Finding a bed pronto for the guy clutching his chest while another patient's screams fill the waiting room is just part of the working day for Christchurch ED nurse Erin Dooley. Follow a day in her life as she switches from a FAST (focused assessment and supportive treatment) role to facing what seems a never-ending queue as triage nurse in one of Australasia's busiest emergency departments.
NAME: Erin Dooley
JOB TITLE: Registered Nurse
LOCATION: Christchurch Hospital Emergency Department
6.35 AM ALARM GOES OFF
Press snooze while trying to re-jig my morning plan in my head.
I have been nursing for eight years, all of those at Christchurch Public Hospital, first in plastics and orthopedics and for the past five years in the Emergency Department.
I work full-time on a six-week rotating roster and today am on a 10.30am–9pm shift, so I have the luxury of extra time this morning. I keep hitting the snooze button.
Listen to the 7am radio news, somebody died in a car accident in Christchurch overnight, I lie in bed wondering if she made it to ED. But now I need to get moving, I head out for a walk, music blasting – this is my thinking and planning time.
8.10 AM HOUSEWORK
Home to water the garden and do the housework before showering and packing a bag for work with smoothie, lunch and dinner and my week's supply of socks (there is always one day you forget socks).
9.20 AM COFFEE WITH MATE
Best thing about 10.30am shifts, and living so close is I have enough time to meet a friend for coffee before work.
10.24 AM ARRIVE AT WORK
I have this routine down pat so just make it in time! Change into scrubs and run into handover with my arms overflowing with shoes, socks, stethoscope, tourniquet, trauma scissors, ID and pens. Handover includes a brief overview of the department's current state – busy, not busy, traumas and critical patients – plus an overview of the whole hospital as this impacts on patient flow.
Today the ED radiology consultant also takes us through the CT scans and X-rays of a trauma patient currently in ED.
10.45 AM TIME TO HIT THE FLOOR
We are given our allocated work areas, I work in 10 different ED roles/areas and these change daily. Today I am working in ‘the front’. At 10.30am this area steps up to four nurses: a triage nurse, a FAST (Focused Assessment and Supportive Treatment) nurse, an ambulatory nurse, and a team leader.
I start my shift as the FAST nurse until 4.30pm. The aim of this role is to improve patient safety, aid decision-making and improve the time for the patient to be seen by the first clinician. The FAST nurse initiates assessments for all ambulatory ‘walking wounded’ patients, patients with acute orthopedic injuries and patients awaiting the mental health team. When ED is busy and the hospital is full this role can become overwhelming; you may also have to assess patients waiting for an ED bed or patients referred by their GP to surgical, medical or paediatric assessment units when these units are full.
Today we start on a good foot. They had a very busy shift yesterday and overnight but by 10.30am the department is in settled state, though things could change in the blink of an eye.
I call patients in from the waiting room to get a history of their presenting complaint, assess the area of concern, and initiate appropriate treatment. This may include analgesia, tetanus boosters, bloods, wound wash-outs, X-rays or nurse referral to 'bone shop'. All of this can be done by the ED nursing staff if patients meet the ED's Nurse-Initiated Treatment criteria. ED nurses and doctors have a great relationship and doctors are happy to be called in to review or see a patient if you are concerned at any time.
Today has been a nice morning. Between 10.45am and 1.30pm I’ve seen 12 patients ranging in age from 12 days to 88 years with varying complaints of limb injuries, eye injuries, lacerations, aches and pains, sore throat and facial injuries.
1.30 PM LUNCH
The team leader relieves me for lunch and I nip away to the tea room, which is always a hive of activity and people to chat to.
2.00 PM BACK TO IT – PACE STEPS UP
By now there is a steady flow of GP referrals and work-related injuries; some have been referred to specialist teams, such as plastics or orthopedics, but need to be seen in ED first so have a work-up from ED nurses while they wait.
I have seen nine patients since returning from lunch; things are busier but I have had some time-consuming tasks – the FAST nurse is not always fast! Luckily the team leader has been helping 'FAST' others while I am tied up.
I spend a long time trying to remove an 80-year-old lady's wedding ring that hasn't been off her finger in 60 years. She has a nasty wrist injury and we need the ring off before the hand swells anymore. I try every trick I know, lubricant, oxygen mask elastic, cotton, but this ring is not budging; we have to resort to using the ring-cutter, which I absolutely hate – not only is it heartbreaking cutting a wedding ring, but it's slow and painful on an already broken limb.
4.30 PM CHANGE TO TRIAGE ROLE
Triage is the first point of contact for most patients and determines where the patient needs to be placed within ED and how long it is safe for them to wait until seen by a clinician.
I have been trying to keep track of my patients today for this article but the influx comes too thick and fast. Triage is like a constant multitasking battle; you have patients walking through the door needing triage while mental health liaison wants to discuss a patient; registrars ringing about patients due in; the children’s ward saying they are ready for the patient you called about earlier; a triage 5 patient asking how much longer until they see the doctor; and all the while the patient the police brought in is yelling and screaming and making a scene… but first you need to get the guy clutching his chest a bed in Resus (Resuscitation Area).
6.00 PM TEA TIME
Every time I look up, another two people have walked in and joined the queue in front of me. My tea room escape is timed perfectly.
6.30 PM BACK TO IT
While at triage, you constantly scan the waiting room and the ever-growing line to ensure no one is deteriorating before your eyes. I always explain to patients that if they feel their pain/symptoms are changing, to please come back and see me. (It’s the patients that sit, wait and don’t complain that you worry about and keep looking for). If I get a break in traffic,I will quickly pull a patient in for a FAST assessment or try and update the computer system with the details of patients who have been seen and discharged.
8.30 PM CALM TAKES OVER
Calmness sweeps over the waiting room, just in time for the next shift to arrive and think we haven’t been really busy! This is also the well-timed arrival of a patient who comes up to the desk and says, "I wasn't going to come in but I see that you’re quiet so thought I might as well". You want to scream at them, "It's not quiet, there are no beds anywhere, patients in the corridor and clearly if you are going to say that then you don’t really need to be here!" Instead I take a deep breath and remember all patients have different views on what is an emergency to them. To some patients, an infected toenail or an eight-month-old knee pain is an emergency, as they have had enough of it. Others are very honest and admit they are only here because they can’t afford to attend their GP or After Hours and they are happy to pay in time and not money. So I put on a smile and say, “How can I help you today?”
8.45 PM NIGHT SHIFT ARRIVES, HALLELUJAH!
I give a handover of the waiting room patients, brief and to the point; for example, "lady in second row, blue top, finger injury, seen by FAST nurse, for ambulatory". I also hand over the expected 'incomings'.
8.55 PM DEPART
Walking into the changing rooms, I hear a trauma call come… part of me wants to stay and see what’s coming but as soon as I’ve taken off one shoe I remember the bliss of going home and quickly get changed and head away.
9.20 PM HOME
I walk in the door and park myself on the couch and submerge myself in Facebook or something else completely mind-numbing; I'm over talking and listening to people. My partner pours me a wine and after about 20 minutes I look up from my phone and ask how his day was – I’m now ready to enter the world again.
MIDNIGHT TO BED
Crawling into bed, I tell myself I meant to have an early night. I’ll try again tomorrow night..
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