Written by Geoff Ibe BSN, RN, FNP May 21’

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When people think of the ER, I imagine they think of the hit TV show. Complete chaos, dramatic music in the background, and blood spewing everywhere. It's not like that at all… well, kinda. The chaos is there, but chaotically controlled between rooms. The music is playing, but it's a symphony of ventilators, heart monitors, IV pumps, providers hollering orders to the unit clerks, and patients screaming in pain (and for turkey sandwiches and a blanket). And blood isn't really spewing everywhere… only on my work shoes.. Along with feces, phlegm, fluids, and God knows what else. 

In a Level 1 Trauma Hospital, we handle life-threatening events like heart attacks, strokes, and traumatic injuries. So yeah, we see the big bad things. The images that keep you up at night. The moments that can make you never forget how to recognize a critical event. The stories you could tell a regular person, and they would never believe you. But we also see the good things. The patients that give you purpose and pride to be a nurse. The adrenaline and satisfaction of saving a life when they come into the trauma bay.

So what's it really like working in the ER? Here's what it could look like in one hour:

You're checking your assignment. An 80-year-old lady, just transferred across the ER to your room for a ground-level fall. She takes blood-thinning medication for her atrial fibrillation. She lost consciousness after the fall and had to have EMS called by her husband. She's got a nasty 4-5cm laceration across her forehead and needs her IV replaced before another repeat cat scan. Unfortunately, she's getting confused and pulling at her line, the one you just put in trying to get out of bed. You'll deal with that when she gets back. Off she goes.

As you send the fall patient off to CT scan, you visit your little 15-year-old female who tried cutting herself tonight at the dinner table because of an argument she had with her family. Mom is at bedside, unwilling to make eye contact with the child. You can see her frustration, concern, embarrassment, and sadness all at the same time. The patient keeps her back towards mom as she stares mindlessly at the hospital TV screen. You double-check with her sitter at the doorway to keep an eye and will find out an update from the social worker on her case. Tough situation, but the call light is ringing in your coworker's room.

You head over across the hall and see a middle-aged gentleman with kidney stones curled over in the bed, asking for more pain meds because he thinks he is passing his kidney stone. He has called every 5 minutes to let you know the pain is worse and 'whatever you gave him isn't touching it', so you make a note for the doctor to figure out a pain management plan for him while he passes the stone. The doctor is busy down the hall dealing with a trauma patient, he won't be available soon. The patient is not a happy camper and states how no one is doing anything. 

Breathe. You gotta go to your other patient right now.

You're gown'd up in PPE (Personal Protective Equipment) and your respirator to go hang antibiotics for a symptomatic COVID-19 patient who's trying to rip off their BiPap mask. They weren't like this an hour ago. They say they can't breathe, but you yell through the mask if they take off their oxygen mask, they might as well call it. You clearly see their oxygen saturation at 91%, even with full delivery of the oxygen. You need the doctor in here sooner than later. 

Oh, by the way, you're getting a new patient in your other room for crushing chest pain that started an hour ago with a history of a triple bypass surgery nine months ago.

So now what? How are you going to prioritize this? What if grandma starts trying to sit up and gets more confused, making it difficult to get the scan? What if your little girl starts arguing with her mother, and your sitter needs security to be sent in to deescalate the situation? What if your kidney stone patient hollers out the door requesting to leave right this very second? Do you delay any of that to get the doctor who is currently in a trauma bay treating another patient? Decisions, decisions, decisions. 

How do you deal with it? The answer is: not alone. You have your coworker aware of the situation with your 80-year-old lady willing to go to cat scan for you to give a sedative. Security and your sitter can handle the situation, and your charge nurse is aware. You have the unit clerk overhead page the provider to head to your COVID patient room as they finish up with the trauma patient. The respiratory therapist is on-site and preps for possible intubation. Registration is headed over with you to your chest pain to get them triage'd and ready to be treated. Breathe. You got this. We got this.

The ER is goal-focused, team-oriented, and extremely chaotic. These realities create the culture of why I love my ER family and what makes us great! We all secretly love this shared madness; we thrive on the high-stress, adrenaline-filled moments that the ER brings. But you also gotta know how to lock-in on the variables and delegate tasks if things get too hectic. I could go on with stories, but any nurse reading this should take away these pieces of advice.

Let Your Ego Go - No Time For it Here

Be humble. You won't know everything. Ego has to be left at the door. Do not be afraid to ask for help. But going into every shift with a mindset to learn new things will benefit you and your future patient. 

Gratitude for Your Team

Be thankful. Nursing is a team game. There is plenty of help in the ER, so when things go south, your coworkers have your back, and they should know that you appreciate them. Appreciate the techs that do the grind work and make sure you can focus on your nursing tasks. Always learn at least one name from environmental services and thank them for keeping your patient rooms clean for the next patient you'll be getting. A life of gratitude in your career goes a long way.

Do What Drives You

Find purpose. If the ER is not your jam, then find out what drives you to come to work for 12 hours. If you feel your talents match better with having more bedside time with the patient, then home health or floor nursing could be for you. If you love meeting new people and experiencing different clinical environments, travel nursing could be the option for you. If you're a seasoned nursing vet that has put the work in the hospital and now would like a little less stress, then outpatient clinics for procedures could be the lifestyle you want. Whatever it is, be honest with yourself and with companies like EARN to help guide the next step in your career. Finding your purpose does not always have to be permanent, which is the beauty of our nursing degree. 

If that sounds like your kind of nursing, keep up with the EARN blog for more. They have a vision to precisely match RNs and NPs with the positions and organizations that fit your skills and personality. The right fit means everything.