A Day in the Life of an ER Nurse

I know, it’s been a long time. It’s June. I last wrote over three months ago, and as we all know, life as we know it has changed. As a reminder, I am a new grad nurse in an busy inner city emergency room. This year has been one of the most challenging yet gratifying years of my life. This is a day in the life in my shoes.

At 1000 I wake up sore from the past two shifts. I take ten or so minutes to wiggle around, discovering two new aches and pains that weren’t there when I woke up yesterday: my jaw is sore from wearing a heavy NIOSH respiratory for at least ten hours of the day, and my right foot and ankle are sore for some unknown reason. It’s okay. It’s day three of three and I can get through it. I am looking forward to those sweet four days of freedom.

I hobble over to the Keurig. Coffee is a priority. I do my business in the bathroom as the bubbling sound of the Keurig breaks the silence in my apartment. My sweet black lab mix stretches herself out on the floor and slops up some water.

The mid-morning light streaming through my window reveals a nice blue bruise and swelling in my foot. Awesome. That explains the pain. I grab some ibuprofen and an ace wrap. I don’t have time to ice this morning. I’ll just have to deal.

I slowly pack up my bag and “lunch,” wondering if I’ll actually be able to eat it tonight. Not that my hospital doesn’t provide breaks, but often there just isn’t time to stop. I slap on some moisturizer and mascara. The only feature my patients and coworkers can see are my eyes. Makeup is discouraged because of the mask decontamination process. No concealer for the purple bags under my eyes.

As I walk down the hall toward the parking garage, I notice that my ankle really does feel unstable. I also have a backache, but that isn’t new. The light of the sun and the warm air hits my face. I take a big deep breath. I won’t see the outdoors for about twelve hours.

My car is a biohazard disaster. I haven’t had time to wipe anything down. Daily assignment sheets, syringes, flushes, angiocaths, and empty water bottles all make a rustling sound as I set my bags down on the passenger seat. I hate having a messy car. But I don’t have time today. Maybe on my days off.

My drive is easy. I listen to some of my favorite songs to raise my spirits. I have a long day, but I also feel excited to go to work. I love my job! I learn something new every day. I’m finally feeling more comfortable in my brand new career as a registered nurse. Most patients are appreciative of the work we are doing. I’ve been getting more “thank you for everything you do’s,” lately. I appreciate this part of humanity. I don’t come to work to be praised, but it helps.

I walk in an entrance which is normally public, but is now badge-in only because of the pandemic. I clock in, then wait for my assignment. Our census has been starting to go up. The regulars are starting to trickle back in. Today is the first day in a couple of weeks that the department is full. We have many admit holds, and most of those are ICU. My assignment is called “death row,” a row of four rooms at the front that typically have the worst of the worst (not including traumas). Any room in our department can receive any type of patient, however.

My intuitive nature has the ability to “feel” a room and know what moods people are in, particularly stress levels. I have really been working on not being an emotional sponge, something I have struggled with my whole life. I have my moments, but I’ve gained a better handle on compartmentalizing at work. As I walk into my pod, I can feel something in the air. Tonight is going to be really…interesting.

I, like most nurses, do “drive bys” of my rooms. I like to peak at each patient very quickly even before getting report. I can see a lot just from a glance, and that way I have an idea of which patient will be my priority. This time, I see two patients who are intubated with soft blood pressures. My other two patients are at least breathing on their own.

After getting report, I get completely gowned up with my mask, respirator, face shield, gown, and double gloves to go into my priority patient’s room. His pressure is tanking. I do a quick assessment. The ventilator is in place and on the correct settings given to me by the respiratory therapist. The patient’s oxygen saturation is only 85% at 100% FiO2. We are forced to be satisfied with that number. His MAP is about 62 and dropping. I need to figure out what the next step is. As I trace all of my lines, I discover that the vaso drip is occluded. I breathe a sigh of relief. I flush the line and restart the vaso. Two minutes later, I have a MAP of 72 and I throw two big thumbs up to the nurses and doctors watching me from outside the room.

One problem down, many to go. While in the room, I get a call from RT that the ETT needs to be moved back. I chart my assessment as I wait for RT to gown up to come into the room. I signal for my preceptor to come to the window. I want to increase sedation to move the tube now that the pressure is holding steady. Everything except the vaso is on extension tubing with a pump outside the room. I have to ask another RN to titrate the norepi, fentanyl, or versed. He’s kind of a bigger fella, and there was already some response to pain during my GCS assessment. There are no restraints, and if this guy pulls out his tube, he would most likely die.

I’m actually nervous to suggest titrating the Versed up. I’m a new grad. This is actually the first time I’m in a level 1 critical room on my own. There is a lot going on. This guy is super. freaking. sick. I know I have many hands outside the room to help, but my preceptor is giving me space to take the lead. I’m met with a “that’s a great idea, what do you want it at?” My preceptor pushes the buttons for me and shows me the pump screen to verify. Thumbs up, again.

RT is in the room. We come up with a plan of action for moving the tube. It’s just the two of us. There is a high suspicion that this guy is COVID+, so I don’t want to put other people in jeopardy unnecessarily. Our plan is in place. She nods her head. Moving the ETT is considered an aerosolizing procedure. She moves the tube and the patient starts coughing and moving his arms toward his mouth. Shit. I grab his arms and nearly lay by body across his to prevent him from moving. The ventilator begins beeping loudly, and the patient’s O2 sat drops to 70%.

“No, no, no!” RT exclaims. I do not like this situation. I motion to another nurse standing outside the room. I point up and she understands to increase the fentanyl. The versed is nearly maxed out and this guy cannot afford to lose any more perfusion. We get the ETT secured to the new location, and the patient calms down. This whole time, we are trying to talk to the patient to reassure him. I don’t know what he can hear. I don’t know if we’re helping.

Thirty minutes is way too long for an initial assessment when I have three other patients to see. I need to get out of this room, not only to limit my exposure, but to also see my other, more stable, intubated patient. I wait until his saturation reaches 80%, and I signal that we’re ready to come out.

Forty-five minutes into my shift, and I’m already soaked in sweat. I doff all of my equipment and take about 30 seconds to breathe before I have to gown up again to go into another room. This other intubated patient is hemodynamically stable, so I do a quick assessment and let the patient know who I am and what I am here for.

The next couple of hours I work with several people to get my sick patient to the ICU. Those warriors work very hard, so it takes a while to coordinate the transfer. We have to take at least four people in full PPE to transport this patient across the hospital, with other folks ensuring the hallways are clear so that other staff doesn’t get unnecessarily exposed. Before we even leave the department, we are all drenched in sweat.

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After about 30 minutes, I am back in the department and of course there are a dozen more tasks that have piled up since I’ve been gone. There’s no time to breathe, take a drink of water, or pee. I have to make a priority list and get several things done first.

I’m still learning how to manage my time. Every few hours, I try and make a “list” of my priorities, whether that be in my head or chicken scratch on paper. I also try my best to help my co-workers as they deal with codes, strokes, STEMI’s, and frequent fliers.

The biggest time hurdle of the day is a septic DKA patient that I can’t get lines on. They need at least two IV’s, two sets of blood cultures, an insulin drip, two different antibiotics, and fluids. My 22g in the thumb isn’t going to cut it. It takes time to find someone to sono, and finally I come to the conclusion that this patient needs an EJ. An hour later, I’ve missed my sepsis times and I’ve fallen behind on my other three patients.

Seven hours into my shift, I haven’t stopped to pee, snack, or thoroughly chart. I’m okay, though, but it peeves me when my 2 hour LOS is complaining that we are starving her to death by not offering a turkey sandwich. What the public doesn’t understand is that in an emergency room, we treat emergencies. If hunger is your biggest problem then I have good news for you. You are going to survive. I do care, but I am trying to keep the person next to you alive.

It’s finally time for my “break.” This consists of rushing to the microwave, setting it to 2 minutes, and hoping I get to come back to eat it. I also gulp down a huge glass of water and some tylenol so I can convince my stomach that it’s full for just a little bit longer. Luckily, today, I get about 10 minutes to eat and chart at the same time. One of my patients is up for discharge, so I used this time to back-chart. This patient was a soft ESI 3, and probably could have handled things at a primary care. But unfortunately, many primary care offices are not seeing patients, so people have no choice. I write some quick assessment notes on this 34 y/o knee pain. His vitals were stable the entire time and his biggest concern was getting a work note.

My food is somehow already gone, and I mask back up. I place the N95 on, secure my surgical mask over it, and I wipe down my eye protection before putting it back on. I scrub my hands and continue back to work. The next four hours whiz by, as I shuttle about ten patients in and out of my rooms. Some are easy in and out discharges, but others are ICU holds. I fall extremely behind by 2300. I have been asking for help when I can, but everyone else is slammed, too. By midnight, I still have work to do. I don’t like leaving tasks for the next shift, especially when they are simple. But I just got 3 new patients between 2315-2330. I have been focusing on the septic one and haven’t even worked up the others. I did a drive by, and I know they are hemodynamically stable and breathing, so I don’t have a choice here.

The nurse taking over for me kindly waits for report. I give some details while pulling heparin out of the med room. “This is for my septic guy with multiple PE’s. You’re gonna want to see him first. His pressure is soft, he’s alert and oriented to himself only, and he was a hot mess of a transfer from another hospital. The good news is that he has 3 lines…” I chuckle a little on that last part.

“You have one COVID+ in room 16. He’s stable on 4LNC, 93%. Nice guy, low maintenance, everything’s done on him. I haven’t seen 17 yet but she is ambulatory, breathing, and I think someone did line and labs. She is here for a rash. Room 19 is a 35 y/o abdominal pain from a chronic issue. Line and labs done. She is very uncomfortable and the doc ordered morphine. But she is stable.”

Any floor nurse or ICU nurse would cringe at the report I just gave. Just a few sentences for 4 patients. That’s all we have time for. Just the basics. ABC’s. So if you’re an ICU/floor nurse reading this, understand why we give the report we give! Sometimes we just don’t know. In the ER, if I see someone walking themselves into a room, I know that I probably have a few extra minutes for my sick patient next door. My goal is to get vital signs within 5 minutes of all new patients, ambulatory or not. But sometimes, all I have time for is, “Hi, I’m Sky, I’ll be your nurse today. I’m going to hook you up to the vital signs machine, can you tell me briefly what brought you in today?” I get them hooked up, make sure their ABC’s are intact, and then I’m out the door.

It’s not that we don’t care, it’s just that we literally have people dying.

I meet up with the other girls on my shift. We all walk out together and each person vents about the shift. We all just got our asses kicked. But I’m happy. I’m exhausted, but I love my job and I wouldn’t trade it for anything!

Skyanne, BSN, RN

P.S. ALL of these patient scenarios may be based on real-life cases, but none of them actually match patients I had. It is merely a mix of the typical cases that I see in a day. There are NO pieces of identifiable information in this post, and even if there were, I made the numbers up. Room numbers, too.

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