're still going through growth pains. Stay the course.

It's really easy to feel like you are spinning circles when it's busy. When you do, take a second and 1.STOP, 2.THINK, 3.ACT. More than a med-surg floor, you can ask your teammates for help.

When it hits the fan, I take a deep, slow breath. I make a post-it list of everything I have to do so you don't forget anything, and then start going through the list with the most critical stuff first.

My list usually looks like this:

Rm1- VS, blanket

Rm2- VS, IV, ABX

Rm3- Ice water, urine

Rm4-Vit K (INR 8)

Rm5-VS, Stool sample

Don't think about what's going on out in the waiting room or whatever else is going on somewhere else. Sometimes you have to put blinders on and get through what your patients need first. After you have everything settled out, then you can start to look at helping your teammates.

Just wait and see. You'll be helping out the new transfers too, just like you help new med-surg nurses now. You can do it!

I would suggest to know who your resources are at the start of your shift. If you look at the assignment sheet and who is charge, make a plan at that moment to decide who is your ace in the hole. When things become overwhelming, your charge nurse is your resource. You ask that person for a bit of assistance. Remember to prioritize. Vital signs are important, but if you have pain meds, a drip to start, or someone needs to go to the bathroom, make a quick plan. Do you have CNA's or techs? Have them get that person to the bathroom, you get to your pain meds or drip and do VS on that person while you are there. How many patients do you have? Most have 4, at the maximum. Remember, airway first. If everyone is breathing and not actively dying then take a deep breath. It's ok. Shuffle your deck and re-prioritize after each task. Update your patients if you are busy, as people who are informed are much less likely to complain (most of the time).

It's an overwhelming environment, for sure, but just remember that your shift is all you have to endure before it's over. Ask for help. There will always be someone who can help you even with a mundane task, the point being that even a small task is immensely helpful. In turn, offer your assistance to your neighboring nurses. Even if they don't need help, they know that you offered and are there in the future.

Keep plugging away. It'll get easier. Some days it's harder, especially in the summer. Remember to always prioritize. If someone is septic, they are a priority. If you have other patients who are just as sick, you need to speak up loudly to your charge for help, as no one can handle a few very sick patients and keep up.

For instance, if you have an abdominal pain (along with your septic pt), chest pain, and leg injury, I would prioritize in the following way:

Septic patient first. Hold all other things until you have addressed this patient (should take about 20 minutes). IV, blood cultures, labs. If you have phlebotomy, have them draw the labs. Put that person on the cardiac monitor, have their BP cycled q 15 minutes. Once you have that antibiotic up, you are settled enough to move along out of that room, knowing that you have a window to their vs on the central monitor.

Next, get to your CP - hoping that the EKG was done within the first 10 minutes, that is the priority. Next, start that IV and send labs. Put that person on the monitor, also with cycling bp's. You are essentially settled in that room until the MD orders meds (asa, ntg, etc., as well as cxr). That should only take maybe 10 minutes. Then move on to your abdominal pain - IV, labs, send u/a. Etc and so forth. All the while you peek on your sicker patients ensuring that they are stable as your move from patient to patient. It is hectic, but just remember that you can only do one task at a time. Prioritizing your tasks and delegating as appropriate are key.

You'll get the hang of it and look back and think of how it was rough, but you did get through it.

I went through something similar when I first started in the ED 3 years ago. I chose to start right away in a busy metropolitan trauma center...and boy was it a learning experience. For the first 8 weeks or so, I went home and cried every night after my shift. I forced myself to stick with it. I found that as situations started to repeat, I knew exactly what to do. It will take some time to get used to the crazy and trauma drama! I suggest you stick with it. Find a seasoned nurse who is willing to answer questions when you have them. Keep a log things that you didn't understand and look them up later. Now, I am very good at my job. I precept others in the department and work as a relief charge nurse. You can do this!!

For instance, if you have an abdominal pain (along with your septic pt), chest pain, and leg injury, I would prioritize in the following way:

Septic patient first. Hold all other things until you have addressed this patient (should take about 20 minutes). IV, blood cultures, labs. If you have phlebotomy, have them draw the labs. Put that person on the cardiac monitor, have their BP cycled q 15 minutes. Once you have that antibiotic up, you are settled enough to move along out of that room, knowing that you have a window to their vs on the central monitor.

Next, get to your CP - hoping that the EKG was done within the first 10 minutes, that is the priority. Next, start that IV and send labs. Put that person on the monitor, also with cycling bp's. You are essentially settled in that room until the MD orders meds (asa, ntg, etc., as well as cxr). That should only take maybe 10 minutes. Then move on to your abdominal pain - IV, labs, send u/a. Etc and so forth. All the while you peek on your sicker patients ensuring that they are stable as your move from patient to patient. It is hectic, but just remember that you can only do one task at a time. Prioritizing your tasks and delegating as appropriate are key.

You'll get the hang of it and look back and think of how it was rough, but you did get through it.

If they arrive simultaneously, I'd do the cp first. EKG is paramount, if it's an acute mi & stat ekg not done, you'll have a lot os 'splainin' to do. If it's a highly suspect nstemi & labs not sent asap, still have a lot of 'splainin'. Don't assume it's done, know it was done. If not acute MI, line/lab & whatever else is your protocol. 10 minutes max & done. Now you can get to your septic special.

If they arrive simultaneously, I'd do the cp first. EKG is paramount, if it's an acute mi & stat ekg not done, you'll have a lot os 'splainin' to do. If it's a highly suspect nstemi & labs not sent asap, still have a lot of 'splainin'. Don't assume it's done, know it was done. If not acute MI, line/lab & whatever else is your protocol. 10 minutes max & done. Now you can get to your septic special.

This is a tough one as in my department we have target times for EKG as well as for septic pts. I might try to delegate the EKG, but if that was not possible then I would look at the vital signs for the septic one and see if they were stable. If they were very hypotensive I would go there first, place PIV, draw labs and cultures, place on monitor, and hang a liter. Once I have the fluids up I would go do line and labs on the chest pain.

It would definitely be a judgement call which to do first. I would try hard to get a second set of hands so one person was getting a line and hanging a bag on the septic while another was getting an EKG, and a line in the CP concurrently. The fun thing about playing in the ED is you get these scenarios and you have to adjust and figure out how to prioritize each and every time. It's never cut and dry, or boring, or dull...

It's never cut and dry, or boring, or dull...

Exactly! I can make arguments each way in the septic pt vs CP pt showdown. Given that we have a tech--have them get the EKG on the CP, put him/her on the monitor, line/lab, and then I will get in there after I start the septic patient (if the EKG is normal or near normal). I would want to get fluids started ASAP (faster than I would want to give ASA to a CP pt with a normal EKG).

And remember, a doctor and/or an experienced nurse is only a shout away.

Thanks for the advice! Writing things down and looking them up I think will be very helpful; I'm going to start doing that.

Thank you all for the advice and encouraging words!

Thanks for the advice! Writing things down and looking them up I think will be very helpful; I'm going to start doing that.

So much of it will come with time :) If you end up with two critical patients, always ask for help. I've been doing ER/trauma for 5 years, and learning to ask for help has been one of the hardest things for me, but it's so vital! If none is available, notify your charge nurse, as it's ultimately his/her responsibility.

I just want to say a big "Thank You" to all of you! I am a new graduate and started my first job in May. Unfortunately I was assaulted by a patient and am on medical leave with a broken arm until Oct. 4th. I've been getting increasingly more anxious about going back to work. This thread has helped to ease my anxiety quite a bit. The funny thing is that I'm not sure why?! Maybe it's a good distractionI'm just not giving the "assault" a thought and am simply thinking of getting back on the horse. The night that I was assaulted I was devastated that I would be out of work and my orientation would drag on. As the days progressed I've become more nervous about having to face this patient again. (frequent flyer)I know that he won't be assigned to me but I just don't want to have to "see" him or his family again. I won't leave my job because of this guy....I love my job and won't give him that power. (I've worked way too hard to get here). Anyway....I just wanted to say thanks to all the ideas of prioritizing tasks (I especially love the sticky note idea since I can just pull off the little sheet when I am done with those tasks or need to re-prioritize).

One of my favorite preceptors gave me the best bit of advise for when it gets crazy.....When you are being given patient after patient - don't bother to complain about it. Just put your head down and keep going. Complaining is a waste of time, since everyone is getting hit with a lot of patients. Complaining only increases your anxiety which leads to mental confusion. Keep going like a freight train....and get your work done!