The Emergency-Room Nurse Who Always Has to Know Who’s the Sickest Person in the Room

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Evan Caughel, 30
Emergency-Room Nurse
Buffalo, NY

I thought I wanted to be an English teacher. I was nearly done with my degree — three and a half years of time and money spent — but I had lost so much interest in what I was studying. In the Buffalo area in 2007, it felt like you could find a job in education or health care. Otherwise, it was pretty much retail or restaurants.

The thing that was driving me was, I knew I wanted to marry my longtime girlfriend and provide for a family. I wanted to stay in Buffalo. And there was just this … fear.

You’d hear about layoffs in the area, about how your dad’s friend lost his job and he can’t find another one. Plus, my school was pretty focused on music and arts, and recent graduates weren’t finding jobs. I needed to be positive I could live the life I wanted without having to move.

I had worked during school as an orderly at a hospital, basically because I could walk from home and made $8.88 an hour — incredibly high for that area at that time. Within six months, I loved it. I liked meeting new people and helping them, and doing my best to make them feel good. I wanted to be a nurse. So I threw my English major out the window, took my prerequisite classes at a community college, and transferred to nursing school.

I’ve worked at different hospitals and on different shifts — including overnight — but I’m currently on the day shift in the ER at Buffalo General. I work three intense 13-hour days, and then I’m off for four.

We have 58 rooms in the ER, and they’re divided into four pods: two acute and two subacute. Each pod is staffed by four nurses, and then we typically have a few who float where they’re needed. The acute pods are critical care: Patients who are very sick, or have the potential to become very sick. You get assigned to only four patients with the acute pod. In subacute pods, you might get five patients because they’re less sick. But sometimes, the sicker a patient is, the easier they are to take care of. Someone on a ventilator isn’t trying to go smoke, or get their cell phone, or shove you. A patient who hurt his knee might have a bunch of requests: I need a blanket. When can I have something to drink? Why hasn’t the doctor come yet?

Each pod has a 20 by 20 space at each end, with a computer for the doctor, one for a resident, and a small station with two computers in the middle. Once the charge nurse assigns me, I run over to a computer to check everything out for each patient.

As nurses, we try to claim our computers, so we can see our patients as we’re charting. Generally, if you have somebody who’s really sick, you take the computer you need and everyone understands that. Sometimes, you’ll have the resident rotating through, and they don’t think they have to move. And once in awhile, I’ve actually unplugged the power, secretly, and said, “Oh, it’s broken. Guess you have to move!” Sometimes in an ER, you need that minute, and you don’t have time to argue.

When it’s just the emergency-department staff, the computer thing isn’t an issue. But what ends up happening is, you have a consult for urology, maybe, and the doctor will take your computer to make notes. But their patient isn’t your only patient. You have four other patients, and this is your place to chart them. I’d like to say the doctors don’t know … though, really, it says “RN COMPUTER” in laminated signs on top. But I get that they’re focused on their patient, and they don’t really think about how we have all of these other patients.

Once you’ve been doing this a while, you can get on that computer, scroll through the patient’s files, and figure things out pretty quickly. You’re mainly looking at the chief complaint, and checking out what’s been done so far. It’s pretty amazing how much is done via computer: You might bring a patient online, so to speak, to check their vitals. You can click to bring their blood pressure into the computer to chart it, and look at it in almost real time.

So you have to quickly look at all of this and prioritize. The hardest part about the ER is time management; you’re responsible for these patients, and you need to be responsible with your time.

I start with the sickest patient and work my way down the list. We’re a stroke center, so we get a ton of stroke victims. We’re not a trauma center, though we do get lacerations, broken bones, and the occasional gunshot wound. Your first thought is not only who is the sickest but also who needs your time and attention first.

One thing that might surprise people is that someone with a bad laceration or broken limb is not considered that acute. They actually go further down on the list. As long as their pain is under control, and they’re not bleeding out, they can be put on the back burner behind people who are having a stroke.

The most common complaint is chest pain, and the second is abdominal pain. I had a young woman come in last week with ab pain. Her color looked bad; her blood pressure was low. My concern was that she had an ectopic pregnancy, and she was bleeding internally. And, that’s what it was. Had she been home another hour, she’d be dead. I looked at her, and I was just like, this woman is really, really sick. I know it. The doctor can’t see everyone — it’s the nurse who has to make that judgment call that this person needs to be seen right now. Being able to do that is a huge part of the job.

As you’re working, you peel through the orders from the doctors, which is all done through the computer. Technology has made us all accountable — there’s no saying you didn’t get the message. The system lets me know something new is happening: doctor’s order, test canceled, pharmacy changed the medication, lab needs a new test. So you go through everything the patient needs, and then check what the doctor asks you to do, and you’re juggling to keep things up-to-date.

But this is an ER. While you’re putting in IVs or drawing blood or filling out questionnaires for an MRI, a code — meaning someone is actively dying, with no pulse or no breathing — could come in, and you’ll need to drop what you’re doing. That’s why you need to stay up-to-date with all of the orders; if a code comes into your assigned room and you didn’t give someone that medication a half-hour ago, you’re not going to get to it for a while.

You form relationships and trust with your co-workers really fast under this kind of pressure. But there’s still friction between the different entities. For example, our management can tell us that neurosurgeons can’t drill into the skull in the ER — and then it’s like, “Hey, they’re trying to place an EVD in room 34!” Or a resident might order a medication you don’t agree with. It’s a teaching hospital, so that happens. You’re the one with more experience, so you can say, “I’m not going to do this because X,” and you talk it out.

There are incredible moments. When someone comes in who’s in the critical window for a stroke and everyone snaps into action, it’s like a miracle. There are nurses who want to be in the room during a code no matter what because it’s an adrenaline rush. One person is running IV lines, another is monitoring blood pressure, another gets the patient through the CAT scan and back, and everyone is doing what they’re supposed to do. Then we look at the time, and it’s like, wow, all that took 28 minutes. It’s amazing, especially when you get the pulse back and they’re alive.

Sometimes that happens multiple times a shift. When we have moments like that, I’m like, I have the best job! Everyone would love to do this! Then you have to remember that 90 percent of the time, it doesn’t operate that way. If you come to work chasing that adrenaline rush every day, you’ll be let down.

Some days are horrible. One day last year, an elderly woman came in after a stroke. She had a horrible reaction to a clot-busting medication. I came into this case really late, but from what I was told, right after she finished the meds, she mentioned her tongue felt funny. It turned out she had a terrible angioedema, where your tongue and everything around there swells so much that it’s like having a grapefruit in your mouth.

There was no indication that she would have had this reaction. We tried everything. We couldn’t reverse it. We tried to intubate her and couldn’t, and then we tried to crike her, which is an emergency airway puncture, and that didn’t work either. She choked to death. It was horrific. What was so upsetting was, it felt like it shouldn’t have happened. Like it was our fault, even though it wasn’t. You feel like you have all these tools and this training, and that you should be able to fix everything.

I’m sure there were nurses who lost it that day. A patient said to me right afterward, “I know someone just died, but I need water right this minute.” And you have to care for that person. You do have to be a bit desensitized in that way: Someone dies, but you need to give care and empathy to the person next door with a broken finger. You compartmentalize.

A lot of times it’s acting. Other times, you have to take a quick break to calm your emotions — which is why I think some health-care providers smoke. If a patient dies, you need to be most concerned about the family. It’s a horrible time in their lives that they will always remember. Sometimes, it’s rewarding to hug someone and help them start grieving.

It’s also easy to get disillusioned with the abuse of health care. In the ER, we’re required to accept everyone. If someone’s private insurance won’t approve something, they’ll just come through the ER. Or you’ll see someone who takes an ambulance ride literally every day. They’ll check in for something bogus, like a cold, and then refuse care and walk out. They’re using it as a mode of transportation — taking an ambulance out of service to take a ride. How do you control that?

There’s also a lot of frustration about Medicaid and Medicare, so I think we’re all interested in seeing what happens with that. We’ll see someone rack up millions in ambulance trips, or come in for 27 CAT scans in a month. There needs to be some kind of check. That said, there’s a codependent relationship; those costs pay my salary. It’s confusing.

For all the disillusionment and the hard days, I feel lucky to have my job. Yes, working 13 hours straight in an ER is intense. Some days, I’m literally running through the whole shift, without sitting once or using the bathroom. It’s tough on your body and your mind. When I was on the night shift, I rarely saw my family. And I work a lot of holidays.

But I get four days straight with my wife and son every week, which I cherish. I don’t think I could go back to a normal five-day week. We’re paid well; I was able to buy a rental home, and have time to work on it, thanks to this position. I feel I’ll always have a job opportunity — and I don’t take that lightly. We have people come in who weren’t taking medication for three years, since it took them that long to find a job and get insurance.

Overall, I think it’s a noble job. An honest one. You can leave knowing all you did all day was try to help people, and that keeps you coming back. Sometimes, it’s the only thing that keeps you coming back.

The ER Nurse Who Always Has to Know Who’s the Sickest