Nightshift in the Er

By Margaret Mayotte-Hirn

Born in a small town in Upper Peninsula of Michigan, Lake Linden,
Margaret Mayotte-Hirn grew up experiencing her life to the
fullest. Today, she can look back and remember and be glad she
experienced all those things that made her who she is today.
She worked full-time in hospitals for 48 years and began writing
when she was in her 60s. She raised three children, got a divorce,
remarried, and enjoyed three new children in her life. She also
gardened, raised Arabian horses and showed them, played
softball since she was 26, and volunteered in her spare time.
It didnt leave much time for serious writing, but the desire was
there.
Leaving full-time hospital work did give her more time to do
more. She volunteered and was selected Volunteer of the Year
for 2 different organizations. She traveled states-wide to play
softball in tournaments. She was an advocate for senior action
and exercise.
At age 70, she underwent bilateral knee replacements which
slowed her down for a little while. Determined to return to former
activity, she dove into therapy. Within 6 months, she regained all
her mobility and resumed all her activities. During her sloweddown
time, she thought about publishing the 2 books she had
written in past years. With that taking place, who knows maybe
her next passion will be writing.
Inquisitive, daring thoughtful, caring and looks at life in a simple
straight-forward way and addresses its challenges. These
attributes are refl ected in her writing.

• Language: English
• Publisher: Xlibris US
• Release date: May 20, 2011
• ISBN: 9781462863587

Margaret Mayotte-Hirn

Marge Mayotte-Hirn grew up in Northern Michigan and felt comfortably at home in the wild forests of the Upper Penninsula. A naturalist at heart, she understands the plight of the redwoods out west. Although this story is a book for young people, it carries an important message about ecology and preservation, and encourages our youth to take an active part in that effort. This is Marge’s second book, since she has gotten the writing urge in her 60’s and 70’s. When an idea surfaces, she runs with it until she has 100-some pages. She enjoys putting her thoughts on paper and sharing them with others. Her words are light and endearing, often colorful and descriptive. Marge is an artist, as well, painting and drawing. And now, she draws pictures with words.

Book preview

The Nursing Lounge

The nursing lounge is a small room, filled with chairs and a long table, an overhead TV, and bulletin boards on every wall. The ante-room to the main lounge has a refrigerator, microwave, water cooler, coffee maker, cupboards with juices and crackers, plastic utensils, straws, and the time clock. A coup- le of offices lead off from one wall, while all other walls have doors that lead out into the halls or into the main lounge. The main lounge has a door on it’s far side that leads into a small locker room, and way off in the back is the employee’s bathroom.

Everyone knows where you are going and why.

The long table in the lounge is invariably filled with papers, food, ER supplies removed from pockets before nurses go home. When the table is empty, it invites someone to make a pizza run or a donut run. Nurses can’t stand for that table to be empty.

Here, staff meet to receive their assignments for the shift, and chat briefly before going on duty. Depending on the mix of staff, this time can be hilarious. ER nurses have a sick sense of humor.

Monica is a shy sweet nurse who had just finished taking her ACLS (Advanced Cardiac Life Support) renewal course. She shared with the staff about her teacher for the class. He was also, mild, seemed sweet and shy, she related, until he reached the subject of people who took Viagra and NTG (nitroglycerine), and had heart attacks. He told the entire class that he had taken Viagra, and found it did nothing for him, until 7 hours later when he developed a very painful erection that he could do nothing about. Everyone laughed, nervously, because many, like shy Monica thought that was a little TMI (too much information).

Everyone gathers in the small lounge before shift to get assignments and any memos that the Director wants them to know about. The head nurse from the previous shift makes the assignments and most times, there is no discussion about one’s work plan for their shift.

But this is a brief time to greet fellow workers and catch up on the news so this time is filled with chatter.

Roxy sat in a chair next to a table with a spray bottle of Nitroglycerine setting on it. Someone had forgotten to remove it from their pocket before leaving their station. Marie asked, Is that yours, Roxy? and Roxy quipped, No, I have my Starbucks.

One evening, all the nurses in the lounge at change of shift were female. This is very unusual because many male nurses chose ER to work because of the higher salaries, and the excitement, and the lack of judgment on the part of patients, families, and staff towards them.

At such a time, sexist jokes can be mentioned and they are. Mandy joked that she left her third leg at home, while Mary teased that the jury was still out on Michelle. But soon, a few men appeared on the scene. This didn’t really stop the banter, but it was all accepted in good humor. Terry had just gotten a new haircut. It was short and boyish, and she felt good about it. Irene complimented her on it, saying she looked younger… . about an hour younger.

At the end of a shift, all the nurses do a boobs and butts dance. They pat themselves down in those vicinities. What they are actually doing is checking all their pockets for leftover Morphine or Dilaudid vials that need to be wasted. They also empty their pockets of paper clips, alcohol swabs, syringes, saline cartridges, notes, gloves, masks, specimen bottles and tubes, and of course, the pager and cellphone. They do not want to take all that stuff home.

One evening when staff arrived for their shift, there were 33 patients out in the waiting room, 5 ambulances parked in the bay, all rooms filled and the ER was closed to saturation, which meant no further ambulance admissions would be accepted. An APB (all points bulletin) goes out to the community ambulance companies and police and fire departments that any patient must be re-routed to the next closest hospital for awhile because this ER cannot handle anymore patients. Either for lack of space or lack of personnel, the PFC (Patient Flow Coordinator) in charge can make this call when it is necessary and it will be observed by all forms of emergency transport until the restriction is lifted. The MICN (Mobile Intensive Care Nurse) phone doesn’t ring during that time. The MICN (is free of concern for that duty of answering the calls from ambulance drivers and firemen and paramedics at the scene of accidents. This communication with the Base Station, the ER, gives legal and medical support to the team in the field who are trained to give life-preserving treatments at the scene. IV’s are started, medications are pushed or given orally, or intramuscularly, certain protocol treatments are initiated for presenting symptoms. But the field personnel contact the Base Station and discuss the planned treatment with trained MICN first. She/he has the training and skill to know just what must be done to treat the presenting symptoms.

At some moments in the ER, there are 35 people milling around the nurses’ station. Paramedics, policemen, social workers and technicians of all sorts, mingle with nurses, doctors, secretaries, intake personnel, chaplains and transporters. This mass of people doesn’t include the patients and their family members. In spite of all those people getting a salary and claiming part of the income from the ER, the ER is a thriving busy place in the hospital, and is considered one of the money-maker zones. For that reason, the ER comes under close scrutiny of upper management and carries many expectations for high quality service to the public and for efficient use of man hours and delivery of care. When the hospital was noted for long waiting periods before service and curtness, even rudeness to citizens coming through their doors, a consulting firm was brought in to assess the situation and give recommendations to turn around the current trend. In this day and age of strong competition for heath care dollars, good service is the key to winning clients. The consulting firm surveyed patients and families and staff to learn areas of complaint and situations for improvement.

Turn-around time was a big factor in making money or losing it. Time is money. Patients who stayed too long in ER held up a bed for another patient to be treated. There were countless reasons a patient did not go through the process quickly and efficiently. Some were related to personnel working too slowly, not knowing where they were in the continuum of care, not caring about time, wasting time with needless activities of care, and countless other reasons. The consultants were effective in focusing on key reasons for delay of service and making a list.

A computerized tracking system was instituted, with all staff being inserviced in it’s use. This was a major task because the staff had just recently been taught another computer software program for order-entry and patient recording. The two systems were foreign to each other, non-integrated. It all seemed like so much double work, but with any computerized system, heavy support was put into place to help all personnel get up and running with computer use. This in itself was a major task for some nurses and doctors to learn and become familiar with the computer.

Eventually this system proved to be very helpful in tracking patients’ time of service, and helped increase efficiency in delivery of all the care that was ordered. Everyone knew what was ordered, when it was ordered, when it was executed, and when results were back so that disposition of the case could take place. As one nurse aptly noted, Treat ’em and street ’em. That’s our goal.

Another point the consulting team found to be very important, was lack of communication between staff and patients and families about the progress of the patient’s care. Patients became weary and upset with long times between intervention and answers and this dissatisfaction rang throughout the surveys as a point to be addressed.

A new service-oriented module was instituted, with all staff being formally trained in a special way of communicating with patients and families. They had to be sure to introduce themselves, and then acknowledge appreciation to the patient and family for their patience in waiting for the care being delivered. Then, with every treatment and procedure, staff was to keep them informed of estimated time frames in which they would get some answers. Simple courteous things like this were all that people expected, but hurried, harried nurses and doctors had forgotten their manners and had resorted to impersonal words and actions in the delivery of their care. This all reflected on the ER quality of care from the public’s viewpoint. It affected the hospital’s reputation and many citizens of the community didn’t want to come here. Within six months, this was all turned around and follow-up surveys showed a 99% turn-around in public opinion. This was a first step in winning customers.

The second step was maintenance of that gain. Staff was frequently audited with spot-check surveys of patients and their families about their present service. And personnel were rewarded for good reports, individually and collectively. They were recognized in the monthly newsletter, and got pizzas and ice cream for high grades. The best way to win a nurse or doctor over is to reach their dear spot, their stomachs. Foods is the best incentive for change that an ER nurse can get.

For that reason, the long table in the break room is usually filled with various food cartons from local pizzarias and hamburger joints. An added bonus is when local restaurants bring over trays and trays of leftover food from their day in appreciation for the hard work ER staff perform day in and day out. Usually everything is gladly consumed.

A favorite reply from one of the nurses to the question, Where ya been? is, In my skin. And I like the skin I’m in.

Charlie is notorious for his brutal, gross sexual comments, but he is a happily married father of a son he is extremely proud of, and he is harmless, a fact that allows him to continue his vulgar comments to everyone of the opposite sex. It is not considered sexual harassment. It is considered entertainment.

On one night, he is assigned to Room 8 with Connie, a young, vivacious, pretty nurse wearing a purple T-shirt under her burgundy uniform. She quickly informs everyone that she will not be removing her uniform jacket this night. No T-shirt, tonight, and Charlie summons her to join him at the start of her shift with, Come on my little purple plum. Let’s go do it.

Everyone knows about Charlie and Martha check’s her schedule before she checks her closet so she knows what to wear to work. No snug, low-necked T-shirts on the night Charlie works.

The PFC usually gives a brief run-down of the days activity and some hint of what can be expected after change of shift.

One day, George allowed the on-coming shift to critique the day, going around the room eliciting responses from each nurse. Closed to ambulance runs. No ICU beds in the hospital. Holding 3 critical care patients in ER. Nurses called in. Short-staffed. 27 in the waiting room. And on and on, so that George smiled, and said, I don’t have to tell you anything. You guys know it all. It’s been the same all week.

With all ER’s closed in the area, one hospital may get bombarded. The ambulances are supposed to be used for emergencies only. A neighboring ER called to say they wanted to transfer a patient with a fractured foot to the distant hospital and they called the situation Trauma criteria. This was their excuse for getting the patient transferred and seen. The wise PFC replied, This is your base hospital judgment? In your opinion, what makes this a trauma patient? Do we have to callout our trauma team for a fractured foot? What, in your judgment, else is going on here? Maybe your physician should get better judgment. The patient was not transferred.

Sometimes the PFC will offer the next shift to select their own preference of assignment, up to a point that all areas will be covered. George gave Roy and Connie the choices of being float nurses for a team and covering the MICN duties, or being the team leader for the area. You can flip a coin or arm wrestle for your choices, he said. Everyone piped up with comments like, I’ll put $1.00 on Connie, and… .

As on-coming staff waited in the lounge for report and assignments, considerable griping took place in anticipation of a busy night because there were 5 nurses short after 0300. Mike, an experienced ER nurse smiled, and replied, It’s only 12 hours. This day too shall pass and we will go home. As reassuring as this sounds, it didn’t stop the grousing. A new nurse to the ER scene asked, Is this the same conversation that goes on every shift? Pretty much, was her answer. We are looking forward to getting our asses kicked again.

Another chimed in, This is your break. Enjoy it. It is the only one you will get.

The head nurse arrived on the scene, remarking, I had to revise the assignment so many times because of all the sick calls you will look at this assignment and think I need to go to Retardo School. As yesterday, we are short. There are no nurses in the Nurse Store or closet. So here is the way it lays out.

Every night since flu season started in November, the ER has been packed and the ER nurses have been calling in sick. ER nurses are a hardy bunch but they are exposed to so many germs in the course of their shift that they are bound to come down with something sooner or later.

A new sign was posted. Please return all surgical scrubs and OB scrubs. Do not keep them for pajamas at home. Mike responded to that message with a comment to Marta, a young, new nurse. Don’t forget to bring your old scrubs back, Marta, to which she replied, Mike, I haven’t been a nurse long enough to have old scrubs for pajamas.

Some nurses like black scrubs, but Bill thought he might be mistaken for a reverend if he wore black. Or a grim reaper. So he prefers blue or white, beige or maroon. On an exceptionally hectic day, the PFC handed out assignments to the next shift. Her parting comment to them as they started out the door was, You don’t have to be crazy to work here. We have on-the-job training.

Triage

Triage is a small nondescript room at the front of the ER and it has a long window facing the waiting room. This window is bullet-proof glass since episodes of violence in ER’s has occurred around the country. It sometimes would be better if it was one-way glass as well. The nurses assigned to Triage can care for their patients, one-by-one in this room and also observe the people in the waiting room. It is very important in their process of Triaging patients because they need to reassess all the patients often and can do so at a glance when they gain enough experience and knowledge. Nurses don’t even work in Triage until they have worked ER for at least a year, and they take special training classes to master the task.

There are 3 accepted categories for the patients who present to the ER. Triage originated in France but was used by America in World War II to differentiate critical saveable soldiers’ injuries from critical non-salvageable ones. And, even to treatment of inevitable fatal mortal wounds. The practice was modified to fit into ER services when ER departments became places for clinic-type activity. Many uninsured people utilize the ER as their access to medical treatment because they can not afford a doctor’s visit. Many clinics closed with state cutbacks and the ER is the only recourse for treatment.

Many people abuse the ER system because of laws preventing any ER from turning a person away without being seen and treated by a physician. Drug-seeking people, homeless people, soon learn the important words to say to get immediate service. I have chest pain, or I am feeling like killing myself, work immediate wonders.

The ER traffic increased 10-fold and something had to be done to manage all the patients that presented to the department in a 24-hour period. Hence, Triage was developed and a busy ER in a major city can see upward of 300-400 patients in one day now.

But there must be some system to Triage, some rules that apply, to protect the personnel from litigation. This is the area of most discontent in the ER. No matter how polite the staff may be, the situation of being passed up, not taken in line as they arrived, having someone else decide that this is not as serious an emergency as that person, is food for unhappiness and anger.

Added to their own misery with their emergent condition, the added wait in the waiting room that may extend to 4 or 5 hours on a busy day, tempers can flare, voices can raise, anger can emerge. That is reason for locked doors and bullet-proof glass.

The Triage nurse needs to see every patient within 15-20 minutes and make a decision to place them in an Emergent, Urgent, or Non-urgent category. Doctors formerly did this, but it is now the trained ER nurse’s challenge and responsibility.

An emergent patient needs to be seen by a doctor immediately because it is deemed their status could result in loss of life or limb if not treated right away. They are often seen to be in severe distress, but a wise nurse knows to watch for an extremely lethargic infant who does not seem to be in distress. A tiny oriental baby, sleeping in his father’s arms was found dead of asphyxiation because no one recognized his decreasing level of consciousness. A sleeping teenager was found to be comatose from hypoglycemia after waiting 4 hours for treatment. An elderly man died of a silent MI because his earlier symptoms did not set off an alarm in the Triage nurse’s brain. That is the reason the Triage nurse makes frequent reassessments of the patients waiting in the holding area. Things can change.

The next category is urgent, and these patients require prompt attention but it doesn’t have to be immediate. They need to be seen within one or two hours, but their problems are not life-threatening. Cuts and coughs, rashes and stomach aches, fevers and headaches, can wait, but sometimes, not. That is the Triage nurse’s responsibility. They need to make a decision. Should this condition be seen now or can it wait? Coughs can be life-threatening to a child with croup or asthma who is gasping for air and saturating less than 90% on the pulse oximetry. Fevers can be devastating to an infant who has been vomiting or not drinking and has become dehydrated. A headache can progress to a stroke. That is why the Triage nurse must make frequent assessments of the crowd in the waiting room.

Bruce had just surveyed his patients in the waiting room. Everyone had been triaged and he was aware of the next patient he would be calling into his office when he noticed a small child wretching and vomiting over