7am I pour a cup of coffee and take report, I have two patients in my four rooms, the first is on a mental health hold and expected to leave shortly to go to the MH unit. The second is a little old lady with new onset afib who has had labs and an EKG has gotten some IV Cardizem to slow down her heart rate which has worked well and she is currently resting comfortably.
0705 I go to assess my patients, the MH patient is drowsy from Haldol he was given when he came in but otherwise cooperative. The little old lady is fine, lungs clear still in afib but the rate is now 80's instead of 160's. She is a little short of breath and needs to go to the bathroom. We discuss putting in a catheter so she won't have to get in and out of bed or wrestle with the bedpan. She is agreeable. I tell her I will be right back.
0715 I talk to the doc about the LOL, I tell him she needs a catheter and is still SOB even though her rate is controlled now. He looks at her Xray and orders some IV lasix as he see's she has some pulmonary edema, fluid backed up into her lungs. When her heart was pumping so fast, it wasn't doing it's job of pumping blood strongly enough and it backed up into the vessels in the lungs, congesting them and causing fluid to leak out of the vessels and into the lung tissue and air sacs.
0725 supplies gathered I give the lasix, wash my hands and put in the Foley. I reposition her, get her another pillow and a fresh warm blanket. I turn down the light on my way out of the room so she can rest.
0737 I call report on the mental health patient and send him upstairs with the transporter. I strip the room and wipe down the bed, monitor and cables, the sink and the bedside cart. As a recent cost saving measure they have laid off all but one of our housekeepers and she can't keep up with the volume of the work so we have to pick up the slack. The triage nurse has put a patient who has flank pain into one of my empty rooms so I go in to assess him. I find a pale, sweaty middle aged man vomiting into an emesis bag. I suspect he has a kidney stone so I ask him to give me a urine sample and step out of the room.
0755 I talk to the doc about the new patient and he goes in to see him. I get an IV and blood draw set up and prime a liter of saline. Kidney stones are common and I know what the work up is.
0805 I start his IV, draw blood, hook up and start running in a liter of saline, label all the bloods and urine and send them to the lab. I give some pain and nausea medicine and when he is more comfortable hook him up to the monitor to keep an eye on his vital signs and oxygen levels as I am giving potent narcotics. I inform him and his worried wife that a transporter will be coming to take him to CT and that I will check back in about 15 minutes to see how he is doing but to come and get me sooner if there is a problem. I get the wife a cup of coffee. This all takes until..
0830I know have a third patient, she fell and may have a sprained ankle. I introduce myself, assess her injury checking to make sure that blood flow and nerve function past the injury is normal. She has moderate pain and swelling. i adjust the foot rest on the wheelchair so that the leg is elevated and get her an ice pack while she is waiting for Xray.
0845 I go check on my kidney stone patient to find him dozing, when roused he tells me his pain is now a '2'
0850 I take telephone admit orders from the LOL's doctor and give them to the clerk to arrange for a room.
0900 I think about having some toast but then we get a call that there is an ambulance coming in with a code blue so I go to help the nurse that is getting the patient. Sometimes really critical patients need two, three or even four nurses to do all that needs to be done to stabilize them.
0940 the patient is declared dead and after helping the other nurse clean up the room and body for family to view I go back to my assignment. My ankle injury patient has been xrayed and I give her a Motrin that has been ordered and put the chart up for recheck. The kidney stone guy is in CT. I have a bed assignment so I sit down to finish up the chart on the LOL so I can get her upstairs. The charge nurse has put a child with an ear ache in my fourth room but I decide to wait to see him until after I call report.
0950 The charge nurse upstairs tells me the nurse is on break and will call me back. That is par for the course but it is still annoying to hear when you have been busy and haven't had time for a break. I go see the kid with an ear ache, he is cute as a button, playing around and looking pretty perky. Mom is about 16 but very attentive to her kid and he looks well cared for. I ask her if she has help with him and she proudly tells me that she is finishing up high school but they live in a small apartment and he stays with grandma while she is in school.
1000 I get an ankle brace and fit crutches to the ankle injury, which is a sprain, and discharge that patient. I help another nurse accept an ambulance patient that is coming from a nursing home, the patient is febrile and has increased confusion. We get an IV, labs, hang fluid and insert a Foley to obtain a urine. The most common cause of these symptoms in the elderly is a urinary tract infection. We do all this before the doc ever gets to the room to improve efficiency.
1020 I call report on the LOL. She has to go up on a monitor so i hook her up and take her upstairs.
1035 I clean both my empty rooms and bring back a lady who cut her hand washing dishes and an elderly gentleman with cough and fever. I set the lady up to be sutured so the doc won't have to make two trips to the room. I place the gentleman on the monitor and order a chest xray to see if he has pneumonia, we have a 4 hour window to administer antibiotics if he does. I know he will need labs and blood cultures so I go ahead and put in an IV and get all that stuff along with an EKG. The EKG tech's are long gone as another cost-saving measure.
1100 now that I am done with the pneumonia guy I discharge little guy with a prescription for antibiotics and Motrin. I give him a little stuffed bear. Our ER doesn't have money for stuff like that so some of the nurses go to the dollar store and buy stuffed animals and play dough and crayons so we will have little prizes for our pediatric patient. The kidney stone patient is ready to be discharged home with a prescription for pain meds and instructions to drink lots of fluids and strain urine.
1115 the laceration lady's wound has been numbed so I irrigate it for the doc while he sees another patient.
1130 I get an ambulance patient with chest pain. EKG, monitor, IV. labs, aspirin and a first nitro. I tell that patient i will be back to assess him in a minute. I show the EKG to the doc and send the lab work off and ask the clerk to page for a chest xray.
1147 I am in the middle of cleaning my empty room when I suddenly realize I have to pee right NOW. I go to the bathroom and take two Tylenol for my aching back. Back pain is a work place hazard for nurses.
1203 pneumonia is confirmed so I hang an IV antibiotic and get him a cup of tea.
1208 Chest pain patient is pain free after nitro but has a pounding headache, I talk to the doc and get an order for Tylenol which I give.
1220 Laceration lady is sutured so I clean up her wound and apply a dressing and discharge her with directions to not do dishes until stitches are out!
1240 I bring back a lady with RUQ pain after eating, she looks very uncomfortable. I recognize the signs of a gall-bladder attack and start an IV and fluids before asking the doctor to take a look at her.
1300 The admitting doc is here for pneumonia guy, he asks me to give the patient a dose of IV steroids so I do. Chest pain patient is doing good, labs are pending so I update him on what is going on.
1310 The doc has seen gall-bladder lady and I administer pain and anti-emetic medicine, put her on the monitor and get an EKG.
1330 The charge nurse sends me to lunch. I have now worked 6 1/2 hours without a break or food. I am famished!
1400 Gall bladder ladies labs are back and she is resting comfortably. I put her chart up for recheck. Chest pain guy has an order for repeat EKG and cardiac enzymes so I do the EKG and redraw labs. The charge nurse had transferred pneumonia guy up to the floor.
1430 I have a patient with back pain in my fourth room, he is a frequent flier. I have a bed for pneumonia guy so I call report to the floor and send him up with a transporter. Gall bladder lady is going to get an Ultra sound of her gall-bladder
1445 I clean my empty room and get an ambulance with a lady who fell last night and couldn't get up so spent the night and most of the day on the floor. She is in her 80's and has obviously broken her hip. She has been incontinent of stool and urine. The ambulance crew already started her IV and given her morphine for her pain so I grab another nurse and we give her a bath and insert a Foley. She is hypothermic so we wrap her up in warm blankets after we are through.
1515 that took a half an hour. Chest pain guys labs are all back so I put his chart up for recheck, gall bladder lady needs more pain meds so I give her some. Her work up is completed, i look at her labs and US report and put the chart up for recheck.
1530 I tell back pain guy to find a ride and have it here before I will give him pain med. He has been here before and should know the drill but they always try.
1537 I give broken hip lady a little more pain med and send her to xray. The urine in her Foley looks like coke and I know she probably has rhabdomyolosis from laying on the floor all night.
1550 I take phone orders to admit chest pain guy and discharge gall bladder lady home with pain meds and instruction to follow up with a surgeon.
1600 I give back pain guy a shot since his ride is here. Broken hip lady is back from Xray, I hook her back up to the monitor and notice her BP is low so I give her a 500cc fluid bolus. I tell the doc about her BP and what I have done.
1630 Broken hip lady's pressure is still low so I repeat the fluid bolus and discharge back pain guy. There is a 2 month old with a fever in one of my rooms now and the doc is in seeing her.
1640I call report on chest pain guy and ask the charge nurse if the float can take him upstairs so I can get started on the baby. the police have brought in a patient for a jail clearance .and the other float is checking her into my fourth room.
1645 i get another nurse to help and we start an IV and get a straight cath UA on the baby. It takes 1/2 and hour, three IV sticks and two attempts at the cath before we are finished. The baby screams the whole time. The other nurse and I are frazzled by the time we are done. I hang fluids and leave mom and baby cuddling. Two month olds with fever are nothing to mess around with, she will also get a spinal tap to rule out meningitis before we are done.
1715 Jail clearance lady is getting sutured by the doc. The admitting physician is here for broken hip lady. She has better BP but is hurting so I give her a touch more pain med. I get a teenager with pelvic pain from the lobby and put her in the gyn room.
1745I put a dressing on jail clearance lady and discharge her with the police. Then I go into assist the doctor with the babies spinal tap. I have to hold the infant folded up into a comma, head touching knees. fortunately the doctor is very skilled and it only takes 15 minutes to get the crystal clear fluid which we send off to lab.
1630 I assist the doctor with a pelvic on the teenager, her labs are negative, she is not pregnant but we not a purulent discharge during the pelvic so he orders PID meds which I give.
1648 spinal fluid results are back on baby and are negative. The peds resident is going to come and admit her. I call report on broken hip lady who is going to intermediate care.
1700 I clean my empty rooms and fill them with a lady with asthma exacerbation and an elderly man with a possible fractured wrist from a fall. I call respiratory for a treatment for the wheezer and xray for the wrist.
1710 I hang antibiotics on the baby and discharge the pelvic pain.
1730 I start an IV on the wheezer and give IV steroids and send blood. I start an IV on the other guy who does have a broken wrist and give him some pain meds.
1740 I call report to the peds floor on the baby and take it up.
1755 I get back and find that the charge nurse has brought back another pelvic pain and chest pain. I do an EKG, IV and labs on the chest pain, which sounds more respiratory but he is the right age and has a history.
1820The ortho resident is reducing and splinting the wrist fracture, the wheezer is getting another breathing treatment. I set up the pelvic pain patient and assist the doctor with the pelvic exam. She is a possible miscarriage so she'll need an ultrasound and a UA so I put in a foley for the urine and leave it in so the ultrasound tech can fill her bladder during the test.
1840 I give the chest pain guy aspirin and a nitro patch. I help another nurse clean up her patient that had been incontinent.
1900 i give report to the oncoming shift. I've worked twelve hours with only one break. My lower back and feet are killing me. This is my first of four shifts in a row this week. I'm exhausted but I still have to go home and feed my kids before I fall into bed.
Friday, September 14, 2007
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20 comments:
Yep. I remember the days when I used to have to just sit and take a deep breath before I could turn the ignition key to drive home. Spending all my off time recovering from my on time. Not knowing what day it was, only that it was a "work day" or not. Hearing my name called every 2 minutes to the point that I got sick of my own name. Living on what was available in the snack machine in the lobby because it was that or have my dinner sit in the microwave for hours because there wasn't time to heat and eat. And seeing the glares from people if I dared venture out there for anything that wasn't them. Coming home feeling like I'd been hit by a truck - and sometimes wishing I had.
And people ask me, "You think you'll ever go back to it?" Hmmm...after 20 years? Not if I can help it.
I work 12hr shifts, but I am sitting doing nothing for about 7 of them, and I have the cheek to complain about it. Big respect.
Wow. And I get burnt out just doing 10-hour day shifts.
How do you find the energy to recap a day like that. I used to work at a busy ER where I had many days like yours was, and while some days I miss it, I can't help thinking I have it so good right now. I work in a 5 bed ER that sees about 7-8K pts per year. So my nights are pretty quiet now. It is good for me since I'm pregnant.
Have I mentioned that I think they don't pay you enough?
Printed this out at work and we all sat around nodding our heads and agreeing as we read each thing. You captured it perfectly.
Wow. All I have to say is--where do you work so I can come work there?
You are able to do all the things I WISH I could do for my patients but either don't have supplies or time. We don't even HAVE blankets most of the time in our ED. Half the time I can't even do a proper head-to-toe assessment on my patients.
On a SLOW day I have six patients in my eight to nine rooms. We have one area that has two rooms but also covers the "asthma chairs," which hardly ever have actual asthma patients in them--try DVTs, chest pain, pneumonia, renal failure. Some areas have rooms that are all cardiac monitored beds--so you can have up to 8 patients needing serious care--I've had two or three ICU admits (vented and with drips to titrate) and four telemetry admits all waiting to go up to nonexistent beds in the hospital.
The only thing that's great about our ED is that no matter what, we almost ALWAYS get our breaks. Part of my job when I come in (I work 11:30 am to 12 midnight) is to send three or four other nurses to their breaks as I take over their areas for an hour each in turn. Then I go for my break, and then at 4, the people on my shift each take an area until midnight, and the people who have been relieved go around giving everyone their afternoon breaks of 1/2 hour.
Sorry, totally didn't mean to turn this into a bitchfest. Your post has opened my eyes to what other ER nurses are doing and (as a relatively new ER nurse--two years) helps me to see that things CAN be different.
Guitar girl, sounds like your management isn't to concerned about what is good and safe for their patients. I used to work in an ER where the non criticals assignment was 10 rooms, it was ridiculous. The average length of stay was 12 hours and you could wait HOURS to get your IV and meds. That is not how things should be. Fortunately, in California we havea 1;4 Ratio if they are critical care 1:2, trauma 1:1. that being said, we are frequently out of ratio to get the patients cared for, especially when we get a critical on top of an already full ER.
Ratios aren't magic, but they do help make things safer.
We work hard in the NICU, but at least it's the SAME patients for most of the shift. There are exceptions, when things are getting really hairy, but it's not the norm. I don't know how you keep track.
I have worked the same day so many times. But there are the less busy days- they are coming fewer and farther between.
I empathize with you. I have no idea how you kept all that in your head and were able to write it all down. But thank you for doing so. I'm happy you've illustrated what we do so well for others to read.
Why can't you come work in *our* ER? Even part-time?? Pleeeeease??
Damn.
I am impressed you have floaters and transport nurses. we have to do all that ourselves, and while the bed assignments are only 3 beds per nurse or 2 beds if you have the trauma bay, that does not count the halway beds that magically appear all the time. So you can have as many as 5 patients. And we don't have EKG techs either, we do have housekeeping, but a lot o times, they just can't get the beds clean as fast as we need them.
We must have worked in the same ER, because I have had days like that many, many times!
Oh my gosh, I work a BUSY ER as a traveler and I can TOTALLY agree with this. I just come off of 3 back to back and it was the worst 3 days ever, I'm fairly new I guess 3 years into ER nursing. But the fair is in town and this honestly was the busiest 3 days ever. I worked nights up until just recently and I am thinking of going back. I do not think people realize just how Friggin tired we are and how hard we work. I am trying so hard today to just recover from those 3! All I can say is that ER nurses are some tough peeps! I will pat all of us on the back and say JOB WELL DONE!! Because if we wait on praise from pts/ mgt we will be old and grey! I very much enjoyed your post, it was such am accurate account of what actually goes on ;) I think we might work at the same hospital.
very typical in the ER scene...
I salute you =)
uhm....i love you i mean really but not love as in love love but more of appreciative love damn the work you do is really something else...i hope to be an ER nurse someday
cheers mrs. energizer =)
Thanks for taking the time to share your experience in such good detail. It was exactly what I was hoping to find.
THANKS!
I know this is old, but I'll comment anyway. I love that you brought tea to Pneumonia Guy. That's so sweet.
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