The hardest adjustment from inpatient nursing to ER nursing has been the frequent handoff.
In the inpatient world, you need to know everything about your patient and have everything done for your patient. Many a nurse will huff, roll eyes, groan, or otherwise note their displeasure with your work if you: A) – do not know something about your patient or B) – have not done something for your patient. In that 12-hour shift, your patient becomes your family member. You know them and have cared for them, in some ways better you’ve taken care of your loved ones and even yourself.
In the ER, the nurse taking over really just wants to know what needs to get done. Only major highlights of past medical history and recent history are needed. Little details about their life or bowel patterns? Who cares! What brought them here, and what’s keeping them in our bed instead of their own or an inpatient one?
The hardest adjustment from in-patient nursing to ER nursing has become the frequent handoff, the constant letting go of my patients into other people’s hands.
At least once a week or so, I have a very sick patient, an ICU level patient whose room I rarely leave. Ron was that man the other day. He was a quiet man in his late 60s with a history of cancer and blood clots (and currently taking blood thinner medications) who came in at the urging of his wife Karen. Ron had a low-grade fever of 100F and a steady heart rate of 120 at triage. Within an hour of sitting in an ER bed, his temperature climbed to 102.1F. HIs lactic acid was elevated. His white count was elevated. Objective signs and test results pointed to sepsis, a severe infection affecting the entire body.
Too, Ron was needing more and more oxygen, even during his short stay in the ER. Increased oxygen demand with a history of clots meant a distinct possibility of a clot in his lungs called a pulmonary embolism or PE. Within yet another hour, his temperature stayed the same (thanks to good ol’ Tylenol) but his blood pressure began to drop while his heart rate creeped even higher. I had fluid to hang, antibiotics to start, report to call, and much more to get done when I got a call on my personal headset.
“Hello,” I answered.
“Hey! I’m out at the desk if you want to go to lunch,” my co-worker said breezily.
I glanced at my patient. He looked more pale and diaphoretic than earlier. I glanced at his electronic medical record. I had things to do before he went to the unit. I glanced at my watch. It was 3:30pm, and I just started work at 11am. Much too early for a lunch. “Um, I’m a little busy in here. You can get someone else first.”
“You’re my only lunch. I can help take over,” he offered. “What room are you in?”
“Be right in.” Moments later, he was. “What can I do?” my co-worker asked. I listed a litany of things. We hung fluids, got another IV line, took a repeat labs, hung antibiotics, and he called for another one of our nurses to come over to take the patient up while I called to the ICU to call report.
The ICU nurse asked me about everything (as expected): every inch of his skin, his full past medical history, his full neurological status, his everything. I groaned in frustration as I repeatedly told her all that I knew and said, “I don’t know. I just met him 2 hours ago. He needs to get up to you before he can get his CT scan so they can really figure out what’s going on.”
ICU did not like the unknown. She pestered me further, wanting to know everything that was wrong with him to fix it. We didn’t have all the pieces of the puzzle yet, I explained with increasing impatience. The doctors were worried that Ron had a PE, but he had a allergy to contrast dye and needed to get to the ICU to get medications before his CT scan to rule out a clot that X-ray didn’t show.
I didn’t know what exactly was wrong, which is what the ICU nurse was asking. I didn’t know exactly what needed to be fixed, though the blood cultures and repeat were sent and would provide answers soon. All I knew was we were supporting his body with fluids, antibiotics, and oxygen, and he needed to get to the ICU in case he also needed the support of vasopressor medications for his blood pressure while we were waiting to figure it all out. I knew he needed to go out of my hands into hers, and that was all I knew.
I returned to Ron’s room, frustrated. I smiled as I introduced Ron and his wife Karen to my co-workers taking him up to the ICU and mentioned the name of the nurse he’d meet upstairs. Karen gave him a lingering kiss before my co-workers wheeled him away.She was shaking as I walked her to the waiting room. “He’s in good hands,” I said as I put my hand on her shoulder.
“I know,” she said with a small smile as she hugged me. “Thank you.”
“He’s in very good hands,” I said as I hugged her back, parts of my heart doubting the skills of the ICU nurse Ron would soon meet. Karen nodded with tears in her eyes, her lips pursed in determination not to let them out, and went to the waiting room.
That’s the last I’ve seen of either Ron or Karen. I haven’t heard what happened to them. I probably won’t ever see them or hear about them again either.
The hardest adjustment from inpatient nursing to ER nursing has become has become the frequent handoff, the constant letting go of my patients into other people’s hands.
I don’t get to hear how they end up. In the inpatient world, people know who knows a patient and will give you update. If you really connect with one, you can even visit them on another floor.
But I don’t get that luxury in the ER.
Sometimes I hear about a patient, and it’s usually only because they’ve died or we missed something or something turned out worse than we expected. I don’t get to hear who goes home, who gets better, what the exact cause was, how the surgery went, etc.
All I get is a name of a nurse who is taking over, the name of the team taking over, an unfamiliar voice on the other end of the phone. All I can give the family is a name, a floor, and a phone number. I’m new to the hospital, so I don’t know if a doctor is good, if a nurse is experienced, if a floor is well-staffed, or even where any of it is.
Yet I have to trust that my patients are in good hands.
ER nursing takes a lot of trust. I have to trust my co-workers. I have to trust the report and assessment of the nurse who triaged the patient. I have to trust the expertise of the nurse covering my lunch or taking over my patients. I have to trust the report of the EMS workers bringing in a patient. I have to trust my patients are telling me the truth. I have to trust the skills of my doctors. I have to trust the skills of my technicians. I have to trust the unit clerks are paging the people I need. I have to trust registration is registering patients correctly. I have to trust security wouldn’t let back violent family members and protect me from violent visitors and patients. I have to trust X-ray and CT technicians to take good diagnostic images. I have to trust my pharmacists are checking all my medication interactions for me.
I have to trust so many other people, and I don’t always get to know what happens in the end.
Yet, as an inpatient nurse, I still had to trust my patients were in good hands.
I might have been able to see more patients go home and get better as an inpatient, but I also saw some get no better or even worse. I saw some sit in the same bed for months, even a year, with little improvement. I saw some, still full of tubes and unable to speak go to long-term rehabilitation facilities. I saw some remain out of their minds, never coming back to who they used to be. I saw some families hold onto a near-corpse instead of letting them die peacefully. I even know some died, and I even was there as a few could not brought back from cold clutches of death.
I still had to let them go, just as I still let me patients go, and let them go into the Divine Physician’s hands. It’s the only way I can bear to witness suffering. I have to trust when the doctor tells me to stop CPR that my patient’s heart and soul is still in the hands of the Divine Physician. I have to trust that even I let go of the dying woman’s hand that the Divine Physician never stopped holding hers. I continually have to trust that even though I haven’t seen the full outcome for all of my patients, the Divine Physician is caring for them.
Like all realms of my life, it is and has been most difficult to let go of the things and people I love into the hands of the Divine Physician, into the hands of Our Heavenly Father.
I want so badly to know how it all works out, to see how all the puzzle pieces fit together, to understand why this happened and when this is going to happen and why this is happening. I want to have control of my life, my future, my destiny, or at the very least, understand it.
Yet even Jesus, all-powerful, all-mighty, all-knowing Jesus, let go of His life into the Father’s hands.
When Jesus is asked how to pray, He teaches his disciples to say to the Father, “thy will be done” (Matthew 6:10). Every day, Jesus perfectly did the will of His Heavenly Father as He perfectly obeyed His earthy parents. Jesus always put His Father’s Will first, even if it confused His earthly parents, as it did when He was lost in the temple as a young boy. Jesus healed many, preached to many more, all in the name of His Father.
In the garden of Gethsemane, mere moments away from humiliation, suffering, and death, Jesus prayed as He taught. He prayed, “Father, if you are willing, take this cup away from me; still, not my will but yours be done” (Luke 22:42). It was the will of the Father for Jesus’s suffering and death on a cross for our sake, and Jesus accepted His cross without bitterness.
Yet I cannot even bear the small tasks set before me without a little bit of groaning. I cannot even bear the unknown of my patients’ health without a little bit of anxiety. I cannot even bear thinking of my own future without a little bit of dread. I cannot even go about my day without little pangs of bitterness entering my heart.
How, how, could Jesus trust like this?
He knew He was in good hands.
Jesus, unlike us, was never burdened by the weight of original sin, never suffered the loss of perfection connection to the Father. He knew He was loved, He was known, He was safe, He was cared for, in the hands of the Father.
As a nurse, I am constantly humbled by my patients. Being a patient takes a lot of trust. Without knowing me, knowing my doubts about my skills, knowing my weaknesses as a person, knowing my past mistakes as a medical provider, they put themselves in my hands and trust me to care for them.
My patients are constantly teaching me to place myself humbly in the healing hands of the Divine Physician, in the scarred hands of Jesus, in the good hands of Our Heavenly Father. So, as they each leave me, for home or for hospital, I pray for the hands that will be caring for them. I pray for both the physical hands of the next providers and the spiritual hands of Our Heavenly Father to guide them closer to Him in this time of suffering.
We cannot know nor control everything. While on earth, we’ll never have all the puzzle pieces completely figured out. Just as we offer up our activities to the Lord, we can also offer up that which we cannot control, our passivities, to God as well.
In those passivities, in those letting goes, in those moments we can do nothing else, we pray as Jesus did on the cross: “Father, into Your hands, I commend my spirit” (Luke 23:46).
Truly, we could not be in better hands.