I am super pleased to report that my first buddy shift on the floor was absolutely awesome. Emergency nursing is like nothing else I have experienced in clinicals. In one shift, I was exposed to so many different presenting complaints and patient populations, it was like my entire clinical rotation on fast forward. Nancy, my precepting buddy nurse (it changes every shift) last night, was really great to work with. She's been at this ER since it opened and has been an emergency nurse since forever. And, importantly, she still loves it. I didn't get the whole burnout vibe at all, from anyone.

So for anyone who hasn't had exposure to emergency nursing before, I will try to elaborate what the flow is like. This particular ER doesn't assign specific patients. They have recently implemented team nursing, so a bunch of nurses will be assigned to a wing and work together to meet the needs of all of those patients. My preceptor was assigned to float between the two teams, as well as cover charge and triage for breaks.

My shift started at 1530 and we took report from the off-going charge. I noticed that the report went very quickly, identifying only the chief complaint and how long they'd been there, and any labs that needed to be drawn.

We toured the unit and she pointed out all of the equipment in the different rooms. I've been volunteering on that unit since November but it was cool to see it through fresh/knowledgeable eyes. There is a minor procedures room, orthopedic casting room, EENT (eyes, ears, nose, throat) exam room, 4 stable beds, 4 fast track beds, 4 monitor/observation beds near the desk, 2 gyne/peds rooms, 2 trauma/resuscitation rooms, 1 reverse isolation/positive pressure room, and 1 secure room with superstrength door and optional camera monitoring.

morganlens.com

After the tour, we got started with the day. Nancy went out to the triage desk to admit the first patient. We had a look at the rack of charts from the triaged patients and it wasn't too busy. She picked a triage level 5, a young guy who got some metal in his eye while welding. We called him from the waiting room and saw that his v/s were taken less than an hour ago so we didn't need to reassess them. We took Eye Guy back to the EENT room and I gave him a Snellen test to assess his bilateral visual acuity. It was cool because he sat in a chair like at the optometrist and I flicked the different letter sizes across the wall in the dark. Not something we learned in clinical (it had been briefly mentioned in lab, I think, in our assessment class in second year), and here I was administering it to my first patient on my first day :) Nancy was very supportive of me doing my own thing to help out instead of just being her shadow and I was glad for her guidance. You know how it is, sometimes you just need that push to go out there and put theory into practice!! There was some talk about administering a Morgan lens, as we learned about in orientation, but I'm not sure what happened with him after all.

Like a lot of you, I think, I have followed a ton of emergency nurse blogs since well before nursing school in 2008, including those of the illustrious Nurse K, Girlvet, and NNR, newer ones like newnurseinthehood and Maha, and newer-to-me torontoemerg. Like you I have uttered many a guffaw and/or facepalm at the stuff people do to end up in the ER at odd hours when other people, such as myself, would much rather be home in bed. I am (pleased? saddened? resigned?) to report that I saw several examples yesterday in one shift alone that amazed me, especially in terms of my rosy nursing school glasses.

My next admission was a young man with throat tattoos (listen, I LOVE tattoos. I have two large ones myself. But I have never seen a throat tattoo that I didn't immediately associate with Tapout) dressed head to toe in Ed Hardy who came to visit us with a migraine. Okay, I've had migraines as a teenager. All I could do, once I got the visual disturbance aura, was get home ASAP so I could lie in bed in dark silence and barf my guts out while praying for it to be over. Seriously, the ED is the LAST place I'd want to have a migraine. This young man did not exhibit any of these symptoms. I'm not sure what he got discharged with, but I think he waited a while.

San Francisco General Hospital

I saw my first conscious sedation, an older man who tripped and fell and dislocated his wrist. It's the first reduction I've ever seen. The physicians snowed him with fentanyl/propofol until he would not react to them touching his eyelids. They then grabbed his little frail old arm and reefed on it until it went back into place with a couple of clicks. One guy held traction down on the wrist while the ortho tech put on a cast. First time I've seen all of those procedures. It was very cool. Initially I was squirming inside because the patient was obviously feeling the pain of the reduction, moaning and grimacing. It kind of flew in the face of everything I've seen so far. One of the nurses caught my expression and said "don't worry, he won't remember it." And he didn't - I walked past his room an hour later and he was sitting up admiring his new cast and chatting amicably with the physician who had been poking him in the eyeballs to check his response.

Another interesting thing was a little boy who had stuck a not-so-little bead up his nose. I have never worked in peds before outside of postpartum and preschool participatory observation for a few days. I had no idea what they would do. The RN grabbed him and wrapped him in a full-size swaddle, pinning first one arm and then the other as they rolled him tightly into a sheet like a little sausage. I helped to hold him still as the physician tried to excavate the bead via suction. No dice, but one of the nurses found a metal tool that bends at the tip when you press the trigger and they threaded that through the bead. Success! I was amazed at how big it was. Wonder how it fit up there in the first place!

A few other things I saw -

• The ortho tech showed me how to do a wrist assessment to help decide which carpals were affected, and determine which x-rays to order
• Nancy starting IVs so fast she made it look easy, and I was consumed with envy
• A roughed-up prisoner who got into quite the scrap (I've never seen someone look that, well, beat up before)
• A little baby with a case of Grade A diaper rash
• Oozing shingles pustules
• An ECG on a woman with a heart condition and chest pain - she was graduated to an observation bed. Her husband peppered me with questions about why she was getting a N/S infusion and why they ordered what tests they did, and, MOST importantly, how long they would have to be there. Apparently there are places more important to be than in the hospital ruling out MI...
• Query fish bone stuck somewhere deep in a guy's upper GI, not sure what they did with that one
• Nancy also volunteered me to admit a query anaphylaxis reaction. Lady had hives on her tongue and reported throat closure/swelling. I was pleased when my brain suggested I auscultate and listen for evidence of decreased air entry. So I busted out my stethoscope and listened to her perfect breath sounds all the way down to the lower lobes. Nancy approved of this and had me chart it. I think my hand shook a little as I signed my new designation, haha :)

My shift was a total whirlwind. Literally every admission was different from the next. We covered triage for a while and I was a bit taken back by how every sick person coming into the ER was seriously inches away from our faces. Yuck. One of the nurses told a story at lunch about how an angry guy with "back pain" launched himself at her, through the window, when she wouldn't put him back right away. Yeah, past the gray diaphoresing guy reporting crushing chest pain.

I saw way more things in one day that I saw in weeks at clinical. I seriously loved it, every minute. I was also super grateful for the extremely kind staff who were more than happy to show me cool things and ask me tough "thinky" questions.

I can't believe I get paid for this!!! I would have been there for free. Wait, don't tell that to my boss..

Can't wait for my next shift tomorrow :)