Reality Check: Being a New Grad in the ED

Hellloooooo! It’s been a hot minute. Since I last wrote, I graduated from nursing school, started my residency, and passed my NCLEX! Woohoo! I wish I could say that the NCLEX was the last stop on the nursing struggle bus, but really starting to feel like it’s stop number 5 out of 100.

I accepted my dream job. I had a picture of how it was going to be. I spent over 300 hours in the ED during nursing school, so I thought that I would have *somewhat* of a smoother transition into practice. I WAS SO WRONG. Being a new grad in the ED has proven very difficult for me.


Canboc Stethoscope Carrying Case for 3M Littmann Classic III/Cardiology IV Stethoscope – Extra Storage Taylor Percussion Reflex Hammer, Reusable Medical LED Penlight

One, the ED I’m working in now is a little bit over twice the size that I had experience in, plus, it’s a Level 1 Trauma Center. New grads don’t really touch the trauma bay, and I didn’t expect to for a couple of years anyway. However, my coworkers are super great and are very supportive of learning opportunities! So I have spectated in the trauma bay a few times for some interesting cases.

Secondly, I don’t know where the heck anything is. I’m still getting lost, it takes me twice as long to find supplies, and ALL OF THE EQUIPMENT IS DIFFERENT — The pumps are a different brand and can only handle one primary line and a piggy back – no adding channels…gotta get another pump…????, the tubing is different (as well as the way to prime), the IV angiocaths are different (I do need way more practice with sticks, though), the blood culture bottles are a different shape and color, the medication dispensing system is different, the labeling process for specimens is way more complicated (the hospital recently transitioned to EPIC, so I’m not sure they’ve caught up with what other hospitals are doing), labs are drawn from different colored tubes and therefore the order of draw is different, mixing antibiotics is more complicated, requires an extra step, AND an extra piece of equipment that I’m not used to either. I could go on…but all of these little things are slowing me down immensely.

Thirdly, I am getting different instructions and directions from each nurse I interact with, so if I do something that isn’t quite what that person does, I am also slowed down because they want to explain what they are doing and why. Most of the time, I learn something new and am very excited to have a more efficient way of doing a task! But sometimes I just want to tell them that my preceptor instructed me a certain way and I would like to keep that habit. For example, I am already familiar with EPIC, but this hospital just transitioned. There are a dozen different ways to find information in the EHR. I have my favorites saved and my hands literally have two years of muscle memory to find certain pieces of information very quickly. I’m having trouble finding the balance here. I love and appreciate each piece of advice, but in the end I am responsible for my license and charting, and as long as it accurately reflects the patient’s condition and care within facility policy and the board, it’s six of one and half a dozen of the other. If you’re reading this and have advice–let me know!!

Let me get to the fun parts!!

Yes, the transition has been tough, the patient load is insane, and I feel like I got hit by a train. But I have learned SO MUCH in the three weeks I’ve been in patient care. I’ve seen a lot of new cases such as Cushing’s triad, clamshell emergency thoracotomy, ROSC, subarachnoid bleeds, and open fractures. I’ve also been able to reenforce and improve my knowledge and skills when it comes to the common cases I saw in my internship such as RSI’s, STEMI’s, strokes, and sepsis.

Being a registered nurse is really, really fun. I love seeing immediate improvement in a patient from an intervention or medication that I gave. Everyone is so supportive, and although I am a new grad, I feel like a part of the healthcare team. No one has treated me poorly or looked down on me (at least not to my face or that I know of). I’m really struggling with time management and clustering care, but my preceptors are supportive and patient.

The skill that I feel most confident in right now is my “customer service” skills. I can talk to anyone. I can stay calm in front of patients and do my best to explain what is going on. I can grab that extra blanket or take 15 seconds to take deep breaths with my patient. But I can’t wait to get better at it!

The only advice I feel qualified to give right now as a 3-week-in new grad in the ED is:

  • Don’t be afraid to ask questions! I feel like I ask a question every 5 minutes…
  • Be confident in what you know, but have the attitude that you can always, always improve and learn something new.
  • You can advocate for your patient right away! If something doesn’t seem right, grab someone for a second look.
  • You are going to feel like you are drowning, but my supervisors and preceptors have been telling me that it is a normal feeling.
  • Write things down (checklists, SBAR, questions, etc.).
  • Write out goals for each shift and take 2 minutes to share those goals with your preceptor.
  • Be appreciative of every learning opportunity and be respectful!
  • Learn some positive phrases such as, “Could you clarify this for me?” or “Could you remind me how to _____?” instead of “I don’t know.”
  • If you need to cry, do it in the bathroom or in your car!
  • Get to know your techs because they know more than you and can help you. I can’t tell you how many times a tech has saved my butt already.
  • ASK QUESTIONS. I already said that, but I feel that it is the most important for me right now.

I wrote this post about the transition before I graduated nursing school. It talks about some of the barriers new grads have with adapting to their new role. I re-read it today from a new perspective and thought it was really interesting. I am most definitely in that “first 3-4 months” where the grad nurse feels anxiety and self-doubt in the new role of a registered nurse.

I also grabbed this pocket guide called Emergency & Critical Care Pocket Guide. It’s a cute little flipbook that fits in any of my scrub pockets. It has basic information about common emergencies, ACLS charts, medication compatibilities, and more! I love being able to just grab it and learn something new.

Check out my previous post about essential emergency room supplies. Not much has changed about what I brought during nursing school versus what I bring to work now!

I also highly, highly recommend Hoka One One shoes. Listen, y’all. I had constant foot and back pain during and after my clinicals in nursing school. These shoes were recommended to me while I was in school, but I couldn’t afford them. After I got my first big girl paycheck, I ordered these shoes, and I feel like I am walking on a cloud. My pain has decreased and I can last much longer without feeling pins and needles.

Save up some money, buy some good nursing shoes and compression socks, and save your back and feet. You’ll thank me later!

Long story short, ER nursing has been a wild ride so far. I could go on and on. The bottom line is, if you are going straight from nursing school to the ED, get ready! It’s a lot. I’m only three weeks in, so please take anything I say here with a grain of salt. Not everyone will have the same experiences and I am not trying to portray that I am an expert.

Happy nursing!

Skyanne, BSN, RN


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FIVE Things I’ve Learned Working in the Emergency Department

1. Staying on Task

The first few months of working as an intern, I found myself just running around with my head cut off with no sense of direction. I have (mostly) learned the art of writing things down and setting alarms on my watch. I no longer hesitate to delegate to our awesome, amazing, wonderful tech’s. I can methodically organize tasks by patient priority. It feels less chaotic for me! I try to go through four “steps” for each patient:

  1. Initial assessment/ABC’s/Intake
  2. Orders
  3. Maintenance/Repeat Labs/Comfort
  4. Discharge/Transport

I like to write the word “comfort” near the middle of my chicken scratch report sheet. Although not a priority in the emergency room, sometimes getting that patient an extra warm blanket can ease them up and give you time to handle another patient.

2. Using SBAR to Talk to Doctors

Before this job, I had never actually done this. They teach it to us all the time in school but I have always been afraid to do it. My tip? I write down my talking points. Each phone call has gotten smoother, and I usually get what I need for my patients!

An example of my talking points:

S- Mr. X, the 80 y/o male in room 16 who is here for respiratory distress now has an O2 sat of 87% 30 min after the breathing treatment

B- He has a history of HTN and type 2 diabetes

A- BP 142/88, RR 30, HR 94, SpO2 87% on 6LNC, no temp. bibasilar crackles

R- I recommend another breathing treatment and a stat chest x-ray

In school, I felt like they teach us to include everything in our SBAR. There are a lot of situations that would warrant a more thorough SBAR (like giving report to the floor nurse). But when something is needed very quickly in the emergency department, you have to just grab the basics (ABC’s) and run with it.

3. Hospice/Palliative care.

Some of you might be wondering why this is happening in the emergency department. Well you know what. The situation warranted it. We are often on saturation, which means no where else for this family to go for several hours to days. I’ve cried with the families that are waiting for a room somewhere else. I sat with them and ignored the noise and chaos down the hall. I took extra time with the extremely uncomfortable patient to make sure the bed was made perfectly, all trash was picked up, and that the family always had fresh ice water. 

When that family makes a decision for their loved one to be DNR, and we cannot get them a room upstairs, the emergency department becomes the place where the family must start the process of grieving.

4. Confidently Asking for Help

Instead of saying, “I don’t know what I’m doing,” or, “I’m really sucking today,” I say, “Hey, it’s time for morphine, could you pull that for me please?” and “Could you please page respiratory?” My preceptor knows my limits, and I am finally feeling like a real nurse.

Negative self-talk can really hinder your day. I don’t know what I’m doing all the time. But I already know that and I don’t need to bring myself down because of it. I also use statements like, “Could we review this process? I think I misunderstood something.”

ALL. NURSES. NEED. HELP.

If your preceptor says they never ask for help, they are doing their job wrong.

5. Targeted Patient Education.

How often have I ever stopped to thoroughly explain something to a patient? Never in my clinicals, honestly. My preceptor usually does it. And in the ED, it isn’t at the top of the priority list. Patient education does not have to be some crazy 30 minute presentation! I can explain insulin and blood sugar during times of illness. I can explain a sliding scale. And I can do it in about three minutes. So yes, that sounds so simple, but I’ve always been afraid to take that initiative!


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My First Code.

I am still processing my first full code experience. I had previously been involved in a “chemical” code in which the family chose no intubation and no compressions. The patient did not survive, but he was in his 90’s and probably ready to go. I had another code called during seizures, but the patient’s heart never stopped. This was my first full on ER code blue experience. There are some potentially gross details in this story. Read at your own risk. Portions of this story (i.e. room numbers, times, names, etc.) are adjusted and no private information is given in this scenario.

All Emergency Departments have that phone. Some are red, some are white, all of them are loud enough to pierce through the chaos of a busy shift. There’s a phrase that makes everyone stop what they’re doing and prepare for the worst–“CPR in progress, ETA 10 minutes.

Room 1? Room 1. Let’s go.

In our city, ETA 10 minutes via EMS usually turns into 15-20 minutes. Our preparation was like clockwork. The intubation box was set up and opened. Crash cart plastic ripped off. Body bag placed under the sheets. We didn’t want to use it, but EMS reported asystole and 4 rounds of epi at the scene. I grabbed a handful of gloves, pocketed my stethoscope and badge, tightened the drawstring on my scrubs, and set up the stool. I was set to begin compressions upon arrival.

Upon arrival EMS is vigorously performing CPR on Mr. X. He is easily twice my size and no more than 10 years older than me. “Who else is rotating compressions?” I ask. I have help. We transfer the patient and I immediately begin compressions. It’s a whirlwind. Something came over me. I’m pushing as hard and as fast as I can. I’m exhausted after a minute. But I kept going and had excellent quality compressions.

My team is organized. Methodical. Everyone has a job and knows their job. Hands and arms are working around me, placing stickers and pads, getting lines and blood. The patient’s torso is wet from whatever he vomited before arresting.

Two minutes! Time for a pulse check!” Our recorder says assertively.

I stop compressions and check a carotid pulse while other team members check for radial and femoral pulses. Nothing. The code leader calls for another round of epi. My colleague knows I need to switch out. Five seconds later, compressions are resumed and I snap out of “compression mode.”

This guy is laying here and we don’t know anything about him. We have little to no history. We don’t even know his name.

I look at each person in the room. Everyone is hyperfocused on their task at hand. One nurse is documenting. Another nurse is keeping track of time with that person and giving medications. Another nurse is at the crash cart drawing up everything imaginable. Respiratory is bagging the patient. Another tech is standing near the door. The doctor is setting up the ultrasound and attempting to get a gown on. Two minutes goes by faster when you’re not the one doing compressions. It’s already time for another pulse check. Nothing.

I’m resuming compressions and I notice that the second time around is much harder. My upper body is already exhausted from the first round. I readjusted my position so that I was nearly on the bed. I need as much leverage as I can get. The doctor says that at the next pulse check he will check for movement with the ultrasound. This requires that three of us move our position, one person takes the front pad off, and another person squirts the ultrasound jelly on the patient’s chest. We only have 15 seconds to coordinate.

Two minutes! Time for another pulse check!

To me our movements seem choreographed. To an onlooker it probably looks chaotic. But the job gets done. No heart movement. More medications are pushed. My colleague is resuming compressions and the team gets ready for rapid sequence intubation. “This should have been done at the scene,” I thought.

Two minutes. Time for a pulse check and more epi.

Mr. X is having PEA. It’s not really a rhythm. It’s not shockable. It’s my turn for compressions again.

By the third round, I feel like my whole body is going to give out. My hands are slipping around everywhere because of the vomit and ultrasound jelly.

I can’t continue compressions!” I yell.

Do you need to switch?

No, I need friction!

I lift my hands up for half a second and someone geniously throws a towel over the patient’s chest. Perfect. This is perfect. My compressions are now high quality again. Everyone is ready for intubation. A mask. I need a mask. This guy probably aspirated and I don’t want whatever that was all over my face, too.

Can someone please put a mask and shield on me?

I continue my compressions as my colleague places a mask on me. He did a great job considering I was half on the stool, half on the bed, hair astray, and using all of my body strength to try to bring this guy back. I’m exhausted. I’m thinking to myself, “How much longer can I do this?” It isn’t about me. Everyone in this room is busting their ass for this patient. I’m not going to be the one to give out.

Two minutes. Pulse check!

Asystole. No pulses. No sign of life. Intubation is done and there is a significant amount of fluid coming out. CO2 monitor said 7 but now there are just dashes. No movement on the ultrasound. The doctor wants to resume compressions but he says it will probably be our last round. It has been a total of 45 minutes counting EMS time.

My colleague resumes compressions. He and I are both dripping in sweat.

We have given everything we can. H’s and T’s are checked. Bicarb, calcium, D50, fluids, etc. We have exhausted everything. As a team we were thinking massive pulmonary embolism which is very hard to come back from, if not impossible. I don’t think he was really moving any air.

Are there any objections? Does anyone have any other ideas?” The doctor asks the room.

We all look at each other and realize there is nothing else we can do for Mr. X.

Time of death 1148.


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