A day in the hectic life of a children's emergency room nurse

It’s not exactly a superpower, but nurse Joe Schwartz can tell with his nose what’s making his patient in the emergency department at St. Paul Children’s Hospital look so weak and thin.

When 10-year-old Juliana Jones says hello, Schwartz smells a pungent odor on her breath, like that of rotten fruit. This suggests a buildup of acid in his body, which likely means a dangerous complication of undiagnosed diabetes.

“My sniffer is pretty good,” he said. “That’s where I think we’re going.”

This is how emergency room work works, tapping basic senses beyond medical skills as nurses deal with infections, trauma, mental illness and chronic illness. The jack-of-all-trades nature of this job, combined with stress and occasional conflicts with distraught parents or delusional patients, makes it one of the hardest to fill in Minnesota health care.

Children’s has launched a campaign to hire 176 additional nurses by the fall as parents bring more children to its hospitals, but the company has fallen behind in recruiting for its emergency departments St. Paul and Minneapolis. The pediatric provider offered a behind-the-scenes look at Schwartz, a particularly versatile nurse, earlier this spring to spark interest in this branch of nursing.

“They have to be really experts in everything because they see everything,” says Yinka Ajose, a clinical director at a children’s hospital who is leading the recruitment drive.

Schwartz, 27, was destined for pediatrics as the son of a nurse at Children’s Minneapolis ED. He worked in child care and children’s programming at a fitness club before joining Children’s as a clinical assistant and completing his nursing degree on the side.

“Children have always been a passion of mine,” he says.

It is 11 a.m. when Schwartz takes Juliana to room 4.

It’s been a manageable morning since he started his 12-hour shift at 7 a.m. with a sip of his ultra-caffeinated drink. “I don’t think it does anything to me anymore,” Schwartz laments.

First comes the pale 20-year-old in room 18 who threw up all night after eating seven pot stickers at the San Francisco airport. Next comes the 5-year-old girl in leopard-print pajamas and holding a stuffed hedgehog in room 22. She suffers the double insult of strep and the flu.

“We’ve seen this a lot lately,” he says.

Next comes the rambunctious 6-year-old with strep who can’t sit still. Schwartz guesses he’s still infected because he skipped doses of antibiotics and is just restless after being stuck in bed for days. His mother fears that he may have PANDAS, because she has read how this mysterious illness causes bizarre behavior after infection.

PANDAS are rare, but listening and ruling out possibilities is part of Schwartz’s job. He kneels down to look at his patient at eye level.

“He’s been screened for ADHD,” his mother insists, “but nothing like this. Here, it’s different.”

The lunchtime challenge is clear to St. Paul’s general manager. Eleven nursing shifts on a staffing sheet are highlighted with a yellow marker, meaning they were open at the start of the day. Six remain vacant. The number of patients in the emergency room has increased from three to 18 and will soon reach 23 – with five more waiting.

Staffing shortages are usually filled at the last minute by nurses willing to work overtime, still-licensed administrators, or expensive contract nurses. Clinical assistants can also take on mundane tasks so that understaffed nurses can care for more patients. But these palliatives might not last, Ajose says. Children’s Hospital projected last fall that it would need to increase its nursing staff by 10 percent in one year to meet demand.

Children’s hospitals were so underutilized during the pandemic that Children’s put workers on extended leave. Some have retired. It is now under pressure, in part because general hospitals are reducing their staff. Mercy Hospital in Coon Rapids is one example, converting its pediatric beds to adult use.

“During COVID, we had no one waiting in our waiting room,” Schwartz says. Now, delays of four to six hours are not surprising.

Juliana’s arrival created a buzz. A charge nurse takes care of the agitated boy so Schwartz can focus on this fragile girl.

Blood tests are urgently needed, Schwartz told the distraught mother. Juliana lost weight due to school stress, but the whole family is skinny and her mother didn’t suspect any problems until her daughter vomited.

“We’re worried about her,” Schwartz says, “and we want this to start sooner rather than later.”

This is the third IV line Schwartz has installed in patients’ wrists today so they can receive fluids and medications, but none are more difficult. The sour smell suggests the girl’s blood is flooded with ketones, which turn fat into energy when people haven’t eaten. A lack of insulin in people with diabetes causes the liver to overwhelm the bloodstream with these acids, sometimes fatally.

Juliana’s veins receded from dehydration and illness. Schwartz has trouble finding one to draw blood.

“What is your favorite activity to do with your kittens?” » » he asks to distract himself.

“Hug them,” replies the young girl.

“Oh, puppy and kitten cuddles are the best!”

Schwartz works in the emergency room some days, but other days he’s a charge nurse or training new hires.

That day, he was followed by Shanna Jorgenson, who left an administrative job at a competing hospital to return to hands-on nursing. She senses the urgency and helps, but cannot find the supplies Schwartz needs in an unfamiliar cart.

“There it is, the white packaging,” Schwartz said, directing her to a pad. “Good, good… Right under your hand!”

Schwartz rushes to a trauma room to find a scanner that will analyze the acidity of his hard-earned blood sample. The first scanner is out of power, so it searches for a second one.

“Do you have it?” Jones’ doctor asks for the results. “Are you still cooking?”

“Another 100 seconds,” Schwartz replies.

They are concerned. This didn’t happen overnight.

“She had to lose weight for a lot longer,” Schwartz says.

Erectile dysfunction nursing can mean celebrating small successes without closure. The result confirms suspicions and Juliana is prescribed insulin to reverse the harmful chemical reaction in her body.

Diabetes specialists at Children’s Minneapolis are ready to take over care, so doctors take the girl back through the door she came in hours earlier.

Schwartz may not see her again, but then there’s the next patient: a newborn who needs X-rays to look for a bowel obstruction.

“I tell everyone who looks on the outside looking in that the ER is a different beast,” Schwartz says. “Ultimately, you’ll know you’re cut out for this by the end of your first week. Usually.”