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4th week at ED.. it's hell, we should be called gods of labor

Wow, ED is where it is at! I am on my 4th week of internship, of which the 2 were didactic. Originally as a MS nurse, I can't hide my shock at how much crap one nurse is responsible of at the ED. I am close to getting crazy at this place. I knew ED was busy, but MAN, there really is NO TIME to chart, let alone sit down.

exemplary scenario: old, confused, febrile 80y/o pt with dung caked all over her perineal area, her bp 70/40, obvious sepsis, having to get blood cultures, ivs, lab works, notifying docs, etc etc... and I haven't even asked anything to the family about her hx or assessed her properly yet, then another EMS stretcher rolls in next door, this time numbness/tingling, not as critical but having to do all the work plus ekg, then another doc gives stat ekg order for a pt in other room whose K+ comes back 6.5. I haven't updated vitals on anyone yet, got a pt to discharge, UAs pending which I totally forgot about until my preceptor reminded me, and my bladder is about to burst.

At this point, I am telling my preceptor "how the hell can you do all this?" Oh ya, I haven't charted anything yet. There is no help either. The charting system sucks( meditech.. piece of crap). It's so busy and fast pace that I forget things unless preceptor reminds me. I am so darn scared when I am by myself that I will kill someone or forget to report something or just get backed and behind, that I will start missing tons of things.

I remember sitting on my rear on obs floor when I wasn't busy, just chilling after 2100 meds. Here, I am running around and brain sparking all 12 hours. Maybe it's just anxiety of being overwhelmed at new place, but I don't think there is any department busier than ED.

If you have quick tips on how you survived, and how you managed to remember things, and just ER tips, throw it at me, cuz I need them. Thanks, and dang we rock.

Wow. To think I want that makes me question my sanity. Please keep us posted on progress and lessons learned.

Of course. I think the hardest thing is not having help. On floors, all I needed for EKG was call RT and they will come and do it. Vitals and most of cleaning, techs would do them. Things went according to plan most of times, and if a pt is tanking, I could just focus on that pt. But at ED, it's different story. You are responsible for critical pt, and everyone else... starting from walking them to restroom, getting vitals, giving meds, charting, filling out charge sheet, and discharging, to doing EKGs or sending blood work (God, I pray for phlebotomy team...). Every little things to big things are nurses' responsibility. Challenge? 100%

I love the ED. Love, love, love it. Wouldn't be anywhere else.

Your ED sounds a lot like mine. We have EKG techs, RTs, and phlebotomists, but we don't have techs to assist with keeping up on vitals, obtaining specimens, transporting to the floor, etc. We are responsible for a lot. Fortunately, the doctors do a lot, too. They're pretty hands on and will do splinting and wound irrigation and such themselves rather than delegating to the nurse, so that's really helpful- and good, because I suck at splints!

I try to batch my charting as best I can. If I'm entering vitals, I enter my observation note at the same time and vice versa. If I'm really running behind, I can scratch notes on a paper towel and go in and backchart when I get the chance, but that's not ideal. I've even seen other nurses make notes on the bed sheet, but I don't know if the ink comes out or if the bed sheet will just be trash after that (obviously the least of your worries if the patient is crumping or coding). Best to chart as you go as much as possible. I agree, Meditech stinks and I don't envy you having to use it, but you will get faster.

And, as discussed in other threads, there are very few things that can't wait two minutes while you empty your bladder, so do so. Don't get into the habit of playing the martyr and foregoing self care.

sandnnw specializes in Emergency, MCCU, Surgical/ENT, Hep Trans.

You will learn WHAT is important now, in 5" and in 15". Disgusting as it sounds, feces is not emergent, nor is charting and certainly not stewardess type services. Give it a few more weeks and model folks around you who have been there a few...you'll see! Bravo for your work.

Aggie RN specializes in ER, HH, Case Management.

How long is your internship? Maybe ask your preceptor to help with your load a little more so you don't feel overwhelmed and can process more. Not sure if that's a viable option but hoping this suggestion might work out for you. Just remember to be patient. It will come.

Esme12 specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

Welcome to the ED.

It is a tough place to work and over whelming for the new grad...which is why they take on so few new grads. YOu will get better in time. You do focused assessments. Write quick notes on each patient. I kept a little pocket note pad for med times/stuff done. Everything you do MUST be focused chit chat isn't always "allowed". You will learn to focus on the task at hand...get important info first. If they have an O2 sat and good vitals and pain free...on to the next. As you gain experience you will get quicker at the "tasks like EKG's and lab draws.

No you don't sit (most of the time) Yes you are busy. Meals are rare and bathroom breaks only if you are going to wet yourself. ;)((HUGS))

It does get better.

emtb2rn specializes in Emergency.

I'm the king of initial paper towel notes. Once I get the triage & initial documentation done, I chart on the fly as I go.

Speed comes with experience. You will become much more efficient. No techs? Yeesh. I love my techs.

And as stated above, feces don't kill. And either does pain for that matter.

You also need to know when to ask for help from your co-workers. The ER is a team sport.

Good luck, have fun.

@stargazer: can't really say if I love it (I don't like healthcare field in general), but the experience and intensity is above and beyond compared to floors, so if I decide to stay in health field career, I could go to OR after 2-4 yrs (which is my end goal at the moment) and ER exp really helps, and I can work on my NP as I go. Our ED is about 50-60 room, 5 pods, and supposedly techs are in each pod, but I never see them. It drives me crazy that I even need to clean up the bed after pt is discharged; literally there is not even time for checking blood sugars lol! And yes, Meditech really sucks, lots of double charting. You would chart on eMar that iv fluids are started, AND chart separately on interventions the start time and stop time of those fluids; I don't even have time to chart vitals, and I got to do what? right now I am trying to figure out what is the minimal charting I can do just to get by. which boxes can go un-clicked and be okay, those stuff. Everyone says it will come like you said, and God I wish that comes fast.

@sandnnw: I am continuously trying to tell myself to have the mindset of "this is ER, it's not floor" but it's slow process. At floor, there's not many times where you are in hurry, or have emergent things piled up, so you can respond to little things like getting a pillow or blanket or cleaning someone, but at ED, you have so many critical things going on you just have to learn to ignore lots of things; but when the admin is geared towards pt satisfaction scores, they ignore all the important things you did and focus on stupid little things you didn't do such as putting someone on bed pan or getting them a blanket. It's nasty world with nursing ruled by presganey and "scores".

@aggieRN: A&M all the way, although I didn't graduate from there, lots of my friends did. The internship is 13 wks, and I do have preceptor who is basically on the ball. I take 2/4 pts while tasking with him on all 4, but really, I can't survive an hour without this guy. He has 2 stat ekgs, charting which doc he showed it to, 2 new EMS admissions and 1 discharge, cp work up, sepsis work up, and somehow does all this while I am wrapping my head in panic, whipping out my notepad asking ems triage qx to paramedics and family about the pt while he doesn't even need notes to remember all that for charting.

@esme12: I have 1yr and half of floor exp, and I am completely overwhelmed, no question for new grads! I bought me a thick mini spiral note pad, so hopefully this will come to my aid :) you said things need to be FOCUSED charting, and I am trying to figure out how to minimally chart (not as a negligence but because there are already way too much to chart, and there's no time) just to get by. Everyone does say it gets better, so I am just hoping on that.

@emtb: it seems to me that I can't even make time to chart those initial triage and assx when things hit the ceiling fan. I feel like I spend too much time with tasks like starting IV, getting blood, hooking pt up to monitor and cuffs, etc. Like you say, efficiency has to come with time I suppose. I do need to start overlooking somethings to get more important things done, but it's hard not to clean up old septic lady with UTI from her own feces, but it just takes up too much time, and there's no help :***:. I had my preceptor so I had help, but what if I am by myself? A lot of anxiety comes when I think about when I am off orientation and all on my own. I might have to steal someone's xenax or valium:no:

So a few comments from my 4 years in the ED (2 rural, 2 urban)...

1) You don't NOT have time to chart vitals... seriously, this one's gonna come bite you in the butt when your patient crumps and the last vitals are 3 hours old from triage... or a doc's gonna hunt you down to say, "why do we have no vitals?"

Seriously, get in the habit of leaving the cuff on and set the monitor for q30 min. Then be sure to cruise through and take a quick note of the vitals... truthfully, I round sometimes... I can't remember if it was 126 or 133 so I round to 130... (actually, in my case, our monitors are linked to the EMR so I can just pluck them off of the data page).

2) Make a habit of doing quick fly-bys to note that patient is not in extremis and then chart, "no acute distress at this time." Doesn't take but a minute.

3) And you really don't NOT have time to check sugars... little story for you... I had an LOL with regular fsbg checks ordered... was busier than sin but kept popping my head in on her... she was always awake and responsive... mentating at baseline... when I finally got to check her sugar: 25...

4) Keep working on your prioritization... When I'm crazy busy, I give a pass to the detailed history, detailed report, and thorough assessment... Those are all important but not compared to finding that sugar before it hits 25 or having current vitals on sickies. I can do a rapid assessment in about 45 seconds on most patients.

5) Keep track of the time... I note each 30 minutes of passage just to help keep track of where I am and what's left undone.

6) Pericare is important but pretty far down the list when compared to other items

7) Don't get hung up in rooms... if patient or family wants to talk then assertively but politely excuse yourself.

Curious... you say that there's no help... is that really true? Other nurses won't pitch in to help you out? If it's really an 'every nurse for him/herself' environment, then you've got a real challenge in front of you.

So a few comments from my 4 years in the ED (2 rural, 2 urban)...

1) You don't NOT have time to chart vitals... seriously, this one's gonna come bite you in the butt when your patient crumps and the last vitals are 3 hours old from triage... or a doc's gonna hunt you down to say, "why do we have no vitals?"

Seriously, get in the habit of leaving the cuff on and set the monitor for q30 min. Then be sure to cruise through and take a quick note of the vitals... truthfully, I round sometimes... I can't remember if it was 126 or 133 so I round to 130... (actually, in my case, our monitors are linked to the EMR so I can just pluck them off of the data page).

2) Make a habit of doing quick fly-bys to note that patient is not in extremis and then chart, "no acute distress at this time." Doesn't take but a minute.

3) And you really don't NOT have time to check sugars... little story for you... I had an LOL with regular fsbg checks ordered... was busier than sin but kept popping my head in on her... she was always awake and responsive... mentating at baseline... when I finally got to check her sugar: 25...

4) Keep working on your prioritization... When I'm crazy busy, I give a pass to the detailed history, detailed report, and thorough assessment... Those are all important but not compared to finding that sugar before it hits 25 or having current vitals on sickies. I can do a rapid assessment in about 45 seconds on most patients.

5) Keep track of the time... I note each 30 minutes of passage just to help keep track of where I am and what's left undone.

6) Pericare is important but pretty far down the list when compared to other items

7) Don't get hung up in rooms... if patient or family wants to talk then assertively but politely excuse yourself.

Curious... you say that there's no help... is that really true? Other nurses won't pitch in to help you out? If it's really an 'every nurse for him/herself' environment, then you've got a real challenge in front of you.

we do hook them up on monitor and auto time interval q 30 min, but at this point, it's even hard to chart those as I have hard time even keeping up with q2hr vitals. I do try my best to chart as I go, but when everyone is expected to chart even stupid details like "IV start time and stop time" when simply that can be found on the eMar (which is double charting)... the charting system really doesn't help one bit. I would say out of 10 times, maybe about only 3 or 4 times we would get help, or at least as it seems. I am actually night shift and I hope once I move into it, there will be more help? My preceptor and I always pop into rooms that get EMS whether they are ours or not just to help out, but I don't see that happening from others all the time it seems. The challenge seems pretty clear.

turnforthenurse specializes in ER, progressive care.

I have not used Meditech....but are you able to associate the patient to the room that way vitals will automatically download when you click the time in the computer?

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