Earlier this month, I wondered what it was going to be like in the ER without being able to divert ambulances. Right after I wrote that post, I went to work. It was a Monday. According to the nurse in charge that day, we had the highest acuity and census ever, and we survived.

I walked through the door that day skeptical and concerned. Quickly, I was filled with pride. A Physician's Assistant (PA) was in the waiting room. He was seeing, treating, and discharging patients behind a screen. It seemed, at first, so antiquated to me, but it served a purpose of moving patients through quickly.

The afternoon progressed and in the end we needed to resort to "Code Help." This is our version of a hospital wide response to high census in the ER. So, instead of depending on other hospitals to bail us out, we look into our own facility. Administrators become involved. Beds are forced open and nurses from ICU/Intercare are floated to the ER to care for critical patients that have no beds.

From an ER point of view, "Code Help" is a godsend. Barriers that we had become so used to dealing with have now been obliterated. Floor nurses can no longer refuse report. Beds can no longer be hidden. Other staff from within the hospital will see why ER patients come up to their floor in the state they do. The ER is no longer silently suffering.

The change can even be felt on ‘normal' days. Our patients are moving to their rooms faster than ever before. It doesn't feel like we are holding as many patients, either. I know they are happier; as am I. This change has freed me up to do what I love best: Emergency Nursing.

But, still, it all leads me to wonder what it must be like now on the floors. I was once an inpatient nurse. I remember dreading a patient from the ER and the amount of work that came with it. I remember a time when I never wanted to function in the emergency an environment. And, yet, at times, that is exactly what they, the floor nurses, are going to be forced to do.

The other night, I worked with an Intercare nurse who was floated to the ER. She said she felt useless. She didn't know where we kept supplies, how we got our medications, or even how to go about charting. It was in that moment that I realized a little bit of planning on the administration's side could maybe have softened the blow. If we were going to force nurse's to work in our area, wouldn't it make sense to help them?

I tried my best to make this nurse as comfortable as possible. I wanted her to know that I appreciated her presence. Her knowledge of inpatient care was a relief to me. I did what I could to help ease her anxiety, but I don't think it helped her all that much.

Cautiously, I am breathing a sigh of relief. Maybe the horror of ER overcrowding can be changed. Maybe the answer can be found in the form of a law. And maybe, just maybe, the patients I'm nursing will get the care they deserve. I guess only time will tell.

January 1, 2009 was the day designated by the Massachusetts Department of Public Health to end diversion for Emergency Departments in the state of Massachusetts. In a letter addressed to all hospital CEOs, the Commissioner and Director clearly stated their intentions: to reduce the boarding of patients in the ED and the subsequent overcrowding that is a direct result of this problem.

To describe the situation more clearly, I think I need to explain a few things. I work the evening shift from 3pm to 11pm. This is a time of high volume. Though the ED is rarely predictable, there are some patterns I have come to recognize. For example, say it's Monday. The hospital has a predetermined schedule of surgeries for that day, some emergent and some elective. Over the weekend, there have been more admissions than discharges. The hospital is virtually full by 7am to accommodate those patients that are already there and those that will be admitted following their surgery.

Patients come into the ED throughout the course of the day for their problems. More patients are admitted with nowhere to go. By the time I come in at 3pm, we are holding a large number of admitted patients. This number can range from 3 or 4 to over 30. The flow of patients increases after 5pm when most doctors' offices close.

The main part of the ED I work in has 31 rooms plus hall spaces for acutely ill patients. This includes areas for telemetry monitoring, critical/trauma patients and psychiatric patients. If we are holding 15 patients for admission, that equates to half of our available beds. So, technically, at this point, we are half full. The kicker, though, is that patients keep coming. They walk in or ride in an ambulance. By law, we cannot turn them away.

So, now, I am the ED nurse. I have an assignment that includes both admitted and ED patients. Imagine next that there is a two-car accident on the highway. We have three trauma patients coming in. I get pulled out of my assigned area to take care of one of them. My area of the department is down one nurse. My team members, who also have their own patients, now need to take responsibility of mine.

I am in the trauma room for 30 minutes. Meanwhile, orders have been entered on two of my patients and a cardiac arrest comes in. The patients that have been there, admitted and not, will sit and wait until someone has time to take care of them. This holds up the entire process. No one goes anywhere because there is not a nurse to do what needs to be done.

This is the typical scenario of when the charge nurse would go on diversion. Doing so, would prevent new patients from coming in by ambulance and give the nurses a chance to care for our current patients, instead of starting something new that we won't have time to finish.

The letter reminds the hospitals that: "It is important to point out in this context that the Medicare Conditions of Participation require that inpatients boarding in the ED receive the same care and services that they would receive if they were in a bed on an inpatient unit, and this requirement is subject to enforcement just as is any Condition of Participation." Oh, how I wish this was possible.

What I am trying to say here is that the problem is so much more complex than it appears on the surface. I do not believe that a law is going to help, but maybe it can. Essentially, hospitals need an overhaul. Small changes have occurred over the years to address the problem, but I believe it's going to take a lot more than that. The Department of Public Health might just be right in ending a dysfunctional tool that benefits no one in the long run. The hard part is going to be dealing with it. The economy is hurting right now. Budgets are being slashed in hospitals and reimbursements are low. Change costs money that CEOs of hospitals claim they don't have.

But maybe some changes can come for free. That would involve cultural adaptation, a more arduous process. I want to believe that nursing can do it. Different departments can work together to achieve a common goal of safe patient care. I have seen it happen more than once in my ED career, during times of crisis. I'd love to see it take hold permanently. This challenge is not the first obstacle we in the ED have had to face. As a matter of fact, we are driven by them. I know we can do this and everyone will benefit as a result.

My family gathered together a few days after Thanksgiving. We were laughing, talking and celebrating. The atmosphere was light, playful. The time had come for all of us to say good-bye. My mother was making the rounds, plopping kisses on her offspring when my grandmother, Nana, started to not feel well. In a few seconds, she was pale and unconscious on my kitchen floor.

I had been summoned to her side just before she passed out. My nurse mode kicked in, allowing me to maintain control over the situation. Each and every family member present assumed a role and helped out. Even before my Nana regained consciousness, an ambulance was on its way, my brothers had caught her and removed her jacket, and I started a full assessment on her.

It's at times like these that I am thankful I am an ER nurse, but at the same time feel cursed with too much knowledge. In a split second, ten different diagnoses crossed my mind; none of which were very positive. While I waited for the ambulance, my Nana slowly woke up. She began to follow commands, move all extremities and speak. What my family (and I assume most families) didn't know, was that I was able to rule out so many different diagnoses just from interacting with her. I was feeling calmer by the second, while they waited anxiously for answers.

Westfield Fire arrived, carrying their gear and acting confident. I recognized the paramedic, but didn't know his name. I felt immediately grateful for their presence and backed off to let them do their thing. For the first time, I allowed myself to hope that everything would be ok.

In the ambulance, the medic started an IV, did a twelve lead EKG, full set of vitals and a head to toe assessment on my Nana, all before we left my driveway. I was amazed at how much he accomplished in so little time; I had never been inside an ambulance. This experience confirmed what I had always said about calling 911: care starts at the door, not when you arrive at the hospital.

Paramedics can do so much more than the average person realizes. I think they do more than many ER nurses realize, too. They function under direct scrutiny of an anxious family in almost any setting. And yet, they are so frequently overlooked as an essential part of emergency care.

Well, after this experience, I want to make it a point to value them, no matter what. A good paramedic makes my job as an ER nurse easier. As a family member, they took the burden of care off me. I was able to return to being a concerned granddaughter with someone else in control of the situation.

My Nana ended up being ok. She spent a few days in the hospital, receiving stellar care from everyone, from the ER to the telemetry floor. I don't think there is anyway to express the gratitude I feel to everyone that was involved. I know she feels the same way. So, I'd like to take this time to thank everyone who helped. You are remembered and appreciated.

It is said that experiences change us and evolve us into who we are today. I hope that as this event moves further back into my memory, I can continue to appreciate all the skill sets that each level of hospitalized care provides. After all, as the song from High School Musical says, we are all in this together.

Recently, I have been asked this question more than once. My first instinct was to provide the trained response of "Yeah, I'm fine." But I didn't. Instead, I decided to stop pretending I was happy at work and begin to seek advice from those around me. After all, we are in the same boat. Maybe someone could help me get over the hump that seems to be in my way.

I don't believe in complaining; I feel it is counterproductive to solving problems. But lately, solutions have been more difficult for me to conceive. And, to make matters worse, when I do think of them, it seems that the barriers are bigger than they used to be. I am at a crossroad and need some assistance to find my way.

I began by turning to colleagues that have been in the ER longer than me. They were the first to notice my decrease in enthusiasm and to ask if everything was all right. I responded honestly and openly. I received real pointers and pieces of advice that I was able to store in my mind for future reference.

One woman, whom I admire for her strength and strong leadership skills, stated that she doesn't allow an opportunity for argument when she needs something. She does this by stating her expectations without posing them as a question. For example, I tend to find it difficult, at times, to call report on an admitted patient, because the floor nurses are too busy to take it. She said she does not ask to give report, she simply states that she is going to, leaving the floor unable to reject her. If the nurse is not available, she will report to the charge. Her patients deserve real beds in real rooms and she is advocating for their needs. "Because that is my job," she stated.

Another nurse I spoke to encouraged me to be more verbal with my needs. "If you just speak up and ask, then most likely you will get." That seemed reasonable enough to me. I decided to take both ideas and try to integrate them into who I am.

And finally, the big test came. I knew it was going to, my supervisor, Gillian, reads my blogs. But when she asked me, that all important question, part of me wanted to blow it off. In a split second, I realized I would only be cheating myself. I was not ok and needed to talk about it.

The hard part was that things were changing. I had already begun some soul searching, some looking into what I desired. A few opportunities had come along that challenged my knowledge base and reignited my passion. I had recently recertified in Advanced Cardiac Life Support, reminding me that I was competent in my skills. So, I took this conversation as an opportunity to explore new phases I needed to develop.

We sat together for a while, discussing my hopes and dreams, my fears and weaknesses and my strengths. I left her office with new hope. I knew I could make it. The happiness would return in time. As a matter of fact, it already has.

It wasn't easy to admit I needed help. It hasn't been fun searching for answers. But as I look back, I am grateful that people asked me if I was ok, and even more grateful that I was honest. If more of us could share pieces of ourselves with co-workers then maybe more nurses today could avoid burnout. It's never too late to ask for help or to reach out and give it. So if you are worried about someone, go ahead and ask, "Are you OK?" When it is your turn to answer, try to be honest. They wouldn't be asking if the didn't care.

A recent conversation with one of my mentors really turned my thoughts around. The Clinical Nurse Specialist from our department is someone I highly regard. His wisdom can seem quirky to those who are not comfortable with his teaching style, but I believe I don't always need to be given the answers. I only need to be given the tools to find them. With most conversations I have with him, I walk away thinking harder than ever before. And to me, this is the best tool anyone can give me.

At a class last month, I brought up the incident I described in my blog. His response to my frustrations was simply, "Loretta, you do not always have to be ‘right', only effective."

What is that supposed to mean? I thought to myself for days on end. I even went so far as to look the word up in the dictionary: effective: (adjective) adequate to accomplish a purpose; producing the intended or expected result.

For weeks now, I have been searching for ways to be effective. Then, I realized, after I looked up the definition, that I first needed to decide what I was attempting to accomplish. The ER may have lost some of its luster because I have accomplished many of my goals. I am hungry for the next level. But I have found in staff nursing, that next level can be difficult to define. Was this the reason for my past feelings of wanderlust? Could this be why I am restless now? And maybe, just maybe, could this be one of the reasons so many nurses are leaving the bedside?

My thoughts are racing. My passion has been rekindled. I still do not yet know exactly what my plan is going to be. I don't even know what opportunities are available, so I need to ask. I also need to take a chance now and again. I am on a committee; maybe through that I can start to effect change. Through it all, I should be able to further refine my definition of effective and implement it in due time.

The team I was working on that day included many hall patients and the trauma room.  This meant that in the event of a trauma, all care for patients would shift away from the trauma nurse and onto the rest of the team members. This is a time where team work matters. I must be able to alter my abilities quickly and continue following up on patients I may not even know.

The first part of the shift was spent spreading myself between a stable patient and ensuring his orders were carried out properly, and keeping an unstable patient alive. This is where the new grad really helped. I scanned the orders and knew what had to be done.  She assessed the orders more thoroughly and together we problem solved a safe way to give medications that needed monitoring.

Throughout the day, we managed to get almost everything done for the patients in our area and get a quick bite to eat. Upon returning from break, a new critically ill patient arrived. One of my teammates assumed care of him for me; I was extremely grateful.  The new grad I was working with stayed with her to learn more about what to do in this situation. This freed me to tie up any loose ends in the area and prepare my very first patient for admission to the floor, finally. And find out that the transfer of the other patient had been canceled.

Calling report, however, was not so pleasant. Instantly, I was questioned about what had been done, because nothing was charted in the computer. (We do not yet chart that way.)  My feathers were ruffled and I became defensive. I wanted to fight. Instead, I took a deep breath and assured the nurse I would give her all of the information in report. With each question fired from her, I repeated myself and asked calmly to hold all questions until the end. My insides were fuming. At the end, I thought she was able to see a clear picture of the scenario and I felt better. 

While I was waiting to transport this patient, a bunch of things happened. For me, it's so normal that it doesn't even faze me. New patients come in that need to be started. New orders need to be carried out. Family members approach me frustrated and angry that "nothing is being done for their loved one." So, by the time the man was finally transported upstairs, the nurse was again frustrated with the ER, as was I. Needless to say, her welcome was not warm and supportive. I left irritated yet again.

My return to the ER was greeted with overhead pages and an accusing tone from the nurse in charge. I almost lost my cool, but instead looked at the clock. My day was almost complete and an argument was not going to help. I knew that I had spent the day doing the best that I could. I also knew that defending my actions would be futile.

I left that day disgruntled. Lately, it seems this is happening quite a bit. I'm not sure why or what to do about it. Am I at my wit's end? The answer is not quite clear to me yet, but with further investigation I should be able to figure it out. I'll keep you posted.

Over time, I don't think I have stopped to realize how experienced I have become. I was quite adept at taking patient histories, listening to their stories, and making triage decisions based on all of the facts as they presented themselves. I could even write on the chart without ever taking my eyes off the patient. My gaze has recently shifted to the screen and the keyboard, and that bothers me.

This new system has me clicking on different windows to enter information. I have to search for the proper place to relay the pertinent facts I am receiving. And, for any of you who interact with patients regularly, you know that no story is ever organized neatly. So, I click and I type and I make the patient repeat themselves more times than I ever have needed to in the past. And then I laugh, at myself.

Why am I laughing? Well, because one day it occurred to me that I am no longer a novice. I actually feel like I am learning how to nurse all over again, but without the burden of inexperience. This process has forced me to take a hard look at the way I assess patients and make decisions. It has made my brain work in new ways. It has shown me ways to better protect my patients.

This adjustment has been hard for many of us, but I think it is going to be ok. Once we go completely paperless, I won't have to search for charts anymore. (That's a plus!) And, I won't have to deal with deciphering bad handwriting, either. My brain might throb a little bit more, but that's because it is growing, right?

And, in the end that is what matters. Learning to do the same process in a different way will keep my skills sharp, my knowledge up to date. Complacency can lead to harm. So, I will endure the brain throb knowing that it is in the best interest of my patients, making me a better nurse with a stronger practice. Maybe a massage next week will help them, too. I think I'll call the spa right now.

On Aug. 19, 2008, the ER removed all dry-erase boards and switched to an electronic tracking system. The monitors provide visual labels of where patients are, new orders entered and available lab results. In the main part of the department, not much has changed. Triage, however, is now drastically different. We no longer have triage notes; everything is entered into the computer. (I am so glad I took a typing class in high school.)

We used to practice two tiers of triage: 1^st and 2^nd. The person would arrive at the window, state their chief complaint, and the nurse would assign them an acuity level, based on the five-tier acuity system. If appropriate, the person would go to the waiting room to wait for 2^nd tier or be deemed necessary to come in right away. Level 4 and level 5 patients, who require few resources, would not receive a 2^nd tier triage. This reduced our triage wait times, but created problems that were missed because the whole story was never revealed to a triage nurse.

The new process has changed 1^st tier triage to ‘triage'. The 2^nd tier is now called ‘assessment'. Everyone must come in for an assessment. It is the triage nurse's responsibility to decide, within minutes, who can wait for an assessment and who can not. This does not seem like a huge process change, except that now it could be an hour or more before a patient can receive an assessment versus a few minutes in the past. The triage nurse needs to have astute assessment skills to avoid sending a potentially ill patient to the waiting room without a full assessment.

What I like about the change is that is promotes patient safety. Each patient, no matter what the chief complaint is will see a nurse. All details of the precipitating event will more likely be discussed. Allergies and past medical history are both entered and immediately visible in the electronic chart. We are now able to focus our attention on providing more focused care right from the start. This is a big change from the move-‘em-through-as-fast-as-we-can attitude that had resided in our ER for years.

I do not like how slow ‘assessment' has become, however. Many more questions need to be answered in the computerized forms than in the past. The learning process has put the brakes on a skill that many of us in the ER used to be able to complete in four minutes. Check marks were easy when compared to finding and clicking on the right box. Typing in answers feels like it takes forever.

Also, as the triage nurse, I am responsible for sending people to the waiting room for who knows how long. At least with the old system, we had found ways to speed up the process, decreasing the amount of time before a thorough evaluation was completed. It can be scary to be at the window and know that a patient's status can change quickly, leaving me vulnerable to endless possibilities.

I take comfort, though, in knowing that all of us are capable of learning and mastering this new system. That is where management's support has been instrumental. Countless classes were scheduled for training at all times of the day. Computer training rooms were set up for staff to practice. And, best of all, a large group of staff members, called SuperUsers, received intensive training to be available to help us through the first ten days. Supervisors and educators were on staff 24 hours a day. No one was left to figure this out for themselves. In fact, so many people have been present to help it felt very overwhelming at times.

Change is never easy, especially for those who are not computer literate. And, I have to say that I do find myself falling back into old habits. But with gentle reminders, intelligent instruction, and the mental support that our management has given us, I feel very well prepared to tackle this project. I know that the changes are going to continue. I'm looking forward to them this time, because I believe that, finally, priorities have shifted. It seems less about making money and more about patient care. Who can't support that?

At the young age of 13, my passion for nursing was born. The second I stepped into a hospital, I knew what I wanted to achieve. When I turned 23, my dreams began to take shape. My nursing career did not start the way I had imagined it; it has ended up being better than I could have hoped.

Years of change, learning, and life led me away from another dream I had had as a child. It took losing my father to coronary artery disease to bring me back to writing. Coping with grief, I rediscovered a part of myself I had let go. I learned that loss really can bring great gains.

I have been writing this blog for a year now, and I still can't believe I have been blessed with the honor of combining my two loves: nursing and writing. I don't really know where this new road will take me, but I'm willing to give it everything I've got. 

This video I made is a small glimpse into the people that have helped shape my dreams along the way and make me into the person I am today. I thank everyone, seen and unseen, for the support they have given me. I wouldn't be who I am without you!

Working in the ER, I see a lot of life altering events. I frequently realize any one of these could happen to me or my family. I try hard not to bring my work home with me, but sometimes the feelings are hard to leave behind. I can see my family members in the faces of visitors or the eyes of the patient. When I call home just to hear the voices of my children, my husband knows something tragic occurred that night. He doesn't ask; he expresses his love.

Sexual assault survivors are especially difficult to forget. The horror of their experience can not possibly be understood; the motive of the perpetrator may never be justified. It is not easy for me to participate in evidence collection or explain why I have to give them certain medications before they go home. When I discharge them, I know the road that lies ahead is uncertain and lined with obstacles they didn't ask to endure.

When I go home and see the faces of my children, I begin to fear for their safety. I have to hold back the urge to package them in bubble wrap. How can I as a mother, with the knowledge of an ER nurse, keep them innocent yet aware? I don't want to make them afraid or cynical.

After taking a class on Pediatric Sexual Assault, I realized I needed to do more than just talk about appropriate versus inappropriate touches with my own kids. Many cases presented involved people the children perceived as safe. The perpetrator coerced or manipulated their victims into silence, using fear. Children endured a behavior they didn't understand. They didn't tell anyone what was happening because the perpetrator threatened to hurt them or their parents. An adult would know not to believe this, but a child does not. I had to relay this to my kids.

The opportunity presented itself sooner than I expected. My daughter and I were having a girls' day, enjoying the warm weather and conversation between mother and daughter.

Finally, I asked the question I had been holding in my heart, "Anna, would you tell me if anyone ever touched your ‘privates' in a way they weren't supposed to?"

She kept painting her nails and nodded, "Yes."

"What if that person told you they would hurt Mommy or Daddy if you told?" I assumed she'd say yes, again.

Anna looked up at me. She tilted her head and scrunched up her nose. I could tell she was thinking about her answer. "I don't know." She said and resumed painting her nails.

I was surprised at her response. I thought my child would know better. I quickly informed her that Daddy and I could protect ourselves; she should tell someone anyway. She smiled and agreed.

That conversation was short, but very hard for me. I know there will be many more. I began to wonder if I am doing enough for my son, as well. We've had a few talks, but maybe it's time for another. I found two websites that gave me some more information:  Day One: The Sexual Assult & Trauma Resource Center and Children's Trust Fund and wanted to share them.

I know I can't fix things for my patients, but maybe their experiences can teach me how to help others. I also know sexual topics are difficult to approach, but educating and empowering young people can only lead to a stronger generation. So, next time you are given the gift of a child's attention, you can use it to share information that may help to protect their innocent lives.

I am thankful ADVANCE for Nurses has political coverage on their home page; I am not sure how well informed I would be about our current Presidential candidates without it. This winter my son and I kept up on the happenings because of his interest in politics. But, alas, it is now summertime. Swimming, camp, and the great outdoors have reclaimed my nearly 10-year-old son, leaving our television dormant most of the day. These days I catch glimpses of the news in the morning or just before bed. To stay informed, I peek in every now again at various websites to stay updated on areas that interest or concern me. And, of course, with the impending elections and health care crisis, I do my best to see what each candidate proposes to fix our country. Locally, I like to read what the general public has to say about health care.

After reading one such article titled: "Healthcare costs expected to rise over next two years" that appeared on a local televisions station's site, I felt like banging my head against a wall. The article ended with the statement: "So why is healthcare getting so expensive? According to an industry report, one of the main reasons is that those with insurance are picking up the tab for those without it."    

I will whole heartedly agree with the above statement, but so many people outside of the healthcare field do not realize all of the many pieces of the system that contribute to the problem. The largest problem of all is our culture in general. We are a society who needs instant gratification, can not wait for what we feel we deserve, and then when we don't get the answers we want fast enough, we sue for money to make us feel better.

Let me elaborate on that horrible run-on sentence. Last year, Massachusetts mandated that every single citizen carry their own health insurance. Unfortunately, Massachusetts is struggling with a shortage of doctors, according to the Massachusetts Medical Society . This means that even if people want a Primary Care Physician (PCP), they may have trouble finding one to accept them. Also, because of this said shortage, the PCPs we do have are so overwhelmed that they can not see their patients in the timely manner, as expected by our society, so instead of risk being sued, they send them to the ER for evaluation. Massachusetts is not the only state with a shortage of PCPs.

So the way I see it, the problem snowballs into one huge mess that is not fixed with one easy solution, such as universal health care. It will take years of small changes to the system and a lot of cultural growth before we can begin to untangle this mess we call health care. Patience, persistence, prevention, preparation and Primary Care are the five Ps I think we need to institute to save ourselves from healthcare doom.

Recently I had the pleasure of meeting the guys from the country music band Emerson Drive. Their song "Moments" has had an impact on me greater than I was able to express to them that night. It is difficult for me to put into words the emotions I have regarding this song. There are many complex pieces to put together, about homelessness and helping a person in need that I missed the first few times I heard the song. It wasn't until I listened to the words that I began to understand the story.

My first thoughts after seeing the video for "Moments" were about the homeless people I care for every day in the ER. Nine times out of 10 they are intoxicated and in desperate need of a shower and food. Sometimes they are kind, nice and fun to be around. Other times they are combative, argumentative and inappropriate.

In the 6 years I have been in the ER, many times I have thought about the regular "drunks" and wonder how they got to the place where they are in their lives. I often speculate what their story is, and wish at times I could ask them about it. It is those ‘moments' for me that these patients become human, more than just another "drunk" to take care of. Every time I hear this song, it reminds me to think of them in a more positive way.

"Moments" also tells me that every life has its ups and downs, and the Emergency Department is not the best place to see the positive side of people. As a nurse, I hear the sad tale of what brought that person to the hospital, not who they are every day. I see a mere glimpse into an entire lifetime of someone else. Another ‘moment' shared with them could reveal a different aspect of their personality. It can be hard to remember, but through the words of that song I can try.

Finally, I have come to realize the many types of ‘moments' that I have had in my life. I have done things that I thought I would not be able to do. I have survived challenges. I have had disappointments, but I have also had support along the way. Sometimes it came in ways I didn't notice or expect. Other times, I have found the strength within me to keep going. In the end, it comes down to one thing: what you do with all the ‘moments' you are given.

I hope that I am making the best of what I have been given, every day. Most times my job does give me the sense I am helping others; it is a privilege to have the knowledge to save lives. I can only hope to remain satisfied and avoid seeing the negative aspects of nursing in the ER. Songs like "Moments" can keep me going and seeing the world in a different way. So, Brad, keep singing and definitely choose "The Extra Mile" as your next single. It will be another song I can sing to keep strong even during the most extreme moments of my job.          

The trauma room was once an elusive place to me where lives are magically saved and miracles occur every day. I waited anxiously to receive notice that it was time to take the Trauma Nurse Core Class (TNCC) and orient to the elite status of trauma nurse.

Over the years, I have developed a state of mind that I refer to as my ‘Trauma Daze.'  This is a way of thinking that directly reproduces the concepts of TNCC and allows me to function effectively in a very fast-paced and unpredictable environment. It leaves no room for emotion or the nurturing aspects of care. Patients are initially nameless, naked, and treated so fast that they have no opportunity to object. Decisions need to be made quickly and actions are performed one after the other, sometimes simultaneously. In a matter of minutes a trauma patient can be in CT scan, the OR or downgraded to the regular ED. This is emergency nursing at its peak.

This process can be repeated again and again in one shift, leading to such a sharp focus that the ‘Trauma Daze' becomes difficult to shake. It's not often that I stop to think about the impact this event will have on their lives. I assess, intervene and send them on their way. On occasion, I wonder how they are doing, but frequently I don't have time to follow up. There is always another trauma patient on the way.

One recent news story, though, have led me to examine my ‘Trauma Daze'. Kimberly Dozier is a trauma survivor, injured in Iraq. She reminded me that permanent change occurs from one random event. In her story, Kimberly said that her road to recovery was paved with talking and writing about her experience. The hard part with nursing is that HIPPA binds into silence. Or does it? We all need to share our hard days. We all need to talk through the tough times. Maybe if we as nurses felt we could talk more we would last longer. Maybe we should just reach out to each other, through the ‘Daze' that we all have come to know. Nursing is emotional work; sometimes it's ok to stuff the feelings away, but sometimes we need to feel. So, next time I feel the ‘Daze' overwhelming me, I am going to take a step back and just try to feel.

Sometimes the ER can become a hum-drum shift of pacifying angry people. Working in triage can feel more like being in the penalty box than any other place on earth. In 2003, our triage and waiting area was redesigned with large picture windows to increase the safety of the patients in the waiting room. We can now easily see everyone in need of care. However, the downside means that they can also see us, the nurses.

As I have stated before, Baystate Medical Center is a large level 1 trauma center that cares for over 100,000 patients per year. In a nutshell, we are very busy, everyday. This means that we triage a large number of patients every hour. I work 3pm-11pm, the time when it seems everyone is suddenly very ill and in need of emergency care.

Alas, I have approximately six minutes to obtain medical history, allergies, vital signs, medication lists and FINALLY make a nursing assessment of the patient's triage level. It can be pretty draining to prioritize care when everyone believes their problem is the most serious I have seen all day. It is hard to remain upbeat and leave cynicism out of the equation.

I will never forget one night though, where one very small person made a huge difference in my shift. He was about three months old, with a smile that took up his entire face. He giggled and laughed at the slightest provocation, reminding me that even when times are tough, life can still be good.

He was chubby, with cheeks that begged to be pinched. His large brown eyes connected with mine as if he had known me his entire life. His grandfather proudly walked him around and around the ER waiting room with such ease. They were both visitors, waiting for news on the well being of a loved one, but neither complained about how long they had been there.

For hours, this boy passed by my window and shared his innocent joy with me. Countless people questioned how much longer it would be for them and each time I had to repeat the same answer: a long time, it's a busy night. But that smile kept me going. Each time I was blessed with his toothless grin, I felt more relaxed. Every time he giggled, so did I.

I have been thinking about that happy boy for a while now. Work has been draining me lately, with many issues that have yet to be resolved. But when I want to quit or get ready to run, I think of that pure, infantile view of life and know that I must persevere. I can do it; I know it will be alright. I have been told that my smile helps others through their day, so even when I don't feel like it, I force it. I may never know how many people it helps, but I think I am going to just keep trying.      

I mentioned in a previous blog, "The RSV Blues," the pediatric emergency department has had a very busy winter. The adult area is even worse. One day last month, we had over 90 patients registered and being cared for in our 31-bed unit. How can this happen? It seems the more room we make in the hospital, the more patients we have waiting to be admitted. Luckily, our management responded and the hospital decided to declare Plan D-a disaster situation. It has since happened again.

What is Plan D? It is when our emergency room is so overwhelmed with patients that the entire hospital becomes involved in patient care. Staff can be pulled from anywhere to attend to the needs of patients, more staff is called in, and working staff is required to stay until the demand has decreased. Typically this would occur due to a large number of traumas, e.g. an explosion at a factory. In this situation, our medical director, nurse manager and director of ambulatory services rolled up their sleeves and dove in to help. They pushed stretchers, answered phone calls, did what had to be done. They also called on other managers to open units not typically used for inpatient beds.

As one can imagine, a tremendous amount of resources and energy was required to make all of this happen. An already exhausted staff was pushed beyond their limits with no end in sight. The promise of a hospital addition dangles in front of us, teasing us with hopes of a brighter future we may not survive to see. Just about everyone is miserable. Complaints roll off tongues far more regularly these days; smiles are few and far between.

Our management has responded to us with the best of their abilities. Once the unrest was palpable, open forums were scheduled for all staff to attend. This differs from general staff meetings in that the leaders have no agenda except to hear our needs. Issues and concerns can be verbalized without fear of repercussions. True problem solving begins with honest discussion.

Response was mixed, with only a few attendees at each meeting. I made it a point to go, even though I didn't truly believe anything would change. I figured I had no right to continue complaining if I didn't offer my opinion on the situation. I am a valid member of this community and complacency can only do more harm than good.

I was filled with pride the morning I went to that meeting. My co-workers did more than just whine and cry. Solutions were offered and discussed. Brainstorming brought about goals that have been washed away in our continuing tide of patients. But most of all, we made ourselves heard and our leaders listened.

To date, I have seen a number of small improvements, a few minor changes. It's still chaos, don't get me wrong, but a few small baby steps can lead to so much more if we just give it time. Being a person who thrives on instant gratification, it can be hard to hear that a plan is ‘in the works'.

I cannot say if others have noticed; I've been too busy to ask. But hostility seems a little lighter; more ideas are forming each day on how to care for admissions waiting for a bed. We now have two on call plans-one for overflow and one for general ER patients. The response has been fairly positive, and I look forward to figuring out how I can participate.

So, for all of you out there who believe that open forums are for whiners and don't really accomplish anything anyway, it may be time to change your mind. Situations can only get better if an effort is made. Yes, both leaders and participants need to be responsive but you can start by setting the example. We, the staff nurses, are not powerless. We are front-line defenders of life in general. Why not make that work for our entire unit as well?