When will I feel comfortable?

[nb1104_, ADN]

Hello! I've been a nurse for 6 years now. I was in medsurg/tele for 4 years, then I was granted a training position in ED, February this year for 12 weeks, and I've been working on my own since May. Is it normal for me to still feel dumb or overwhelmed whenever I get critical patients? Like just today. I had a pt who was rule out stroke/DKA/sepsis, but he is DNR/comfort. The family wanted us to intubate him because he was desaturating, and sustaining at mid 80's despite being on bipap highest setting.

 

this is the 2nd intubation I experienced on my own, and the last one was more than a month ago. I still feel soooo stupid and overwhelmed. We were waiting to transfer the patient to ICU but his oxygen was unstable. I was overwhelmed because the hospitalist was telling me to start him on drips and my ED lead said that it's ICU's job. I think I'm starting to look annoying and not knowing anything because I do ask a lot of questions.

 

I guess I'm just ranting because I want to feel better and I want to know that what I am feeling is normal and that it will get better in time 😰🙁

[floydnightingale]

12 weeks sounds like a very short orientation, intubating and admitting a DNR to the ICU are two contradictions, and unless you're a CRNA I can't imagine you actually intubating anybody. Every place I've worked a physician did that. As far as drips being the ICU's job, I dunno, I'd get out before blowing up my license.

[Lipoma, BSN, RN]

12 weeks appears appropriate for an experienced nurse transitioning from an inpatient setting to the emergency department. The reason I say that is because I was given 16 weeks as a new graduate nurse before I was cut from the umbilical cord. Then when I transitioned to the cardiac ICU 4 years later, I was given 12 weeks of orientation. 

That said, I didn't start feeling competent and comfortable with highly and acutely sick patients (think ESI 1-2s) until about year 2, and that was after obtaining my CEN and consistently volunteering for the sickest patients. The knowledge I gained from becoming certified gave me a sense of comfort and foundation to anticipate physician/APP orders or initiate life-saving interventions with a concrete rationale and understanding of what I am trying to achieve. 

Now, since you have med-surg experience, you know how to nurse and how to recognize when a patient is decompensating. The difference you're facing now vs inpatient is balancing multiple sick patients who require immediate or urgent attention. What you're experiencing at this level is learning a whole new specialty, and ED has a steep learning curve. So yes, what you're feeling is normal.

Give yourself up to a year post-orientation to become comfortable managing and delegating. The beauty of the ED is it's really a team-oriented specialty. When an acutely ill patient is present, all hands are on deck until the dust settles.

It's the primary nurse's job, whether they're in the ED or ICU, to initite those drips to keep the patient safe (ED and ICU nurses both manage critical care patients). Gain a deeper understanding of critical care infusions to better support your patients. I recommend Sheehy's Emergency Care.

[Nurse Beth, MSN]

Intubating a patient with DNR status? I don't follow.

[Tenebrae, BSN, RN]

Nurse Beth said:

Intubating a patient with DNR status? I don't follow.

That was my question?

OP its more than OK for you to speak up re the patients wishes. Families often panic and its OK to reassure them as their loved one moves towards death their obs will drop. 

[ON MHFA]

Agree with Nurse Beth. We usually have DNR and DNI status over here in Canada to clarify the situation. I wonder if you have that as well there? Regardless, families tend to panic at the very last minute. The patient's wishes should be followed - and you can always call on an Ethicist or advocate for the patient's wishes.  You will always learn something new with nursing - especially in the ER. Do not feel that lack of knowledge should make you feel uncomfortable. Keep a growth mindset - and you will start seeing learning as a challenge rather than something to shy away form.