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    A thought-provoking blog about what it's like nursing in the emergency department (ED) when there are no beds. 


    What’s the worst thing you have ever seen?

    For those that work on the frontline in healthcare you may have heard this question asked many times… usually by friends or people you meet when you are trying to relax outside of work.

    They often want to hear some awful blood and guts story, something unusual being stuck in an unfortunate person’s orifice or a heroic story of a dramatic rescue. We all have something to tell along these lines. Especially when you work in ED, like me.

    Yep, they are awful episodes, especially for those involved, these awful stories often happen in ED. Car crashes, trauma, cardiac arrests, injured, sick children… you name it, I’ve probably seen it.  When tragic things happen, we have support to get us through them. We have support from our wonderful work colleagues who understand – most of the time black humour gets us through.

    I want to tell you about the worst thing I ever saw, I still see, we all still see. It wasn’t a one off, I didn’t get any support, we didn’t get any support. In fact, it went unnoticed and it happened multiple times and often for hours on end. It’s like being in a recurrent bad dream, the trouble is that it isn’t a dream. It’s real and it's probably happening in hospitals up and down the country today.

    Rose tinted spectacles…

    It’s a Tuesday afternoon. It’s a warm, sunny day.  I have had 2 whole days off. I’m rested and ready for the day ahead.  I drive to work in a good mood. Today is going to be a great day. I walk up to the ED entrance. My hopes of a good day are dashed. There are already eight ambulances outside. I hear the sirens of another in the distance coming up the road.

    Perhaps the department was already empty… it might not be that bad?

    I step inside. Two paramedics wheel an elderly man up to the desk. He looks frail, he has a bruised face and blood running from his nose. He looks frightened. He has fallen in his rest home.

    "… you will have to park him in the corridor, love..."

    The corridor is now an ‘area’ in our ED.  It’s not a walkway between two clinical areas, it’s now clinical area itself. We even have allocated a ‘corridor nurse’ to care for this group of patients.

    The corridor is full. Each side of the corridor there are people. People on trollies, in chairs, in wheelchairs. I feel their eyes staring at me. Someone is calling out for water, someone has vomited on the floor, an elderly lady is wandering around with her hospital gown on, it's not done up properly and everyone can see her bottom. Every few steps I take I hear someone ask when they are going to be seen. I see a couple crying, trying to console each other in full view of the onlooking people who have nothing else to do but wait.

    I must walk down to get to the staff room to start my shift. I feel like I am running the gauntlet. I need to get changed and get on with moving people out of the department.

    I hear staff members muttering "thank god the day staff are here" and "good luck, you’re going to need it".

    Ok,  If I was able to nurse the way I have been taught; ensuring patients are listened to, made comfortable, had medication on time, are given food and water, turned if required, clean… basic nursing care, maybe I wouldn’t feel as crap as I do when I go home. Maybe I’m in the wrong job?  But… this type of nursing takes time. 

    Time is forever ticking, especially in ED. It's all about flow. Get them seen, treated and moved – within 12 hours.  Sounds a long time 12 hours, doesn’t it? It’s not in healthcare. Blink, 12 hours have gone in a flash.

    Site managers constantly circle the nurses’ station with their clip boards, trying to strategically place patients on appropriate wards. Single sexed bays, side room, isolation rooms, monitored beds, surgical, medical, trauma, elective, the list goes on. It must be like playing one of those online strategy games, but it never ends.

    I’m now waiting for handover. The noise is deafening. White noise. I try and block out other people’s instructions, conversations, phones ringing, doors banging. My senses are overloaded. Not only is it too loud, the smell of stale alcohol and vomit is left in the air from an overdose that came in earlier, the irony smell of blood left by lady with a bleeding ulcer, the heat of the corridor and a hint of pseudomonas from a leaking leg ulcer – there are no windows here to give us any relief. This is my next 12 hours.

    People who are wearing lanyards appear. I see them when things go ‘tits up’. No idea who they are, what they do or where they come from. Never have they spoken to me and I have never seen them speak to a patient. They arrive in immaculate clothing and smell fresh, whereas I have been here a few hours and already blended in with the current smells.  They are obsessed with how long people have stayed in the department. I see them frown and start talking to the site managers, who then speak to our nurse in charge, who then will speak to me. 

    "We need to move X number of patients out of here in the next 2 hours.

    So, if I choose to help a man who may have soiled himself – this may take up to 40 minutes. That’s too long. I should have been preparing my patients to move off.  But then if I don’t help him, the ward he moves onto will report me.

    Notes to prepare, IV antibiotics to give with in 1 hour, comfort rounds every 2 hours, mouth care, turn charts, feeding regimes, safety documentation to be completed, toileting, venepuncture, sepsis pathways, NEWS charting, escalation protocols… so many targets to be met. I can’t do this. It’s impossible.

    ‘The standard you walk past is the standard you accept’

    Every time I walk down that corridor – I say this in my head. I have failed.  We have failed our patients.

    That is the worst thing I have ever seen.

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    “Maybe I spent thirty years in the wrong job”

    I’ve thought that sometimes as I’ve reflected on my career as a nurse. 

    But that’s not it. 

    Nursing should be the greatest job in the world, and it was, but over thirty years it has reverted to a state of constant panic as resources have become overwhelmed and too much has become expected of too few. 

    Lanyards expect magic, but magic cannot obliterate the logic of simple mathematics  

    Nor will they listen to the non-magical solution I used to present to them:

    “Operating lists are manufactured workloads. Use your last free beds on elective surgery patients and the whole hospital will grind to a halt.”

    This was information I had dug out of an IHI White Paper on Patient Flow, but day after day at bed meetings simpleton managers made the same simpleton mistakes with monotonous regularity. 

    Who am I?

    i am just a nurse, and I know.

    It wasn’t  me who was in the wrong job.  

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