The Smooth Shift

No two shifts in the ER are the same, obviously. That's partly what makes it fun. Some shifts can be monotonous, with a few patients just trickling in throughout the night. I'd much rather be busy.

Then there is the shift where the ER is packed and overflowing. Every single Monday is like that, for whatever reason, but any other night might be the same. I like to come a little early and walk through triage on my way in to work so that I can get an immediate feel for the situation. Maybe I'll try to clear someone off a backboard, or fast track a patient or two. If there are several ambulances in the bay and patients are spilling outside and lined up on stretchers in the hallway, I can be sure that I will be running hard from start to finish. Or if it's not busy, I'll just chat with the police officers for a few minutes.

Sometimes, but not always, the first patient you see sets the tone for the rest of the night, so I try to choose that patient carefully. If nobody is crashing, I'll try to see someone who has been in the department for the longest time. That way I can be the good guy. When they complain about the wait, I can tell them "sorry, I just got here, and you are the first patient I came to see." That often diffuses their anger a bit. They will still complain in their Press-Ganey survey though..

Some nights, fate intervenes to make everything more difficult. Maybe we are understaffed, or the nurses aren't as motivated, or maybe the lab or X-ray department is having problems. Perhaps the patients' problems are more complex, or the on-call physicians don't call back promptly when paged. Sometimes we will page an on-call physician for over an hour without a response. Usually in that case, the call schedule might be incorrect, or a physician is on call who doesn't usually take call for this hospital. Some patients require 3 or 4 different calls; the dialysis patient with pneumonia and elevated cardiac enzymes, for example. Perhaps the consultant will want us to add another test or three that we haven't done yet, to delay the inevitable admission. Of course, the hospital is usually full as well, so the ER gets backed up and everyone is grumpy. On a bad night, all of these things usually happen at once.

But other nights, when everything is running smoothly, the shift is almost effortless. When all of the components are working together as they should, it is a lot more fun. The shift is over before you know it, and it's hard to even remember any specific patients because they were so easy to take care of. On nights like that, it seems that all of your initial diagnoses are correct, and all of your procedures and interventions are succesful. The patients respond well to treatment, do not require multiple re-evaluations or re-medication, and the flow is smooth. When patients come in at the same rate we can move them out, then everyone is pretty happy.