It’s quite appropriate that I had this topic on the schedule for today. I have just woken up from my post-night shift nap and am in that foggy brain haze that working overnight leaves behind. My neighbor probably thinks I am hung over based on my drinking coffee on my deck while wearing large sun glasses and a tangled messy bun at 2 o’clock in the afternoon. But no, I have been awake all night combating stomach viruses, draining abscesses and trying to reason with dementia patients.
Recently, I’ve received a few questions about what my day to day life looks like working as an emergency department nurse practitioner. I can tell you, it’s quite a nice life if you can get past being scheduled at odd hours and working hard on the job. The ED may not always live up to the hype and drama you see on TV, but it is busy. Here’s what a typical day (or rather night) looks like for me working as an emergency department NP.
I wake up around 2pm after attempting to take a long nap in preparation for my first of three days in a string of overnight shifts. Sleeping during the day is usually unsuccessful for me that first afternoon. The allure of a sunny spring day and my not quite perfect blackout curtains prevent rest unless I am really tired. As I wake up, I mentally prepare to stay up all night. After running a few errands and cooking a quick dinner, I leave for work at 7:30 pm leaving plenty of time to arrive for my 8 o’clock shift.
When I arrive in the ED, a stack of charts awaits in the “To Be Seen” rack. Sunday evenings are always busy and the daytime doctors, NPs and PAs haven’t been able to keep up with demand. The ambulance radio alarms signaling yet another patient to be brought in by EMS. As the most recent provider to arrive, I kick into high gear. I’m the one with fresh legs best suited to get things caught up. I know that if I work hard my first few hours, patient volume should slow and I will be rewarded with a steady, but not overwhelming night. Usually, anyway.
The first chart I grab is for room 4. This patient was brought in by ambulance after a motor vehicle accident. The 26 year-old male is complaining of neck pain, a headache, and chest pain. I recruit a few nurses to help me get him off the backboard, examining him first to make sure there is not concern for spinal injury. Satisfied with my findings, we carefully slide him from the board, leaving his c-collar in place in case of neck injury. Based on my exam I decide to order a CT of the head and cervical spine as well as a chest X-Ray.
While waiting for his imaging results, I grab 2 more charts off the “To Be Seen” rack. With many patients waiting I aim for efficiency. I walk to visit room 16 where a 54 year-old woman with chest pain is waiting to be seen. I glance at her EKG. Although it isn’t entirely normal, I don’t see any signs of a myocardial infarction. I mentally make a note to compare this EKG to one of the patient’s prior tests to see if there have been any changes. I order labs and a chest X-ray as well as nitroglycerine and aspirin after taking this patient’s history and doing an exam. Based on her history and risk factors, I am most concerned with a cardiac pathology rather than respiratory.
I move on to room 17, a 24 year-old female who is 12 weeks pregnant. She is having bleeding and is concerned she may be miscarrying. I do an exam, order labs, and ultrasound to confirm my suspicion that she may be miscarrying as well. Unfortunately, at just 12 weeks gestation there isn’t much we can do to ensure the viability of her pregnancy. She thanks me for my honesty in discussing the situation with her openly without sugar coating my suspicions.
After putting my orders into the computer for this patient, I notice the “To Be Seen” rack has emptied and I head back to my desk to begin charting on my first few patients. I am interrupted when two paramedics wheeling a stretcher walk in. The patient they are bringing is intoxicated and was found on the side of the road with a large head laceration. Since I have the fewest patients of any provider in the emergency department, I set my charting aside and hop up from my desk to assess the new patient.
I follow the paramedics and stretcher to room 27. Immediately, I note a scalp laceration that will require staples and ask the nurse to clean the would and get the necessary stapling supplies. I further assess the patient’s mental and physical status. He is clearly intoxicated but stable. I order basic labs including an alcohol level. I order a CT of his head based on his level of intoxication and obvious head injury. I wait to clean and staple his wound until after he goes to CT as the staples can cause artifact on the image. Legally, we cannot let this patient leave the ED until he is clinically sober or a friend or family member comes to pick him up taking responsibility for his care. So, he will remain in the ED all night, occasionally yelling out to the nurses, or any passers by, in his drunken state. His situation is a sad one, but I always enjoy the added entertainment of taking care of a few drunks throughout the night. It keeps my job interesting.
Back at my desk, I notice the CT scans and X-rays from my patient in room 4, the 26 year-old male who was in a motor vehicle accident, have been read by the radiologist. The images show no acute abnormalities. Since this patient’s injuries are mild, there is no need for me to involve the trauma physician in his care. I explain to him his findings, diagnosing him with a cervical strain, closed head injury, and a chest wall contusion. I remove his c-collar and prescribe a muscle relaxer and ibuprofen for pain relief.
Then, I pick of two more charts from the “To Be Seen” rack, a patient with a migraine as well as an 8 year-old with a suspected wrist fracture as a result of a playground fall. After putting in orders for medications and imaging as necessary, I notice my lab results and X-ray readings are completed for my patient with chest pain in room 16. While her lab findings are normal, her EKG has changed since her last visit. I believe she should be admitted to the hospital for further observation and evaluation based on these findings and her cardiac risk factors. I run my impression by a physician who agrees so I page the cardiologist for a consult, as well as the hospitalist to get the admission process started.
My evening continues through a cycle of seeing new patients, working on documentation, and discharging or admitting patients to the hospital. Recently, our hospital has become a trauma center. While I don’t personally see level 1 trauma patients, these critical patients tie up the physician’s time so I take on higher acuity patients myself. Having worked in the same emergency department for a few years, I am up to the task and have enjoyed this added responsibility.
As the night goes on, the emergency department slows down a bit. We still have plenty to do but are not filled to capacity. This is when I enjoy the ED the most. The night nurses take on a more relaxed vibe and we turn on the radio. Although I am tired, the fluorescent lights and chatter from the nurses station keep me awake. Night shifters work more like a team than day shifters, I’ve noticed, so when something needs to be done, MD’s, NPs, PAs and nurses all chip in and get the job done quickly.
The hours between 4am and 6am are the longest as fatigue sets in. I think about how good it will feel to brush my teeth and settle in under my down comforter once I get home. I will be so exhausted that I won’t hear my dogs barking, my husband getting ready for work, or the neighbor mowing his lawn outside my window as I sleep. When I wake up I will have one of those “what day is it?!” moments. The nurse practitioner taking my place arrives right on time and I eagerly turn my one remaining patient over to her for continued care. Taking the last swig of my energy drink for good measure, I drive home windows open and radio blasting to make sure I stay awake.
This has been a pretty typical night in my life as an emergency department nurse practitioner.
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