Predicting the Unpredictable: An Inside Look at the Dynamics of Emergency Nursing

October 7, 2019

“When I first started working as an emergency department nurse, I didn’t realize I was embarking on such an incredible journey. Throughout every shift, I’ve experienced a paramount of emotions and learned so much,” said Tracy Coleman, BSN, RN, at Jefferson Stratford Hospital. 

“As an ED nurse, you’re considered a jack-of-all-trades in an intensely challenging and exciting environment,” continued Coleman, who has been a nurse for 26 years and ED nurse for 13. “It’s not an easy feat, but I wouldn’t trade it for any other job.”

There are various characteristics of the field that make it so unique, says Coleman, including the unpredictability, timeliness, and vast range of cases. 

“Patient arrivals are unannounced. We don’t know whether or not someone with the flu or someone who’s been stabbed is going to walk through the front door. We have to be prepared for anything, and we have to react naturally and professionally,” explains Coleman. “We strive to act fast, think fast, and remain calm to achieve the most positive patient outcomes.”  

Conditions that are commonly seen in the ED include heart attacks, strokes, respiratory illnesses (e.g., COPD, asthma, emphysema), high blood pressure, abdominal pain (e.g., pancreatitis, appendicitis, diverticulitis, gastric ulcers, ovarian cysts, etc.), drug overdoses, broken bones, lacerations, chemical exposures, and psychiatric conditions (which often present with suicidal or homicidal ideations).  

An ED nurse’s primary responsibilities include assessing and monitoring patients, providing treatment, charting, transporting patients, maintaining optimal patient flow (avoiding delays), and most importantly, putting all patients’ best interests at heart.  

“It’s also essential that we align the staff with the proper clinical assignments,” explained Coleman. “This means we want each medical professional attending to a patient whose condition they have ample experience in.”  

The triage nurse for the day will oversee prioritizing which patients are seen first, determined by the severity of their condition and risk-level of deterioration.  

The Emergency Nurses Association’s guidelines for ED patient triage follow a 5-tier system:  

  • Level 1: highest-risk, condition is life-threatening  
  • Level 2: high-risk, emergent, could deteriorate rapidly 
  • Level 3: moderate-risk, but stable (the majority of patient visits)  
  • Levels 4 & 5: low-risk, can safely wait for care (or use fast care)  

“It’s important for patients to understand – and it’s our job to communicate with them – that there is no ‘take a number and wait your turn’ system,” continued Coleman. “However, if there are unoccupied beds, then patients will be brought directly back, without being triaged.”  

While ED staff face a variety of challenges, some of the most common are maintaining patient flow on a busy day/night and remaining professional (setting aside personal feelings, even when it’s difficult).  

“When there is an influx of patients and we run out of beds, both in the ED and inpatient setting, it causes the waiting room to get backed up,” said Coleman. “When things get too hectic, we huddle and try to come up with a creative solution, such as how to redesign the ER to rework the flow. Communication is key – when it comes to keeping patients and staff satisfied.” 

“In a mentally and physically exhausting case, such as when a patient is combative or violent, we must recognize our limits and the limits of our teammates,” continued Coleman. “We operate on the philosophy that there is no ‘I’ in team. If someone is visibly stressed and needs a breather, another team member steps in to relieve them.”  

If and when there is an emotionally challenging case, they can call a “debriefing,” explains Coleman.  “If you’re upset and want to talk it through with your team, you can opt to do so,” says Coleman. “Just a few minutes can really help rebuild that barrier between your work life and personal life.”  

If you are a nurse, or aspiring nurse, who hopes to work in an ED, know that it’s a specialized area of practice that takes time to adapt to, says Coleman. “It’s a new avenue in a profession that never stops giving.”  

pictured above, from left: Katie Farrell, unit secretary; Joe Pagano, DO; Jennifer Morrell, BSN, RN; Tracy Coleman, BSN, RN; Joann Miller, housekeeper; Nathalie Tupas, ED tech.