Leaving a job is like breaking up with a boyfriend

Three weeks ago I turned in my resignation to the ER.  I've been an ER nurse for 5.5 years, and have been in an ER/EMS setting for the last 11 years.  It's like we're practically married.  The ER has been my home and my comfort zone for the last decade.  I don't think I've done anything else for that long.  The ER has been a place of solace and a place of frustration.  A place of knowledge and a place of "holy shit I don't know anything but these people trust me to take care of them".  A place where I could go home triumphant that my coworkers and I kicked some major ass and snatched back a few people from the clutches of death, disease and pestilence; a place that makes you think like you got hit by a train, over and over again for 12 hours; and a place that makes you question how some idiots tie their shoes.

The ER is a unique specialty, and a very coveted specialty among nurses.  If I had to pick a single nurse to be stuck on a deserted island with or in outer space, you bet your ass I'd pick the ER nurse.  We are resourceful, passionate, highly skilled individuals who are innovative, creative, kind, fierce and have a wicked sense of humor.

The ER nurse must be flexible (physically, mentally, and emotionally), must be able to roll with the punches (physical and literal), and must be ready for absolutely anything that walks, runs, crawls, flies, or drives through the doors.  It is this very quality that is an ER nurses undeniable strength, but also her downfall.  "What's that, the unit is full so we have to board the two vented patients down here all night while our waiting room cup runneth over?  Suuuuure.  Bring it on; while you're at it, can you maybe find me a couple of traumas, and a couple more unstable patients to really spice things up?  We're down two nurses tonight, so we could really use some excitement."  The ER has always been society's safety net; unfortunately now it's also the hospital's safety net.  No room for that transfer?  Board them in the ER.  The floors are full?  Board the admit for three days and then discharge from the ER.  Have a rapid response the ICU can't /won't go to?  Get the ER nurses to respond to it.  Have an elective transfer leaving, pre-scheduled days ago that needs a nurse?  Pull from the ER.  Step-down full, but inpatient rehab needs to transfer a patient?  Send them to the ER for admission, and, you guessed it, board the patient in the ER.

I have approximately three weeks left until I transfer out, and here is the ever-growing list of reasons why I don't want to be an ER nurse anymore:

- Understaffed.  While this affects every specialty out there, the ER is a unique setting with a constantly varying census.  Although not at all unpredictable, patient census can go from 10 one moment, to 30-60 patients an hour later, depending on average volumes.  And then there's always that freak accident involving the bus full of nuns on Coumadin.

- Solving EVERYONE's problems, with very limited resources and limited authority over the situations.  The ER is absolutely a jack-of-all-trades.  We are expected to figure out problems of how to get someone's family member into a nursing home, how to perform inpatient care, how to manage transfers that are being boarded awaiting destination, how to deliver textbook perfect patient care  abiding by policy while missing equipment, medications, resources, and staff, how to collect evidence for a DUI, how to admit a patient whose PCP hasn't called back in 8 hours after multiple pages.  By the very nature of the job, we cannot say "sorry, that's not my job" or "not my problem".

- Drug seekers.  While addiction is a recognized medical condition with a complex etiology, it is not a life-threatening emergency, and the emergency room is not a place to manage detox nor a place to come get your fix.  No, we will not give you any drugs, regardless of how hysterical, violent, agitated, cantankerous, histrionic, or abusive you become.  And yes, I'm well aware of the fact that you will either get a satisfaction survey in the mail or a follow-up phone call.  I couldn't given a rat's ass.  I'm not getting you a damn turkey sandwich and blanket after you spit at me and tried to hit me.  I think surveys shouldn't count from people who are abusive to the staff.  

- The Bob's

Imagine having to answer to these people several times each shift.  Having to explain over and over again the rationale for your decisions and requests.  Having to justify your existence when it comes time for annual evaluations by tallying up points of how well you can practice scripted, checkbox medicine.
- The generally ignorant and abusive patients, regardless of what they want (pain meds, work note, footies).  The ER is one of the very few rare places where it's perfectly normally to be cursed out, spit on, and have something thrown at you by a patient or family member, and then they complain that we did not get them a blanket fast enough.  This type of behavior ANYWHERE else would not be tolerated for a split second, and the local police would haul them outside.  Yet in the ER, we are obligated by law to examine you and stabilize you, regardless of how much of an asshole you are.  Repeated exposure reaffirms staff beliefs that Nothing Changes, Nobody Cares.

It's simply time to leave.  I've fought this idea for a long, long time.  Kept telling myself maybe it will change, maybe it will get better, maybe I'll love it again.  The only thing that is still growing is this list and my disdain for the human race as a whole.  ER is not all it's cracked up to be and there are many other sandboxes to play in before walking away from the park all together.

Every single time I've left an ED job I had the same feeling: it was very similar to leaving a bad relationship: (1) once the idea to leave sets it, nothing can change your mind, you only prolong misery by staying; (2) once you actually leave, you feel an immense sense of freedom and inner peace, thinking "I should have done this months ago!".

A Leap of Faith

Time has come for me to bid adieu to my ER family.  I've accepted a job offer back up at Hood Hospital in the PACU.  All the joys of critical care, none of the headaches of long term care.  Essentially, a short-stay ICU unit, with no weekends, no overnights, and no holidays (only on-call).  2:1 ratio, 1:1 for ICU patients until stable, wide open department with full visibility and staff jumping in to help each other, average of 30-60 minute patient stay, then it's off to an inpatient bed or back to day surgery bed for discharge, occasionally an admission hold (not nearly as often as the ER).  Limited family interactions, and even those are always pleasant and grateful that someone is taking good care of their loved one.  Patient satisfaction surveys encompass all outpatient, so, while PACU certainly plays a role, many factors are out of control of the entire department.  Metrics are fairly simple: Beta blockers, Foley, Antibiotics, and DVT.  You know it's going to be a good place to work when the manager asks how you feel about downtime and will you be bored if it's slow.  I'm hoping that the switch to days will be a blessing in disguise, but since it is a fairly behind-the-scenes kind of place, I don't expect much administration to walk around, and as long as I'm off their radar I'll be happy.  Low turnover, one employee graduated as an NP, another one switched to the late evenings position, so day shift has 2 openings.  Staggered shifts four days per week for 9 hours.  Can get crazy hectic but not nearly as draining as the ER.  I will still pick up OT in the ER, simply because it's only a ten-minute drive, so I will have to still play nice nice, but I am glad to be making a switch.  I will miss my friends in the ER but it's simply a toxic place to work full-time, the staff is burning out and leaving, both Hood Hospital and Tiny Hospital.  The new director has her head in the sand and is completely oblivious to the department's problems, no matter how many times you bring them up or throw them in her face.  The Hood Hospital manager sounds like an evil sea witch, and the Tiny Hospital manager is quick to back pedal and protect herself whenever problems are mentioned.  I'm trying not to leave unhappy or disgruntled, but it's hard to see any positives anymore.

$20

Gotta love the feeling of having the attending offer you $20 if you insert an IV under ultrasound into a chronic seeker.

Ironically, that's also the amount that it would cost me per day to change jobs to Big Bob's Trauma Emporium PACU or NICU.  Applications submitted, fingers crossed for new opportunities.

Death and Molasses

Cue another busy Saturday night in the ED.  Steady stream of nonsense interrupted with acutely-ill people.  Down two staff members.  Oh well.   As always, we persevere and overcome.  I'm eager to get the night over with and get home to finish editing my final paper for my first grad school class.  Apparently the great cosmic universe had other plans:

06:38 - day shift is slowly trickling in as I let my r/o ACS patient up to the bathroom.
06:45 - said patient diaphoretic in the bathroom
06:52 - coding said patient in the trauma room
08:39 - TOD

In the few minutes that it took us to get the patient out of the bathroom and onto a stretcher felt like agonizing hours.  Like watching molasses drip out.  Already feeling completely defeated after no break and no food all night, this was enough to push my limits.  Emptied 2 code carts, central line kit, art line, every drug you could think of, and all of my emotional reserves.  It's been a very long time since I've cried over a patient, but this morning it came in stifled sobs, snotty sniffles, shaky voices, and trembling hands.  I sat in the corner of the trauma room, feeling completely drained, lost, and confused.  After most codes I try to keep busy, cleaning up trash and straightening up the room for family to come in.  This was the first morning where I didn't have the strength to do that.  I felt like a part of me left with her, and what remained behind was broken and scared and lost and confused.

Photo Credit: Brandon Plyler (Haynes Ambulance of Elmore County, Wetumpka, AL)

Coworkers said plenty of gentle words to try and comfort without much avail.  Two hours later I finished charting and went home.  I got to go home and she didn't.  And she never will.  For days, the what ifs will haunt me and keep me up at night.  As always, forever will I be haunted by the agonizing screams of a family that lost a loved one.  And I pray that the only thing the family remembers is that I treated her with kindness and respect, bringing her footies and warm blankets, calmly explaining everything.  Her granddaughter spent the night in the ED and I arranged a hospital bed AND an ER stretcher in the same room so they could sleep together.  I pray that's the last memory she keeps.  Not the one where she's standing in the hallway, watching us wrestle her grandmother off the toilet onto a backboard.

The good thing about all the tears is that I know I'm not as dead inside as I seem sometimes.  The cynical, gruff, tough ER nurse has a heart.  It's hidden far away, behind walls built up to keep the evil out, the evil of having witnessed too many codes, too many near-codes, too many traumas, too much violence, too much sadness, too much circumstances of life.  Occasionally some stories find a way under your skin, through the walls and into your heart.  Those will stay with you forever.

Photo Credit: Katie Duke

A photo by another ER nurse (who was fired from her ER job for this photo) sums up so much in one image.  You can almost smell the sweat and tears of the staff present in a resuscitation.  You can hear the equipment in the background.  You can feel the ribs cracking under your hands.  You can feel the hair stand up on the back of your neck.  You can feel your own heartbeat thumping in your temples as you search for a pulse during a rhythm check.  You can feel your heart sink to the lowest pit of your stomach when you know it's over.

My hands shake as I lower her eyelids over bloodshot eyes.  She trusted me and I can't help but feel like I failed.

Best ER Nurse Phone Call

A "nurse call" is typically a phone call from a member of the public calling for medical advice.  Sometimes it's a simple question of "how much Motrin do I give my baby?" but often it turns into complicated and bizarre stories, that get more and more convoluted every time you tell them "Ma'am I cannot give you advice over the phone, you can come in and be seen by our doctor."

Case in point:

2am on a Friday:

- Um hi, do you do lead testing?

- No, we typically don't.  This is the emergency room.

- Well I understand that, and I've already been to Hood Hospital and they wouldn't do it...

Me, thinking, well shit Sherlock!  We're not going to do it either then!

... but I keep having these neurological symptoms.

- Okay, I cannot give you advice on the phone.  If you'd like to be seen you can come in.

- Well will you test for lead if I come in.

- That's not up to me ma'am, that's up to the doctor who sees you.  And he cannot give you advice on the phone either.

- So you can't tell me if you'll test me for lead?  I have these metallic hair extensions and I think they're giving me lead poisoning!

Attempting to stifle my laughter, turning purple, while the charge nurse is sitting next to me laughing at my expressions.

Deja Vu

Finally get home after two consecutive absolutely hellacious shifts in a small community ED at holiday time.   If you've worked in an ED during flu season at holiday time, you know that equates to a nasty four-letter word: HOLD.  As in admission hold.  As in, admissions holding in the ED for 3(!) days awaiting an inpatient bed.

Night one began with the arrival of a patient who required intubation on arrival, while I'm holding the Etomidate the manager calls, opening with the normal pleasantry of "Hi, how are you?"  I reply, "Hi, I'm in the middle of an intubation right now".  In nurse-speak, "Unless your hair is on fire right now, please don't talk to me."  Apparently the nurse-speak wasn't clear, and in reply to my statement I get "There's people in the waiting room for almost 9 hours, you need to get them back."  Did I mention we're down a nurse, so I'm taking care of a couple of patients in an assignment, as well as charge headaches?  Cursing under my breath while the primary nurse is laughing at my facial expressions I nod several times, hoping maybe that will telepathically get her off the phone.  Finally hang up and mentally count to 5 so I don't throw the charge phone across the room.  I understand someone has been out there for almost 9 hours, but in those 9 hours they haven't died yet; however this person in front of me almost did.  Whatever.  Go get the obviously non-dying, not-in-distress 9 hour wait.  Seriously?? Who in the fucking world waits 9 hours in an ER.  If I wasn't dead after 2 hours I'd leave.  

The night continues at the steady pace of bullshitidness, sporadically peppered by truly sick people who cannot wait.  They buy hallway stretcher in my juggling act, and then slowly make their way over to a core bed.  I think around 5am we clear out the waiting room and the back is full.  2 hours left and all I've had is a cup of tea and 3 breathmints.  Everyone else is pretty much in the same boat.  Director calls around 6 and tells us she's stopping by to talk to us about the night, that we did great, and to listen to our concerns.  We bring her genuine issues of staffing and lack of support from other departments (lab, Nursing Supervisor, other floors), and  as we're finishing up I clearly warn her that for Night 2 we are fixing to be in very bad shape, as we are down a nurse at 7p, and will be down a total of 3 nurses at 3am.  I reiterate to her that I only have two 7p-7a nurses working, she writes it down in her book of mysteries and promises to work on it.  I go home feeling slightly accomplished.

Segue, Night Two:

Pulling down the side-street, I see my manager standing on the corner in scrubs.  As I nearly hit a telephone pole in amazement, I convince myself that my bitching and moaning this morning actually worked.  Only to have that fragile dream shattered minutes later when I walk in and see that staffing is no better than it was 12 hours ago.  Except that they've conned (read guilted and forced) the 7-3 nurses not to leave at 3am.  Both of them are happy to help me but upset with the manager for asking/making/forcing them to stay.  So much for work-life balance that the new director is pushing.  Somewhere they also dig up 2 IMC nurses to help us until 11pm.  Mind you, all rooms are full at 7pm and we have a 6 hour wait.  Manager flat out tells me "I'm not taking an assignment".  The IMC nurses take out admission holds for 4 hours while we attempt to muddle through the nonsense.  First order of business, take the drunk out of the waiting room who's been out there for 5 hours with a sustained HR of 130-140.  I call security and ask them to meet me by the hallway stretchers reserved for Mr. EtOH and Mr. Psych Eval (who has sat out there for over 2 hours).  Security starts giving me a ration of shit about how they've been out in the waiting room for so long and they haven't been a problem, so why do the have to watch them now.  I turf that fight to my manager with the simple words "They're refusing to watch him, I don't have time for this shit".  Magically, she accomplishes one task and security is watching them both in the hallway.  Surprised that he hasn't hit the DTs yet, I walk away to mix the banana bag for Mr. EtOH.  HR continues to be sinus tach, 130, despite fluids.  CO2 comes back at 13.  Fantastic.  Get orders for 2000mL NSS bolus, bed-ahead submitted for ICU admit.  Gotta love ICU admissions in the hallway.  Hey, at least I can see him.  

Time is creeping up to 1am, and the influx has not stopped.  In a 16-bed ED, we are at 14 admissions, plus my hallway admit, plus my hallway surgical transfer, plus I can easily pick 5-6 people in the waiting room that will be admitted.   All this and a bag of chips: I called in an extra nurse and she worked patients through fast-track beds for a few hours. Call the manager and director to update them of the evolving situation.  We've also run out of IV pumps, chairs in the waiting room (twice), and have only 2 portable monitors left.  Manager and director, as if they're reading from a script, in unison but 20 minutes apart on the phone: "Just do the best you can".  Again, breathe and count to 5 to stop myself from smashing the charge phone to pieces.  

5:30am rolls around and we know we have just a little over an hour left.  We are all completely exhausted.  3am nurses haven't had a break, let alone a hint of when they can leave.  We're working our way through morning labs when the lab supervisor calls screaming "Get my techs back to the lab, they are not there to draw your labs!".  *Gasp*  I thought that's EXACTLY what they were here for.  Notify the house supervisor of what transpired because I'm tired of calling my manager and director.

5:45 - BiPAP.  Enough said.  Bump most stable admission to the hallway and make room for BiPAP.  I already have a AAA transfer in the hallway, along with 2 others we're working up.  The nurse who's supposed to be in her last week of orientation has been taking care of a full assignment by herself since 11pm.  I call the supervisor, laughing manically and deliriously, to notify her that I have a Priority 1 Respiratory patient coming in.  She laughs back at me, asking (completely honestly) what a Priority 1 means.  I growly through the phone "It means they're really fucking sick!"  She laughs again, asking me where I'm going to put them.  I, literally, try to crawl underneath the nurses' desk while I growl back "I don't know, I'm working on it".

6am - 9 hour wait,  18 admissions in a 16 bed ED, plus several more in the waiting room.  Just gotta keep it together for one more hour.  Helicopter couldn't fly the transfer, so he's going by ground right after shift change.

Dayshift starts trickling in and I can see true panic in their eyes.  We are all completely exhausted and totally spent.  Turn over report.  Apparently later on they will have 24 holds in a 16 bed main ED and 6 bed fast-track  Curiouser and curiouser.

Get home around 8am, completely wiped out.  Send the director and manager an email of how unacceptable last night was.  That goes over like a wet fart in church.  Take a power nap, only to wake up and field a phone call from the grand poobah, asking me if I'm suicidal.  Not sure if she actually read my email or not, or only focused on the Facebook post some bleeding heart decided to show her:

It all sounds painfully familiar:

“He liked everything to be right and had very high standards. But he became disillusioned over the last couple of years. It became harder to reach the targets.

“He still liked his job but felt he couldn’t do his best. He wasn’t getting the support he needed or the resources.”

Stuart’s sister Mandy Hicken added: “There wasn’t enough staff. He was working long hours without proper lunch breaks.

“I remember him telling me that he worked a 12 hour shift and had only enough time to drink one cup of coffee - there was no time for food."

OR

What will it take for hospitals to realize this is not OKAY??? This is NOT SAFE. This is NOT ACCEPTABLE.  Lawsuits? Deaths? Suicides? What will it take??

Either way, this ends in a long, forced conversation, at the end of which I'm leaning much more towards violent tendencies than suicidal.  Way to make the situation all about me, when I'm trying to point out critical system problems to you.  Way to go.  And then she utters the ultimate wrong answer, telling me I can post whatever I want but I need to be very careful not to associate with the hospital in any way.  Ahh, there's the rub.  You never gave a damn about my mental health or anybody else's.  You just don't want bad publicity for the hospital.  Well then.  You won't hear from me ever again.  I'll keep my mouth shut, let the problems mount, and let the department implode, just like Hood Hospital.

This further cements my desire to get my NP ASAP and get the hell away from bedside nursing care, and move on to more advanced practice.

The only reason I stick around here is to see what happens next:

Cockpit Resource Management

After several charge shifts of utter nonsense, I stumbled upon Crisis Resource Management (originally known as Cockpit or Crew Resource Management, and developed by the airline industry).  I'll be presenting a few articles at our next monthly meeting, with the hopes that everyone can look inside themselves and develop these skills.  I'm thinking of titling the powerpoint "It's not my emergency, so don't spill my coffee".