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Emergency Medicine: Census and Sensibility

helpEmergency has something in common with Labor & Delivery.

Neither department has control over their census.

Medical/surgical, telemetry units and ICUs have a finite number of beds. When they are full, they are full; they cannot physically expand to more beds.

ED patients and laboring women are never turned away no matter how full the department may be. Oh, the ED may triage and L&D may send a patient in early labor home, but in both cases, eventually, all will be seen.

Labor and delivery has one advantage over the ED.

They can have someone on call.

I’ve never worked in an ED that has had an “on-call” nurse.


I will never understand the logic behind staffing an ED based on the previous 24 hour census.

If the ED does not meet a pre-determined number of patients on one day, the break nurse for the next day is canceled and there is much wailing and gnashing of teeth as the department goes over budget.

Never mind that the acuity level of the patients who were seen was through the roof. Or that 50% of them were admitted. Or that the next day, acuity again sky high, the nurses go without meals/breaks and the department is required to give penalty pay. Again, there is much wailing and gnashing of teeth for having to pay this penalty, a penalty that would never have been required had the break nurse not been canceled.


Now if the ED is slow, staff can always go home early. But not too early, because you never know what is coming in through the doors. So maybe an hour, 90 minutes early, knowing that the remaining staff can handle whatever they need to handle until the next shift comes in.

But what happens when the patients overwhelm the staff, both in acuity and numbers?  Ambulance diversion doesn’t stop the walk-in critical patients. The MIs and the possible CVAs. The GI bleeders. The potentially septic. Trying to get patients out of the department and up to the floor doesn’t work when the floor won’t take the patient for four hours because it would put them “out of ratio”.

This is a huge issue on the night shift. When there is only one unit clerk/registrar, two nurses and an ED tech after 0300.

Of course, at night it is feast or famine.

Either the feces hits the proverbial fan or…it doesn’t.

Which is exactly why we need a nurse on-call.

The ED needs flexible staffing that accounts for those times when the acuity level/census is overwhelming. Not canceling the extra break nurse is one way of doing that on days and evenings; using the on-call system is another way that could be utilized at night. If it can be done in L&D, why can’t it be done in the ED? Surely the money saved in penalty pay for missed breaks and meals would make it budget neutral.

All I know is that trying to drop staff in an ED based on what happened the previous 24 hours makes zero sense.

(And don’t even get me started on why nurse-patient ratios are treated like unbreakable rules on the floors, but it’s okay for the ED to be waaaaay out of ratio and nobody blinks….that’s another whole post!)

*This blog post was originally published at Emergiblog*

I See You In A Different Light

squishycapWell, somebody likes their job, I must say.

Although I can’t figure out why she is smiling.

Her cap looks like conjoined coffee filters!

Conjoined coffee filters that somebody sat on!

Maybe she doesn’t realize it’s squished, and would die of embarrassment if she knew!


The emergency department “regular”.

Every emergency department has them.

A patient can become a “regular” for many reasons. Maybe they are a recurrent cardiac patient. Perhaps they suffer from chronic pain. Sometimes, they become a “regular” because they utilize the ER as a clinic and bring the whole family in over the course of a month. Some regulars are drug seekers. Others are homeless and know they can find respite in the department for at least a couple of hours and maybe get something to eat.

If you work in an emergency department long enough, you will know who they are.

And you will get to know them.


Recently, it dawned on me just how well you get to know them.

I work in a community hospital. It’s one of those hospitals that patients actually request to go to from all over the county. We have our shifts from hell, but it is far from the county-trauma-eight-hour-wait-time environment of the huge medical centers. There is time to talk to the patients, find out more about them than what hurts, what is swollen or what prescription they have lost.

Over time, the conversation stops being scripted and “starts getting real”, as they say.


This particular shift was steady, but not crazy. And almost all the patients I cared for were “regulars”. Easily 90%. For some, it was their usual health issue. For others, something different.

I found out a lot that night over the course of that shift

Someone’s youngest would be starting kindergarten in September; someone’s oldest had just graduated from high school. Someone had gotten into a recovery program and had been clean for a month. Someone had just welcomed their first grandchild, another was mourning the loss of their mom the week before. Someone had lost their job earlier in the week. Someone had gotten married since their last visit. A baby sister was on the way for one of my patients. Another patient had enrolled in the local junior college.

We saw them, treated them and sent them on their way with a wave and a prescription.

Hopefully they left in better shape then they arrived, even if all they needed was reassurance.

All I know is that I thoroughly enjoyed that shift.


I had done all the usual things.  Saline locks, blood draws. Medications and re-evaluations. IVs and education.

But I had also congratulated success, commiserated over frustrations and offered consolation over losses. We covered birth and death, struggles and successes, dropping old lifestyles and starting new beginnings.

That shift, I saw my patients in a different light.


The best part of nursing has nothing to do with disease or diagnoses or procedures or prescriptions.

The best part of nursing is the patients themselves.

I thoroughly enjoyed catching up with my “regulars”.

I hope I was therapeutic for them.

They were most certainly therapeutic for me.

*This blog post was originally published at Emergiblog*

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