The other day was hell. When I came in at 11:30, we were short three nurses. We were down from six areas to four (no, we didn't close any beds--we just divided all of our beds among four nurses), the associate director of nursing for the ED was doing ambulance triage, and the nurse manager was in charge.
I went out to relieve triage for an hour. Poor E was deep in the weeds--people were waiting over an hour for triage. I'm whipping through triages as fast as I can when the patient relations person knocks on my door to tell me there's a "chest pain" outside. I look at the birthdate: 1983. Hmm. Unlikely that this is cardiac. But since there's such a backlog of people to be triaged, all I need is for some young, undiagnosed heart problem to keel over outside while waiting an hour for triage. So I tell her to send him in next. When I say, "So, what's going on with you today," my standard greeting, he says, "I have pancreatitis." No chest pain. Abdominal pain. When I ask him about the chest pain, he says, "Oh, well, it really hurts and I needed to see you as soon as possible, so I put chest pain on there." Seriously.
Then back inside to do ambulance triage for the rest of the day. The nurse manager was completely useless as charge nurse--not keeping the tracking system up to date, which forced me to run around the ED with every new arrival, looking for an appropriate place to stick them in while the nurse manager, instead of delegating tasks and trying to find beds for the admitted patients and getting them upstairs, was getting blankets and starting IVs. I was lining patients up in the hallways where I could keep an eye on them until we found a spot for them...and then we get a stroke code. And a cardiac arrest. And patients from a car wreck. This continued on for ten hours. Interspersed among these patients were people who thought that, because they took an ambulance in, they would be rushed, "ER" style, into a bed as nurses and doctors swarm around them. One woman had back pain, and had been seen yesterday for it. She was given a prescription for something (she couldn't remember what), but it made her nauseous and didn't help her pain. So she took an ambulance back to the ED. When I triaged her and led her out to the waiting room to get registered and wait her turn, she looked at me and said, "I gotta wait here? Oh, fuck this shit, I'm leaving!" and walked out.
Finally, I got down to my last fifteen minutes. It was 11:45pm, and I was exhausted and tired of dealing with people. Two EMTs walk in with a middle-aged man, who sits on a stretcher holding an emesis bag. Complaint? Felt sweaty and dizzy and vomited twice, just after eating some potato salad left over from the holiday weekend. Vital signs all normal; pulse was 99, slightly high, but OK. BP fine--149/78. Sweaty. Blood glucose 145. No past medical history, not taking any meds. Absolutely no pain anywhere--no chest pain, no abdominal pain, no blood in his vomit, no shortness of breath. Just dizzy. One of the attendings sees me triaging him and pulls me aside. "He vomited twice and called an ambulance? Pfft. Put him outside to register." I concur. I start walking him out to the waiting room, and he seems unsteady on his feet. I start feeling uncertain--a little tickle in my brain that's telling me to wait a minute, there's something else here. I sit him down in a chair and take his pulse with my fingers. Irregular. ARGH. I call for an EKG. Sure enough: new-onset A-fib. Ding ding ding! he gets a bed with a cardiac monitor.
And that goes to show: even after twelve hours of grinding labor and dealing with idiots, I can STILL be a good nurse. No matter how tired you are, the assessment skills still stay sharp.