Wednesday, May 11, 2016

Nursing, and the Crocodile of Time

Every day patients present to the Emergency Department for care:

They come in ambulances, they come in vans, and they come in crawling, drunken, and puking in pans.
They come with strokes, overdoses, injuries and pain.
They fall and get fractures from ladders, and many other things that really don’t matter.
They demand the best, the most, the quickest, for free - and yet, when needed, they can’t even pee.
They injure themselves in so many ways; too many to count as there are not enough days.
It is sad really, the condition of people - so grand a species, that finds everything so lethal.
They will not stop coming, these humans with brains, they just need immediate relief of all of their pains.
So in the end, there really is nothing to do; drugs, seatbelts, gravity and rape, learn they will not, these humans with brains; as we will patch them up good, send them back where they stood, and wait for their return, for it is our livelihood.

An ED is a stressful place, quite different than any other work environment, outside of, perhaps, active duty military, paramedics, and police. We, the nurses, are stretched to accomplish all manner of tasks, in the quickest way, without an error, with the least amount of cost, with the most skill, capturing all of the data, with the fewest steps, and with an overwhelmingly cheery demeanor – all day, all night, all year long.

Every second counts, but not only for patient care, speed of service delivery, electronic chart manipulation, management benchmarks and facility goals – but for time itself. Seconds add up to minutes, and minutes to hours. It is the basis of all science. And so, every second lost to a missed step, a mishandled medication, a broken printer, another trip with a patient to the bathroom, is time compounded. Add to all of the thousands of tasks performed in each 12-hour shift, another 2.8-second chart entry, another software screen to navigate, another step in any process. Without taking away precious seconds from another task, this will all end up lengthening the day.

The Massachusetts Institute of Technology (MIT) produced a wonderful study of why traffic comes to a complete stop on the freeway for no apparent reason. The results show that if any one vehicle even taps the brakes for a half second, producing just a quick glow of the brake lights and a drop in speed of an infinitesimal amount, that this action is carried on behind that vehicle - each one driver lengthening the reaction until, one mile away, you are at a standstill. Apply this to any task in a busy ED, such as a printer that won’t function. Such a delay (the glow of a brake light) means you have to re-print a document by altering the print options, checking for a signal, checking the paper supply, changing the default location, etc. Eventually you will walk to another room, or location, and try this same procedure with a different terminal, and a different printer. This simple, yet overlooked delay, has prolonged the medication administration for another patient by 2.4 minutes. On the surface this time seems short, yet compounded with hundreds of others – you are sitting in your stalled car, in gridlock, listening to death metal pouring out of a nearby Pinto.

In addition to the thousands of tiny delays, is the fact that no one person is responsible for eliminating or repairing these delays. This magical fix-it person is actually – you. Yes, the nurse who is actively engaged in the time delay is also the one responsible for finding a solution for the problem. A repair can be something like signing into a ‘work order’ software program and navigating through various fields for hardware repair, resetting all of the default printer preferences – or, worse yet, a time consuming telephone call to some outsourced IT call center, to someone who has no investment in your situation, and is not concerned about the passage of time in any way.

A recent study from Michigan State University in East Lansing, shows that on average, an interruption in a task of only 2.8 seconds leads to a 15 minute delay in completing that task. Think of how many times you have walked toward a patient room, only to be diverted by a call light from another room, or the time you go to the electronic medication dispenser, forget the patients name, and then have to go find a computer, log in, and search. Compound all of these by 100 for a 12-hour shift, and it is no wonder that the length of stay (LOS) is creeping up again. As the complexity of a system grows, so does the potential for delays. And with people only employed to add to the complexity, and not to streamline it, there is no end in sight for the difficulties.

Concerning the hospital LOS, it was decreasing ten years ago, and everyone was quite proud. But as the population has grown and aged, rampant drug use has increased, care has become intolerably expensive, and the computer systems that bind it all together have become more fractured – the length of stay has risen.

Antoine de Saint-Exupery wrote, “A designer knows he has achieved perfection not when there is nothing left to add, but when there is nothing left to take away”. Any experienced computer programmer in the medical profession has this same St. Exupery ability; to create a streamlined user-friendly platform that is modern, and simple, and attains the goals set forth by the care. Think Amazon and Google – two of the worlds most user-friendly and lucrative businesses on earth. They are simple to navigate, never go down for upgrades, and are super efficient. If only charting an intubation in the EMR was as simple as buying a vibrator on Amazon. Oh the glory!

However, by a series of unfortunate events, we the Emergency Department nurses (as well as the floor nursing staff) have been burdened with an Electronic Medical Record (EMR) that is nothing more than ten thousand loose parts flying in formation. I can stream live color video from Saturn on my iPhone, and yet our $390 million dollar EMR cannot spellcheck or convert pounds to kilograms, doesn’t know that penicillin is a drug or an apple is a food. Every day within the EMR there is a tweak, or a change, or a malfunction, or a discovery, all adding tiny little bits of time to the day, all reverse-engineered at the sacrifice of timely patient care.
So, with time being finite, and the fact that patient severity and volumes have increased - and with a limited corporate budget, choke holds on staffing, and with the phrase ‘multi-tasking’ becoming the invisible phrase between each line of a mission statement –all of these measurable factors are pushing quality to its edge.

A study published in The Lancet in 2014 found that an increase in a nurse’s workload by one patient increased the likelihood of a patient in that hospital dying by 7 percent. Staffing ratios also appear to reduce the rate of readmissions, many of which are preventable and constitute a significant cost for hospitals. The Affordable Care Act (ACA) sets penalties for hospitals with high rates of readmissions. In one 2013 study researchers at the University of Pennsylvania School of Nursing examined data from hospitals across the U.S. and found that those with higher staffing ratios had 25 percent lower odds of being penalized under the ACA for excessive readmissions than ones with lower staffing ratios but otherwise similar conditions.

Staffing ratios for the Emergency Department are generally viewed upon as blasphemy by management. It tastes like freezer-burned brussel sprouts to the well-educated palates of higher offices, and it also affects corporate earnings and creates shareholder distain. So, even though the evidence supports staffing ratios, it is not likely to occur anytime soon. So, with an ever-increasing population of very ill humans, computerized charting that bludgeons to death even the most digital savant, and an employing host incapable of understanding the trials of its workers – the future is bleak my friend.

Time is what is killing the nursing profession - or, to be precise, the lack of time.

We have a nurse in our Emergency department, and I will call her Grace. Every department has one - a true to life, dyed in the wool, for real nurse. She holds patients hands, believes their crazy stories, looks into their eyes, hugs them and cries with them, even spends her own money on them. She walks them out to their car, she thinks about them at night, she…cares. There is nothing in the electronic record that reflects her care – nothing. There is no check box for ‘care’, or ‘concern’, or ‘love’. But, she is measured on the same scale as the rest of the staff: 500 data points per trauma patient, LOS is too long, time to pain meds is unacceptable, CMS benchmarks are insufficient, medication scanning is sub-par, etc. Grace decided to use her time for patient care instead of bowing before the graven idols of statistical data – and she will be punished for it. However, is this the nurse you want taking care of your daughter or mother - or would you prefer the nurse that excels in haste.

So how does good direct patient care look to the billers and codes of a profitable organization? The more boxes checked, lines filled in, tabs completed, tasks timed, and redundant research based data entered (all timed to organizational and national benchmarks of speed) – the greater the patient bill, the greater the reimbursement, the greater the ability to pay staff and procure new technology. How does one code for Grace’s level care - you can’t. Nursing has its flaws, but intelligence is not one of them. We all know that taking care of the EMR, even with all of its defects, is better for the bottom line than actual bedside care. The EMR makes money – bedside care does not.

A recent 3-year longitudinal study shows, “that nurses spend about 37% of their time with patients. Work patterns were increasingly fragmented with rapid changes between tasks of short length. Interruptions were modest but their substantial over-representation among medication tasks raises potential safety concerns. There was no evidence of an increase in team-based, multi-disciplinary care. Over time nurses spent significantly less time talking with colleagues and more time alone.” -Westbrook, Open Access.

Additionally, a new study, published in April of 2016 by Johns Hopkins, is claiming that complications from medical errors in hospitals are now the third leading cause of death behind heart disease and cancer. This is a bold statement, and yet it describes the environment where, being over tasked and understaffed, it is almost anticipated. Various entities that hold great stakes in these findings – particularly, the insurance companies, the government, and pharmaceutical lobbyists - will dissect this study with vigor, most likely adding new forms to the already fragmented EMR, adding steps for giving medications, perhaps even an official “time out” with a co-worker as witness, before even a Tylenol can be given. Again – time.

Many new nurses are overwhelmed at the ability to capture time, divide it, and dole it out in safe increments, especially in an active almost battlefield style atmosphere. Multi-tasking is a term that is pushed down the gullets of bedside nurses by all of administration. It is a clich├ęd term, loosely expressing the ‘apparent human ability to perform more than one task, or activity, over a short period of time. Multitasking, however, can result in time wasted due to human context switching and apparently causing more errors due to insufficient attention. I for one do not want my orthopedic surgeon multi-tasking.

This relentless battle for time could be pushing nurses into new directions; instead of hand-to-hand combat with tasks and time, why not join a new legion - where time and direct patient care have been replaced by the ability to create time itself. In 2015, the burgeoning field of nurse informatics now has an average salary of just over $100,000. These are seasoned nurses who have either ‘been there, done that’, or are fresh out of school, intent on good money without the direct exposure to the various illnesses and maladies of humans. Lets face it – informatics is where the money is right now, not bedside nursing. These jobs, however, are as scarce as Bigfoot sightings. But as technology slowly consumes almost all of a nurse’s time, there will be many more openings in the informatics galaxy.

We, as nurses, have twelve hours to produce as much profit as we can for the institution. We, as nurses, all know where our paychecks and retirement plans come from, and we understand the inner workings of the healthcare system and all of its governmental tentacles. We are the data entry specialists. We have 720 chaotic minutes to produce 10-20 complete medical records, documenting up to 250 items per patient encounter, in real time, with good outcomes. We are not measured in care, but in speed. We are not measured in interactions and conversations, but in volume of data points.  We are only measured by the electronic medial record. “If it wasn’t charted – it wasn’t done” is the maxim we live by. Medical care is a huge business – huge! The amount we spend on health care every year has grown from $75 billion in 1980 to nearly $500 billion today. If this rate continues, by the year 2020, we will be spending 40 cents of every dollar we make on health care.

So, there you have it. A finite amount of time for patient care, defined by economics and computer programmers - with an infinite range of potential challenges, defined by human nature and chaos. Emergency care could be described as a fractal -an expanding wave of symmetrical duties; a spiral of events in time, always compounding, never ending. Just like the ticking crocodile in Peter Pan, time is following us all.

The only real solution is to manage, as best we can, the time we are given - and hope for reasonable, noble changes from above. Changes such as; single task, simplify, create practical patient ratios, eliminate redundancy, hire adequate staff, hire the correct staff, streamline documentation, employ shift based problem solvers, use new technology only if it is beneficial, base care on quality not quantity, compensate experience, take pride in effort, talk with each other, and always do the right thing – the first time.

Monday, February 8, 2016

Seeing is Not Always Believing


So, there are a few things you should know about what you see in real life, about what you see on the monitor at home, and what you think you see on the monitor at home. Because all of this “seeing” is going to result in a print – a colorful, accurate, sharp, paper print – that you can hold in your hands, frame, and quite possibly – sell.

Pingora Spire, Wind River Range - Wyoming
 You are standing on boulder in the middle of a lake, with the tripod so low that only a yoga instructor could comfortably look through the viewfinder. Backing up is impossible, and lying down is even more so. Your fingers are stupid with cold, and the whole time you are thinking, why is there so much metal on a camera? The scene before you is fantastic, and the golden hour of dawn is slipping past quickly – clouds moving around, sections of rock glowing pink and then falling again into silhouette. You work quickly to compose the shot, stand up and groan, and then start pushing the shutter release – each 15-second exposure seeming like an eternity.

At this very moment you relax, it’s all up to the camera and the lens now - you are the only witness to this crazy colorful landscape. For a few minutes you watch and memorize the scene, the colors, the shadows – it is beautiful. This is what we work for.

Once back home you scroll through the dull raw images, looking for that one that pops out, the one that reminds you most of what it was like standing there on that boulder, freezing. Eventually one image stands above the rest, and it is moved into a raw processor, and then transferred into Photoshop for fine-tuning.

Of course, your monitor is already calibrated, your image is captured and presented in the correct color space, you have a dark grey background on your desktop, you are sitting alone in a darkened room, and there is no ambient light to alter the work. Simple enough, right? It is like the total opposite of where you were for those 15-second exposures.

You adjust the overall white balance, attend to the green hues in the shadows with some selective color balance, draw down the glaring whites, make sure the shadows are not too deep so that they don’t appear black on a physical print, concentrate on the sharpness, look for dust spots on the sensor, erase the errant purple tent in the background. All of these processes take some time, sometimes hours – and the longer it takes, the more you are being fooled.

I know that once I get involved with an exciting image I just can’t stop until I think it is at a finished state. So, an hour and a half go by and I save the file as a finalized .TIF and compliment myself on the finished image. I drink a toast on a job well done and then do some stuff that doesn’t involve sitting in a chair, in the dark.
Wind River Range - Wyoming

However, when I open the file the next day or, God forbid, look at the image that I hastily posted on my Facebook business site – it looks horrible! The colors are all weird, there is a blue cast that I can’t explain, the oranges are pale – what the hell happened?

Eye fatigue my friend, or more accurately – color fatigue. I am sure there is a scientific ophthalmological term for this, but color fatigue seems perfect to me. It’s like all the cones in your eyeballs just get tired or lazy, “Yea, that’s green, whatever” or, “Orange? Oh this nasty yellow is good enough for now.” You have 7 million color cones in the very center of your eyes’ retina, and its hard to image all of them just falling asleep at the wheel when you are using them the most – but they do.

Each little cone has to transfer a chemical reaction into an electrical impulse and then send it on to your brain. Each one of these impulses takes a little bit of energy, and then the cone has to ‘recharge’, for a lack of better term. We trichromates (red, green, and blue cones) weren’t meant to sit and stare at the emissive display of a computer screen for hours. Instead, we were designed to spot the lime colored edible leaf, to avoid the vivid red tree frog, and to watch out for anything with spots hiding in the grass. I believe that by staring at an image for too long reduces or alters the colors that we see. And the longer you stare – the more you are being fooled.

So, what have I learned? Never post an image to the public for at least one day. Open the image the next day, in the same darkened environment, and look at it again with some fresh cones. Nine times out of ten you will be wondering what the hell you were smoking when you did the post-processing the day before. Better yet, what I now do is take a break while editing. So, about every 15 – 30 minutes, I just walk away. Go get coffee, check for the mail, figure out why that sound of rushing water is coming out of the kitchen. Just get away from the display for a little while.

When you come back from the break you also get a fresh sense of your composition, the center of focus, and the color. It’s like proofing print images – tweaking them until the output color is just right.

Wind River Range - Wyoming

It seems like there are always elements that can alter the way your print appears, many of which are out of your control; the color temperature of lighting, the print paper, the surrounding wall color, the refraction of glass, the yellowing of the human lens and cornea. However, at least now you are aware of color fatigue, and know when to - just walk away.

Wind River Range - Wyoming

Tuesday, December 22, 2015

"A Series of Unfortunate Events" or "How an American Camera Bag Company Lost its Soul".

The mountain village of Namche, in the Himalaya of Nepal.

Update on the F-Stop Gear Loka camera pack.

When I first reviewed this pack, it was awesome. Great use of space, intriguing design, it carried well, and for the first two years it served me well; day hikes all over the mountains and deserts, flights to the far corners of the earth, etc. But, up until my most recent trip to Nepal had I ever worn it day in and day out, in cold temperatures, at altitude, and sweating my ass off. In short, I don’t think I had ever carried it while hiking hard for an extended amount of time.

So, deep in the Himalayas, on day three of our adventure, I was unpleasantly surprised to find all of my lenses soaked with water, my business cards destroyed, lens cloths wet – then frozen, and beads of water everywhere. The zipper had been secured tightly; there were no holes, and no rain or snow either.

“How could this be”, I thought. I closed the back panel, which was steaming in the cold air with sweat from my back, and realized that there must not be any waterproof coating on the nylon back panel. The combination of heat and moisture drives the sweat right through the material as a vapor, where, once inside the bag, it condenses into water droplets all over everything. Even my old Arcteryx backpack is still totally waterproof after ten years. This is so un-cool!

In the Maze, Canyonlands - Utah.
“What the hell!” were my first words. How could this be? It is designed and advertised as a professional adventure pack, built to carry thousands of dollars worth of camera gear into extreme environments. Clearly my day trips had not been tough enough to test the material.  How could a sheet of uncoated nylon slip into the manufacturing process? I was, to say the least, bewildered – and pissed.

The rest of the trip I had to completely zip closed the inside ICU panel, and then zip up the back panel -hardly an easy entry with this extra step. Even with this additional measure, the inside got wet, as sweat soaked through and condensed onto the inner nylon ICU fabric.

Fast forward – six weeks have passed since I have been home from Nepal. I had to shoot images in New York City in November, but made sure that I had contacted F-Stop prior to that for a return authorization number (RMA) so that once home, I could ship the bag back under warranty. The bag was shipped back on December 2nd.

Now it gets complicated.

The way I was locking my pack to a rock in Hawaii. The foam backpanel in question can be seen here.

The customer service phone number that is on the F-Stop webpage is registered to Kent, Washington. The return for warranty address is Saint Louis, Missouri. All of the 14 people who are able to answer a customer service question are located in an un-named country in Europe. The company is based, I believe, in the USA. According to customer service, there are no phones at the F-Stop facility in Missouri, only a computer. There are no North American faculty that has access to phone services – at least as far as I could determine.
The customer service staff all state, in broken English, that they can answer all question. And yet, have answers to none. The 2-second time delay between speaking, and them actually hearing, results in each party talking at the same time, with painful periods of silence in between. It is maddening. What they really do is write down your question, or order, or concern, and email it to the phoneless staff in the USA, wait for a reply, and then forward that email to you. It is a call center. There are no people at customer service that have any direct contact with the products they represent.

I spent a very frustrating week just trying to figure out if they ever got my bag as a return, let alone talk with someone about the fabric issue, design changes, and a possible replacement pack. I was so stoked about this American company, I cannot tell you how many people I have promoted this product too. Now, unless some miracle of customer service suddenly rains English speaking knowledge down on my head, I think this is going to be a deal breaker.

One week later…

I called the mysterious European country again, and started the inquiry process all over, for the third attempt. This time they assured me that someone would call me back with information, and in fact, they did call me back within ten minutes – and told me that they had made a mistake and someone from North America would contact me. This new person sent me an email stating that the camera pack was fine, was being sent back to me, and gave this insightful morsel of help…

“One recommendation is the pack be treated with a product such as Nikwax to protect against external moisture such as high altitude condensation or accumulated sweat.”

So, with a 20-year warranty on this camera pack, I am supposed to treat the foam back panel with some product from REI so that it will remain waterproof?  I have been backpacking for 30 years, and have had backpacks from various outdoor companies – North Face, Arcteryx, Black Diamond, Dana – and have never had the sweat from my back go into the pack, because they are - built to be taken into the backcountry by sweating humans!

So, in the end – this pack failed the true test of adventure; their customer service was a pitiful runner up to United Airlines, and the warranty is purely imaginative. Again, I am so disappointed in the service at this company - I so wanted them to shine above the rest, to prove an American company could stand tall for product reliability, workmanship, and integrity, but instead – just another outsourced, off-shore, phantom company without a human soul to talk with.

Gokyo Lake, Nepal.

Wednesday, May 27, 2015

Lost and Found by Rob Hart

Lost and Found

I have been working on this book for perhaps ten years, and over the last six months, I printed a few copies and had eligible friends proof read them for errors - which there were a handful.

Now, I think it is finally ready to sell.

One thing I have learned about publishing books, no matter if it is a photo book or a trade paperback, publishing is very expensive, and you will NOT get rich doing it. As a matter of fact, you would still qualify for food stamps if you were making a living at this. Ink and paper are very expensive in this country, so without going to China, I have accepted the fact that this book was written for pleasure - not profit.

Everyone asks what the book is about - and I still can't answer them swiftly. A friend recently read it, and for her it meant so much more than I had imagined. It spoke to her heart. For me, it is a tale of travel and adventure, and of finding your way in todays crazy world.


Wednesday, November 26, 2014

Trench Warfare

 Trench Warfare

Emergency nursing is a battle, and the enemy is illness and injury: automobiles, motorcycles, guns, cancer, obesity, suicidality, violence, heroin, amphetamines, and narcotics.  The enemy never sleeps – and neither do the nurses in the trenches.

Each shift we see unspeakable harms; babies, children, men and women, preyed upon by our own species, serious injuries incurred by the technologies of man, and predation by unseen viruses – mutating, hiding, eating. Our academic training falls far short of the reality of it all. It dwells in the archaic principles of a bygone age of nursing; an age of divine care and heroic selflessness - an age before antibiotics, before MRI, before genome sequencing, before daVinci surgical robotics, cost centers, ICD coding, case management, and the cats cradle of legal bondage.  Academically, we do not produce nurses for this kind of battle – they are seasoned in the field, in the trenches with the enemy – and they either fail after only a few years, or become ED veterans, legends of tenacity, inkwells of black humor.

Your only allies are your comrades. You are part of a crazy dysfunctional family of misfits, somehow brought together by adventure, a sound background in herding cats, and the unwavering ability to withstand the abuses of mental and physical pressure. There is no personal space, and sometimes you are cheek-to-cheek to complete a task. Through human sickness, you are all bound together by touch, and smell, and sight. You know your friends by the scent of their shampoo or the boniness of their elbows. We engage in bizarre sudden games of Twister, putting our arms and legs all this way and that, often times holding down flailing screaming nakedness, or cleaning diarrhea from an anguished soul, their minds murky with Alzheimer’s. We cry over a dead baby, and then bring a demanding meth addict his pain medicine, apologizing profusely for the delay, hoping they won’t file a complaint over their slow service. We can sense the seriousness of a patient’s condition by the eyes of our coworkers - no words needed - only that look. These trench warfare nurses are more than just office mates – they are deeply bound together from being elbow-deep in atrocities.

There is also a sixth sense that develops over time – one where you see dead people - although they don’t know it yet. It’s an unnerving feeling, to know the future of certain patients, to see the walking dead - and its even more unnerving to know that, short of a miracle, you will soon be pumping their bodies full of semi-toxic drugs, pumping their chests with battery operated machines, covering their brains with gauze. This sense grows more powerful with time – and as it grows, you accept it as a grace, for with it comes the ability to prepare for the worse, to stay a step ahead of the downward spiral, perhaps even to alter the course of fate.

Experiences are drawn from an endless pool of suffering and the complex machinery of the human frame that is its host. Terminal injury aside, your shift in the trench is made up of a relentless flow of strangers - strangers who want something. Some are legitimate in their request – to repair their fractured femur, to breathe, to once again speak and move the right side of their bodies so that they can tell their family how much they love them – but many are not, and it is this complex set of customers that bring theater to the Emergency Department.  We, the nurses, are on stage – and we are the primary actors. It’s an art really, to be able to go from room to room and change your performance to fit the scene, to get the job done, to be so convincing. This constant play, however, requires a tremendous amount of emotion, and only with great effort can it be played out for the entire twelve hours.

Compassion is a finite emotion. You can run out of it – and once it’s gone, you hope the shift has ended.  Strangely enough, it seems to regenerate. Once your car leaves the parking lot and is pointed toward home, the day starts to fade. The images, scenarios, little victories and disappointments, things that no one outside the theater would ever understand – they all just wither as you drive home to your family, a friend, a dog, or a good glass of wine. By the next shift, your compassion meter seems to be back within operating range. ER trench nurses dole out compassion carefully; it is a need-based commodity, and a very valuable one at that. Once the words fucker or cunt are directed at you a few times in as many hours, you know very quickly who gets the compassion, and who might not. Empathy – we have loads of that, its part of becoming a great actor on the Emergency stage, to step into the shoes of our patients, to know what they feel and want, and to change our language and bodies to deal with their needs. Compassion though – that is precious.

Human interaction is a complex thing - even more so when you, the nurse, are guided in your speech by the haunting cloud of legal gloom that hangs over each of your words. Some patients have a known future, a certain future that you can predict from your thousands of previous experiences. However, you are compelled to avoid the truth, to keep your thoughts and knowledge at bay, you skirt the fact that no matter how much money is consumed by the institution, their loved one is going to die. Instead, you lie – or, better yet, remain silent. Oh yes, a miracle might be conjured, but probably not. You remain silent because people don’t want to hear it – that their weight is the cause of their medical problems, that their smoking caused their chronic back pain, that their addiction was the reason they pulled their own eyes out. Truth is clean, but brutal - and we know it could result in an unsatisfied customer, reduced reimbursement, a chain of migraines for the managers, and possible termination. The truth could leave you without a job. It’s frustrating for sure – but these harsh realities will also wither on the drive home, slowly shaping a shell of invulnerability - every so slowly.

Dealing with these concerns is not taught in school – it comes from experience, from thousands of mistakes made, and the learned ability to repair a mistake. It comes from stories told by your comrades in the trench – both of success and failure. You drink in the wisdom and knowledge of their startling tales, add them to your own, slowly building an empire of knowledge. Emergency nursing is both science and art, and from science comes known facts – kidney functions, ejection fractions, clotting cascades, neural pathways, and ligament insertions – but from art comes the soul of nursing. The ER is a sweeping pallet of colors, and with time, you begin to mix the colors together, blending, learning, discovering, sometimes having to start over, but in the end, hopefully leaving each shift with numerous finished paintings. None will be masterpieces – but perhaps one will be worth framing.

Nursing theory, nursing statistics, research, history, models of care, concepts of nursing, community nursing (collectively known as jumping through hoops, by some) – these are great course for those yearning for work as directors and educators, but for those who desire direct patient care in austere venues, all encompassing hard science and live preceptorship seems the most logical path. Experience is understood as knowledge gained by repeated trials, and without a series of supervised trials, experience will be slow to foster, frustrating, overwhelming, and potentially dangerous. Under real world conditions, we perform tasks over and over, perfecting each step, understanding the reason for each move, until the task is performed efficiently, and with an elegance of purpose. We work closely with each other, double-checking our work, transferring our knowledge up and down a mental conduit, a hierarchy of skills and experiences. ER nurses work on common sense, street smarts, evidence-based science, protocols, and past knowledge – not a modified Roy model.

No theoretical lecture will present you with the truth of the battle – that at any moment you could have your gloved fingers in a struggling vagina, and ten minutes later you would be eating a slice of pizza; that you will become a master of urine concentration, that the nauseating need for diarrhea will pass, and that the three meals a day of peanut butter and graham crackers are all you really need anyway. Some of your patients will hate you, and tell you so every time you give them a meal tray. Some of your patients will love you, want to touch your hair, ask about your family. Everyone you see driving a car will be a potential murderer, high on crack, to be watched and avoided, the children in your car more valuable than anything in your life. The constant coughing of aerosolized infection will drift into your open mouth – and your immune system will strengthen, becoming impenetrable, like the amour plating of a panzer tank – and you’ll wish that just once in a while you could get sick.  

The fellowship of nurses in the Emergency department is a coalition of shared sorrows and triumphs, of near death experiences and close calls, of comedic interactions, violent brawls, blood, urine, and vomit. It’s a place of chaos; old men dying and babies being born, of wailing and sobbing, and of laughter.  We crave the ability to produce a lasting contribution, but are often times tethered by the very profession we live. We work in the muck, on the front line – feeling quite alone, standing apart from the greater architecture that is the hospital, nervous, but so alive. Every day we see the insides of people, splayed open or draining, but always in awe of a creation that is beyond one’s understanding. Goodness and evil live in curious harmony within the ED, fighting it out as we try our best to feed the goodness, starve the evil, and not be taken down in the process.

And yet, every once in a while, when it’s dark and the beds are strangely empty, the trench nurses creep outside and lean against the wintery walls of the building, each feeling the heat from the others shoulders – and silently watch the snow come down - like swirling stars, trapped within invisible cones under the lights of the parking lot.

My friends who work at normal jobs always ask me why I stay. And always, after a pause, I say,  “How could I leave now?”

Rob Hart