Daniel Liptak: ER Experience 10/18/18

(1) The type of patients I observed in the ER varied widely in acuity. As a level

one trauma center, I definitely noted the higher acuity of patients downtown versus

where I work, in Boardman. I learned one night at work in Boardman that there is an

acuity that goes all the way to five which I have only seen for medication refills.

Understandably, those are the patients who are triaged to a much lower priority than a

trauma or case of sepsis. The patients I saw included a confused elderly gentleman in

need of psychiatric care, a bells palsy case, a motor vehicle trauma, a fall with trauma

to the head, and a dyspnic patient.

(2) The members of the ER time I observed included physicians, physician

scribes, a unit secretary, nurse practitioners, nurses, a chaplain, social workers, and

cleaning staff. Physicians see patients and collaborate with others to form a biomedical

diagnosis and decide whether it is most appropriate to treat the patient and discharge

or admit them for continued care. Physician scribes input data into the computer for

what the physicians state and the information they observe and collect as well as the

recommendations on their patients for plans of care. The unit secretary handles phone

calls and assists staff members in mostly non-clinical tasks. Nurse practitioners treat

patients much like physicians do and contribute to the plan of care for a patient either

working under the license of a doctor or autonomously depending on the particular

nurse practice act and defined scope of practice in a state. Nurses care for patients by

carrying out orders directed by APRNs and physicians. As the ER is generally busy,

nurses also suggest things and report pertinent information to providers that may

necessitate interventions. The ER nurse probably has one of the greatest roles in

emergent healthcare with the wide range of tasks they are capable of completing
 Daniel Liptak: ER Experience 10/18/18

including but not limited to charting during a code or trauma, IV placement, lab

collection, ekgs, medication administration, patient ambulation, assessing and

reassessing patients, and more. A chaplain is present in Mercy’s facilities, because it is

a Catholic hospital. They function as counselors and comforters to both staff and

patients offering prayers and healing words to the sick and human companionship.

Social workers put together a picture of the patient and their current clinical status as it

relates to the rest of their life ensuring holistic care. They are an important part of the

interdisciplinary team with functions including facilitating communication therefrom and

ensuring the patient’s needs outside of the acute care setting are met such as with the

aid of community assistance or government programs. I feel that housekeeping is an

important part of the ER just as any other part of the hospital, because they are who

we rely on for clean and safe areas to practice medicine and nursing. A trauma bay

would be unusable if not cleaned and reorganized properly following a trauma.

Healthcare is certainly a team effort, and that goes far beyond those who are clinical

staff and providers.

(3) I did not have time to observe the triage area in the ER, however, triage is the

foundation for receiving care in the most effective and efficient way possible. Triage

nurses are responsible for determining one’s acuity and consequently when they will be

seen in relation to the acuity of other patients who need to be seen. One thing I learned

from my nurse is that nurses can triage up or down the patient based on judgement if

patient status changes or they feel they were inappropriately triaged initially.

(4) Bed assignment in the ER is unlike patient assignments on the floors. A nurse

typically has several rooms and patients wherein quantity is determined by the acuity
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of his or her patients. It is reasonable to expect a nurse to have several lower acuity

patients or fewer patients that require more care and observation. It is the role of the

charge nurse to delegate patients accordingly ensuring safe workloads for all nurses.

(5) The ER nurse functions as an educator when discharging patients home or to

another facility. It is imperative that a patient knows if followup care is necessary or if

they are to take prescribed medications they do not normally take. A nurse must also

ensure that there is transportation so that once they are discharged, they are able to

leave the hospital. The role of education also extends to family, friends, or caregivers.

Often times, patients are not capable of caring for themselves, so it is important that

the primary caregiver is updated on medications and treatments that may follow an ER

visit.

(6) In admission to the acute care setting, the nurse must gather as much

information as possible via psychical or psychosocial assessments as well as

subjective data provided from the patient or caregiver. Subsequent screenings and

medication reconciliation is typically done once they arrive on the floor, but it is up to

the ER nurse to provide the next caregivers with an accurate and helpful database of

information that will provide continuity of care from the ER to admission on the floor.

The ER nurse or the unit secretary will typically fax up the SBAR and call report.

(7) A common ethical concern in ER nursing is patient to nurse workload ratios.

In one example, a patient of mine who was a local ER nurse told me his license was

undoubtedly in danger every shift he would work because his patient load was

blatantly unsafe. Upon finding a new job, the nurse manager assigned him a high

volume of high acuity patients requiring lots of care. This is very unethical, but it is a
 Daniel Liptak: ER Experience 10/18/18

reality of working with people in the workplace be it in accounting or in healthcare.

Mismanaged patient loads are an absolute detriment to the care that patients receive

and how timely that care is–an aspect that may very well affect patient outcomes in the

ER in those who are seriously ill.

(8) My experience overall was great. I think ER is definitely something we should

be allowed to experience more, because it gives us more of an opportunity to assess

and think about what interventions are necessary. I had a patient that presented for a

possible CVA with serious facial droop. The initial reaction of most people is CVA,

however, we found upon further examination that he had no neurologically based

speech impairment and was able to move all four limbs autonomously with

symmetrical strength and sensation. He was eventually discharged home with a

diagnosis of Bell’s Palsy. Such instances I feel are good teaching moments, because

one must look much further and assess in more detail to ensure an accurate diagnosis

is made and prompt interventions are taken. On first thought prior to seeing the patient,

I was thinking about stroke care such as tPA and anticoagulant therapy. Upon

assessing the patient, however, it appeared that CVA was not this gentleman’s

problem. I was much relieved by the autonomy I had as a student in the ER in helping

my nurse as well as the physicians in a cauterization of a patient’s head following a fall.

I do wish that the objectives of this paper focused more on the experience I had and

things I learned than than information regarding emergency care that can merely be

researched from home.