As I started my nursing preceptor shift in the emergency department that night I did not expect to be so moved and so excited to be surrounded by such a great team. Generally, when coming on shift, the patients are stable enough for my preceptor and I to gather our thoughts and begin prioritizing our care and tasks. A few hours into the shift, we hear an ambulance pull up to the ambulance lights and sirens. We had received an incoming radio report that a patient with a tracheostomy and T-bar was being brought in with an oxygen saturation of 78% and with an increased work of breathing. Once we heard the radio report, my preceptor and I instructed the unit secretary to page for a respiratory therapist STAT to assist and manage the patient’s airway whenever they’d arrive.

The paramedic crew brought in a middle aged adult patient from a private residence on a blow by tracheostomy who was clearly dyspneic and presented with a productive cough. We did not notice any cyanosis but did see the patient was in respiratory distress and clearly needed prompt intervention. My preceptor and I began to care for the patient immediately. We placed the patient in one of our critical rooms that had everything we needed in case of rapid decompensation of the patient including a crash cart, intubation kit, bair hugger, the LUCAS chest compression device, and other emergency equipment. We assisted the paramedics in transferring the patient safely to our gurney and we got to work. While my nurse preceptor acquired IV access, drew blood and gathered the anticipated blood samples including a full rainbow i.e. complete blood count, basic metabolic panel, lactate, D-dimer, troponin levels, etc. I switched the patient to our house oxygen, placed the patient in a high fowler’s position that would allow for maximal respiratory expansion, cleaned as best I could the discharge surrounding his tracheostomy, placed him on the cardiac monitor, obtained other vital signs and quickly captured an EKG. By this time, all hands were on deck, the provider was assessing the patient and calling out verbal orders, we had multiple nurses lending a helping hand, documenting and pulling medications from the Pyxis. It was a work of art. Respiratory therapy (RT) showed up and immediately began tending to the patient’s airway by performing trach suctioning. Soon after stabilizing his airway and breathing, RT drew an arterial blood gas and sent it off to the lab. After a few minutes, the patient’s status began to improve. 

I was amazed at all of the moving parts and the organized chaos of the emergency department. That emergency room was filled with so many people but we all had a task to complete. We ensured effective communication by voicing exactly which intervention we were going to perform. If a nurse needed any supplies I was able to be a runner and grab those for them. The delegation and communication between the whole team ensured the best outcome for our patient at that point in time. 

 After stabilization, my nurse preceptor and I became the patient’s primary care team. On multiple occasions, I had to rush into the patient’s room after noticing their monitor alarms beeping at the nurse’s station due to a drop in oxygen saturation. The drop in oxygen saturation was due to the excessive amounts of mucus collection layered over the tracheostomy. I was there to clean the patient’s tracheostomy, assess their needs and provide care. My patient would express their needs via a communication board as well as a notepad.

It was not a surprise to my preceptor and I that the patient would have to be admitted. Luckily, a bed was assigned to them fairly quickly so they could be more comfortable. I was able to give a report to the receiving nurse upstairs and practiced my communication skills in that way. I allowed for any clarifying questions and included important information that would help improve our patient’s outcome. Soon after giving the report, I went into the patient’s room and let them know that we would be transporting them upstairs shortly. My patient grabbed my hand and kept insisting I continue caring for them in the admitting unit. I assured them that they would get the same attentive care on the floor and be in a more comfortable, less noisy environment where they could get more rest and recover more quickly. After transporting the patient, I took a quick break and debriefed the whole situation. It was a moment that helped me realize nursing is not only about treating medical complaints, the collaborative team approach, or the ability to make swift and meticulous decisions under pressure, but also about making the patients feel safe and respected at their most vulnerable state.