Laymen and soldiers
Alike, please understand me.
- A drowning frontline.
Despite so many important and interesting topics to discuss, I’ve decided that it wouldn’t make much sense to move forward without addressing the elephant in the room. Just what do we do in the ED anyways?? I’ve come to realize that there is a lot of confusion regarding what an emergency department is actually for, the environment in which it functions best, and why a place that is so chaotic is the frontline for saving life and limb. The most insightful revelation, though, is that it is not just people who have no ties to healthcare who are confused. Other nurses throughout the hospital are often just as fed up with ED nurses as are patients who have been waiting six hours to be seen. I’m hoping that this post will help bring at least some clarity to patients as well as to fellow RNs.
To start: what is an emergency department for? Though this might sound very obvious, it actually isn’t. And I mean no degradation in my response. Said simply, an emergency department is for emergencies. But emergencies come in all shapes, sizes, and severities. One person may consider a set of circumstances to be minor given personality traits and the environment in which he or she was raised. Another person might not tolerate pain as well as his or her neighbor. Some people have severe psychological pain associated with their physical pain. Some incidences and illnesses impact one’s livelihood more intensely than others, prompting a seeming need for emergent care. So, here, simplicity is not so helpful. That said, it isn’t truly realistic for one entity to tackle that large variety of care. We have cardiologists who specialize in the heart. Orthopedics who specialize in bones. Nephrologists who specialize in the kidneys. And so forth. The crucial point, here, is that emergency medicine is also a specialty, and, more specifically, a specialty of acute care. And within this specialty we have further sub-specialties. Besides the basic positions including beside nurses, PCTs, advanced practice providers, and doctors, an emergency department is made up of people who specialize in even more specific areas of emergency care– imagine a type of Henry Ford assembly line– so that one person can concentrate on one aspect of care in a quick and efficient manner and follow it through to the end. Triage, trauma surgeons, stroke teams, MI teams, anesthesia, respiratory therapists, registration, ECG techs, phlebotomists, CT/X-ray/US/MRI, transportation, environmental services. We are each trained in our specific sub-specialty of emergency care. When an alert is called overhead, we arrive to the room, we gather our supplies, and we get to work. Because each sub-specialty has been defined and that definition has been agreed upon nationwide, every person in that trauma room knows exactly what to expect– what my job is, what his job is, why that man or woman at the head of the bed, to whom to ask this question. No two people are running around trying to get the same thing done. No one is unsure who is in charge. Does this get messy at times? Of course– we are all still human and a person is dying before our very eyes. But, in theory and time again proven in practice, the clearer the rules, the less room for error, the faster we can get er’ done. We have been trained to treat acute situations such as strokes, heart attacks, vehicle accidents, and sepsis, to name a few. Our definition of an emergency is, therefore, quite narrow. Our definition of an emergency is more along the lines of “are you dying right now or could you die within the next few hours without immediate intervention.” When reading that back, it feels kind of dramatic, right? But it’s a real thing. There are some conditions that just cannot wait.
So why am I saying all of this? First, let me speak to my patients. The faster pace makes for what appears to be chaos. Just like you are having an “emergency,” so is everyone else who has come here today. No one emergency is more important than another. But some emergencies are more time-sensitive. The emergency department looks at time-sensitivity, amount of pain, number of resources required, and length of wait as main factors in deciding who gets seen next. You may have been waiting for two hours already, and “that guy” gets a room first. Unfortunately, that means that “that guy” is in the midst of a more time-sensitive situation that you are. “That guy” might be having a heart attack as we speak. Or a stroke. Or his blood pressure may be so low that he is hardly perfusing his body. That doesn’t mean that ED providers and nurses don’t believe that you are in pain or also have an emergency. We don’t like feeling ill or throwing up any more than you do. But this is where the definition of emergency comes into play. Providing emergency departments with a narrow definition of specialty only works if the department is properly resourced in that manner. The rise of urgent cares helps facilitate this. Have you been feeling weak, fatigued, throwing up, diarrhea, and unable to tolerate food or drink for the past few days? Are you unsure how good it would be to wait it out any longer? Are you otherwise healthy without many significant medical diagnoses? Perhaps an urgent care is the correct place for you to rehydrate, rest, and ensure your electrolytes are in balance.
That said, sometimes the closest urgent care isn’t open at the time you need help. Maybe you don’t have one near you at all. Maybe you are just unsure and think that the ED would be the safest place for you. The nurse who first greets you in the emergency department is called the triage nurse. His or her job is to determine the severity of each person as they come in and label them a 1-5, if using the fairly recently revised and improved ESI triage scale. Very, very simply put, 1 means you are actively dying– bleeding out from a car accident, pulseless from a heart attack, etc. 5 means you require very few emergency department resources for your care and are not in a situation that would cause you to die anytime in the foreseeable future– this could be a cut requiring stitches, etc. Triage nurses take into account your past medical history, your pain level, and your vital signs when making a decision. All emergency departments hope for more 1-3s and fewer 4s and 5s by having the 4s and 5s seen at urgent cares. This would decrease the number of people waiting for care, would decrease the amount of resources being used overall (including the time and energy of employees), and would decrease the overall stress and chaos felt throughout the department. But a triage nurse would never turn you away. If you feel that you need to be there, they will put you on the list. Not only is it against federal EMTALA law to turn someone away, but it is unethical to do so.
So, to handle this influx of emergencies on a daily basis, we as providers work as quickly and diligently as we can. As a general rule, there is no running in the ED. Running symbolizes panic. Panic hinders critical thinking and attention to detail. We don’t run. But we do haul ass. We work as quickly as we can on as many patients as our hospital determines safe for us to do so at once. We don’t want you waiting in the waiting room any longer than you have to. We don’t like to see you in pain. We don’t like to feel like we are failing you. To do that we rush from room to room performing task after task. We attempt to keep up on labs and imaging as they result. We attempt to make you comfortable while you await your diagnosis. We attempt to get to know you. But just as we have a narrow definition of care, we also have a narrowly defined goal: to put out as many fires as possible while maintaining as much dignity, autonomy, and comfort as possible. Our goal is not to get familiar with your life story. Our goal is not to treat your chronic issues. Our goal is not to stay with you during a lengthy admission. We stabilize and we send out. This concept is pertinent for fellow RNs. ED nurses often know very little about their patients in comparison to the amount of knowledge nurses on in-patient units come to acquire after taking over care. This often surprises in-patient nurses when it is time for us to give report. A skeleton report is the best ED nurses are often able to give. We can change locations within the department as often as every four hours to cater to department needs. Working in the ED requires flexibility and constant re-prioritization depending on which kinds of emergencies walk through our doors or are brought in by ambulance. The downside is that this kind of flexibility does not allow for consistency. I often give report on patients I have been assigned to for two hours and have only seen once. I don’t study the charts. I browse for outliers and interventions only. I don’t remember where the IV is. It doesn’t matter for my goals of care. When I get in the room, I use the one that’s available and I leave. I’m often not sure the urine output or number of bowel movements unless it’s pertinent to that patient’s current acute situation. I often can’t clean up the chart as much as I would like to before the patient goes up to the unit. Ugh. It sounds so bratty when written down. But I just can’t achieve my goals and your goals at the same time. I just can’t. I’m on to the next fire. I plan to do and know as many things as possible– don’t get me wrong! But how does that saying go: “the best laid plans…” Patients keep coming in, keeping getting upset for waiting, keep requiring more orders be filled. And everything keeps getting delayed for those 1s and 2s that suddenly appear.
As we progress as a culture and adapt to leaning on urgent cares more and more, the hope is that emergency departments will “slow down.” Yes, we always need more staff. 6 patients to 1 nurse is not only unsafe, but it’s inefficient. My feet only move one at a time. My brain can only perform one task at a time, even if I am in the middle of several. I can only answer one call light at a time. But we don’t need emergency departments to become more like in-patient units or long-term care facilities or chronic pain clinics. Emergency departments are good at what they do. Someone has to be on the frontlines, putting out the fires, and getting people to the right places for the best outcomes. But please understand that we aren’t that place. We won’t heal you. We won’t fix you. We will stabilize you and help you get to the unit or the out-patient appointment that will. We yearn for a better community understanding of what we do and why so that we can be used properly and therefore function properly.
Xoxo
The Frontline