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The Hemorrhage of Emergency Nurses

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I started my medical career late. Really late. By that time, I’d lived a few lives, I’d earned a boatload of initials, I’d changed husbands, languages and continents, I’d written a useless novel and I’d been a Mary Kay lady. One day over lunch, as I was looking for something to do with myself, my husband suggested medicine. I spent the next nine years immersed in my medical training, feeling guilty every time I spent time with my family, but I digress.

The day I landed in my emergency department, I was on the wrong side of forty, sporting a short copper red haircut not yet seen in humans and an accent that still takes my patient’s mind off their misery (they’ll spend their last hard-fought breath to ask where I’m from).

My rural ED is hours north of where normal people call north, where winters are long, people are sturdy, and the geese speak mostly French.

Surprisingly, my nurses were guarded at first. They eventually accepted me in spite of my quirks, hair, accent and all, and started teaching me the ropes:

  1. The cold chills are worse than the chills, mainly because the chills don’t exist per se. They’re either cold or hot, and you’d better figure out which. Cold chills are worse.
  2. Eh? is not a question for the hard of hearing, but a marker of nationality.
  3. Bavarian cysts hurt. A lot. They usually grow in the ovaries.
  4. When an experienced nurse asks: “Are you sure you want to give that?” you probably don’t.
  5. If they ask, ”Doctor, would you like to give some vitamin K?” you’d better check the med list for the coumadin you missed.
  6. A “fit” is not trying on a new costume, it’s LOC. Of some sort.
  7. When a nurse overheads you to a room, get up and go. Or run away. Whichever’s easier.

Twelve years later, my nurses and I had many good shifts and more bad shifts. We saved patients, we lost patients, and we wondered what happened to the patients we lost sight of. We learned to trust each other and have each other’s backs, whether we liked each other or not, whether we shared the same patients or not — we work in teams in my ED, almost like parallel EDs, but when the going gets tough, we do whatever it takes. When she asks me, I’ll go to her patient with a heart rate of 160, even if he isn’t mine; she’ll come to put an IV in my 2 months old, even if he isn’t hers. Like soldiers fighting the same war, we’re all on the same side, fighting the fight against death. We muddle our way through shifts, skipping lunch, drinking stale coffee, seeing patient after patient on a full bladder. We get cursed and bit and spat on. We laugh at things normal people wouldn’t laugh about, just to keep ourselves from crying.

A few years ago my friends, the ED nurses, started leaving. Some retired. Some moved to winter friendly places where ice only lives in cocktail glasses. Some went into travel nursing to see the world.

Most of them, however, didn’t go far. Their only point was to leave the ED. They went to the ICU, to surgery, to administrative jobs, to NP school. Few of today’s ED nurses were here five years ago. Even fewer were here before me.

The young ED nurses are lovely. They are lively and funny and smart. They work hard and learn fast. They advocate for their patients. They are lots of fun to work with.

But, unlike my old friends, they haven’t been through 20-plus years of challenging patients, rare diseases, extreme situations, new doctors. When things don’t happen like they should, when the equipment fails, when the patient is like no other, when the doctor is overwhelmed, they’re at a loss. How could they not be? They’ve never seen it before.

How does it feel to be the most experienced person in the room, you ask? Not good.

I miss my old nurses like crazy. When the systolic drops under 70, when I ask for the tracheal hook and I meet only blank stares, when nobody knows where the jet ventilator is — nobody’s seen it for 20 years — wouldn’t you really like to have somebody in the room who knows better than you do? I would.

What happened? Why are they leaving? Where are they? I polled them on Facebook, expecting some answers. I got a ton. It was a deluge of answers, most of them sad, many angry, some hopeless, about the sorry state of Emergency Nursing today. I got answers not only from my ED but also from the south, the west, Canada, even from cruise ships all over the world loaded with well-fed passengers expecting American-style nursing from the cruise ship medical staff.

Here are a few of the answers:

Lack of resources, lack of support and reimbursement for continued education, certification, lack of ability to be promoted, archaic practices/policies supported by admin, unsafe staff/pt ratios, most likely unit to be assaulted/lack of admin support when assaulted, pt satisfaction guided care versus evidence based practice, lack of support for time off to attended national conferences, national professional association functions. I am an educated licensed professional but I can’t have a drink or a cell phone, ….CEO makes $3.2 million, I cant afford a 2 bedroom apartment.”

“Abuse. At the hands of patients, family, either in the form of physical or psychological harm; RNs are sick of feeling disrespected, unheard and dismissed by doctors; The system is broken. Equipment doesn’t work. You have a critical patient who speaks Farsi and the translation devices don’t work and you can’t communicate with patients. This is nothing new. Nothing changes.”

“In the ER you see the worst side of people and society. You see people in pain and distress and they lash out at you to “fix” them right now. In our evolving society where instant gratification is becoming more prevalent, people expect to go to the ER and to be given answers for long term problems. The patients are demanding and want all your attention on them. Our culture has turned to emphasize customer service and caters to those who complain because of fear of a bad review. Management puts more demands on nursing staff to satisfy patient complaints quickly. Nursing feels they can no longer provide quality, critical thinking care to those in true need for fear of discipline.”

“I have been out of nursing for a couple of years. I was watching a show last night on Asian food. It struck me as odd that it would take this Taiwanese restaurant 6 months training on making the noodles that you find in dim sum. It started me thinking that our local ER gave six weeks training then kicked you out of the nest. Hmmm! I will tell anyone that I would rather stand naked on I-95 than ever return to ER Nursing.”

“Healthcare continues to change, primary care continues to retire older providers and were are overwhelmed, patient without true emergencies are seen in climbing numbers and congesting the ER…. we are expected to work long hours day after day, our job is so regimented….. let’s not look at the idea that you may have just provided the best hands on care and saved a life, but you didn’t check this box or this one…. oh and granny down the hall complained you didn’t smile. It doesn’t matter that…. it took FIVE (!!!) Years working there before i was approved a single day off without having to call in sick. You never have a moment to breath just keep trucking to the next. The institution as a whole does not value any employee as an individual rather you are simply a number and someone else will come along.”

“Trickle down effect, as more experienced nurses leave the unit the more I personally feel unsupported and have fewer and fewer people I can go to with questions. Fewer experienced nurses on the unit makes me feel like it’s unsafe and I start to worry about my license. I like my job and I don’t want to leave but I also don’t want to feel unsafe.”

Like it or not, this is Emergency Nursing today. They are burned out. They feel overworked, undervalued, abused, unappreciated, and not supported. I agree.

What should we do about this? You, me, the other doctor, the other patient? Whether you are an ED doc or not, this affects you. Your family. Your neighbors. YOU.

What should we do about it?

Rada Jones, MD, is an Emergency Physician. She practices in Upstate New York where she lives with her husband, Steve, Gypsy Rose Lee, her German shepherd, and a deaf black cat named Paxil. She is finishing her first novel, “Overdose, an ER Thriller” where a lot of people die in unnatural but exciting ways. Find more at, instagram RadaJonesMD and twitter @JonesRada.

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