Tangled

The Easter Bunny visited the ER on Friday, and with her she brought the beginning of a slower season….hopefully.

The past couple of months in the ER have been very busy, and some days insane. I’ve learned so much, and each shift I feel stronger. Sometimes I look to the medics for advice, and then I hear the say….”you’re the nurse….you decide”. Being in a new area of nursing has been quite challenging (in a good way), and has pushed me past my safe place. I have to make decisions on the fly. Sometimes, I don’t feel I have as much time for each patient, like I did when I was a floor nurse, and sometimes that bothers me. But in the ED, I’m forced to spend more time and energy on the chest pain, STEMI or septic patients, then the one with a finger laceration.  My prioritization skills have been sharpened. I’m also learning to ignore the critical comments from some of the critical care nurses. Someday I hope  the CCU nurse and ED nurse can understand one another a little better, and appreciate the complexity of both areas of nursing. Don’t get me wrong, almost all of the CCU nurses I’ve worked with are amazing, but I’ve had one or two experiences that have left me feeling defeated.

For example, during one of my recent shifts, I started my day with two patients, each requiring an abundant amount of attention. Mrs. A was unable to handle her stools, and traveled from bed to bedside commode every 5 minutes. In addition to this, what was coming out of her backside, was also coming out of her mouth as she vomited. She had severe abdominal pain, and her room was in constant need of linen changes, and mopping. I had to page the attending physician several times for pain med orders, and suggestions, because she was in tears and miserable. I spent at least the first hour of my shift with her. Meanwhile, Mrs. B, who is a former nurse, and now blind from diabetes, required help to the bathroom, help with meal set up, needed insulin and took 14 morning medications. She was so sweet, but I spent a large amount of time with her that morning as well, making sure she was  medicated in a timely manner, and settled into her dark world. She was also in need of pain meds, and I had to page the physician several times to obtain the correct order.

It was about 10 am, when EMS brought in my sickest patient, Mrs. C. She was wheeled right into the trauma room, and her rhythm on the monitor read V-tach. Wow. She was obviously labored and unconscious. We went right to work on intubation, with the whole team jumping in to do their part. I ran for the RSI kit in the pyxis, KQ started an IV, Jess placed the patient on the monitor and obtained an EKG, someone else took vitals, RT prepared for RSI, and Kerry helped me draw up meds from the RSI kit. It’s quite nerve wracking being the new nurse, and the one who’s supposed to help coordinate it all, along with the ER doc. Thank goodness I had so much help. After intubation, Jess did another EKG, and then the doctor called a STEMI alert. From that point on, I was knee deep in helping to prepare my patient for transfer to our sister hospital for proper cardiac care. Not only did was there a load of charting to do, that would give explanation to all of our interventions, I also had my fair share of work ahead in coordinating the transfer of my patient by physically preparing her,  and giving report to the critical care transport team. About an hour and a half later, I watched the critical care transport team wheel my patient away.

During this whole critical and important emergency, there were times in which I hoped Mrs. A and Mrs B  were ok. I sent other nurses in to address their needs, because they did call for me several times. I felt guilty, and I shouldn’t have, but I did. I was focusing on my priority patient, which did not allow me to leave her side. It’s what I would have done for either Mrs. A or Mrs. B, if either had been in that situation. And, I gained another patient in one of my Baker Act rooms, that I had not even said hello to at that point. So, when I completed the tedious task of meticulously charting all details of the RSI, STEMI alert, critical assessments and interventions and transfer on Mrs. C, I made a visit to Mrs. A’s room first to help her clean up, and get to her bedside commode for the 100th time that day. I popped my head in to say hi to the new pediatric baker act patient in room 8, and let her know I’d be back soon to take care of her. Then I made my way to Mrs. B’s room. I apologized for my absence and explained to her that I was tied up in an emergency. She was gracious and kind, and begged me not to worry.  Because of her blindness, some of her morning breakfast tray had spilled on the floor, and some of the wires and tubing attached to her got tangled. It was then that the nurse from CCU came down to help transfer my patient from her ED room to her new CCU room. As she approached my patient, she was clearly annoyed, and then scolded me for the wires and tubes that were tangled. She then made it known that she shouldn’t have been called down, unless that patient was ready to go. She huffed and puffed, and was clearly upset, and somewhat rude about it in front of my patient. I kind of understand her frustration. She has a lot going on too. I realize that critical care nurses like things a certain way, and I also feel they view ED nurses as haphazard at times, or less detail oriented. I have nothing against this nurse, and she’s actually been really nice on previous encounters, I’ve had with her in the past. I’m thinking maybe she was just having a rough day. We all have our moments. I didn’t have to say much or respond to her frustration, because the patient did to for me. As I previously mentioned, my patient was a former nurse. After I apologized to the CCU nurse, the patient turned her head towards me and said, “Don’t apologize to her. That was rude! I’m so sick of nurses treating other nurses so poorly!”. This only exacerbated the CCU nurses feelings, but it I secretly enjoyed the defense. And, she was right. There is no need for CCU nurses to treat ER nurses poorly, and vice versa. I don’t know all that goes into caring for the critical care patient for 12 hour straight, and the CCU does not know all that goes into caring for sometimes 3-4 critical care patients that come rolling through the ER in need of rapid response, and stabilization STAT. It happens, I promise. There are times in the ER in which I care for 2-3 critical care patients, before they’re transferred upstairs, along with my other patients. It’s not easy. And, the ER nurse starts from scratch because not only do these patient need stabilization, but there are a gamut of other priorities and tasks that must be completed right away, that include but are not limited to 1-2 IV sites, fluids, lab work, urine, EKG, diagnostic testing, assessments, H&P, charting, charting, charting and charting, and that is only the bare bones on an ideal patient, and not every patient is ideal. Some patients require several attempts at an IV, the use of an ultrasound if the attempts fail, or a call to the IV team and a long wait if the latter two attempts fail. There are family members waiting for updates, constant assessments of vitals, drips to be hung, antibiotics that must be given within a certain window of time in sepsis alert patients, times in which we escort the patient off the floor for diagnostics  if they must be constantly monitored via tele., and some patients require full one on one care, such as those who are critical. Then there are those who require an hour or more of time, if they require conscious sedation, intubation, are coded, are in cardiac arrest, are septic, or have multiple fractures (like my trauma alert that came in with full body fractures and had to be Bayflited out to a trauma center).  And, the ER nurse still maintains the full weight of his/her patients, even if he/she is tied up with the critical patient. The other nurses in the ER step up and help, but they can only do so much, because they have patients too. In ER everything starts from scratch, so sometimes in the rush, wires get tangled.

I’m sure there will be plenty more times in which my tubes and wires will be tangled, but I’m learning to blow off the rude comments that sometimes come from nurses who have no clue what my shift or day has consisted of. I say all of this with the understanding and respect for the CCU nurse as well. I know they deal with a lot and carry a big responsibility in providing care to those who are very sick. The CCU nurse and the ER nurse both carry a huge weight and responsibility, and hopefully someday there will be mutual respect amongst the two specialty’s

The ER has taught me to grow tough skin, and not because I had the choice about it, but because I had to in order to keep going and not run off crying.  Actually, I have left a shift or two or five, in tears. But, I like the challenge, and I know with each shift I’ll get better and stronger. I’m still a fairly new nurse and an even newer ER nurse. But, I’ve developed a few techniques for better efficiency and care of  my patients. I’m finding my place amongst my fellow ER nurses, medics and physicians too.

And, speaking of showing respect to the CCU nurse, I’ll be a bit of a hypocrite and leave you with this picture that I found to be quite amusing.

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