One day in the frantic life of a Children's Minnesota emergency room nurse

It's not exactly a superpower, but nurse Joe Schwartz can tell with his nose what is causing his patient in the Children's hospital emergency department in St. Paul to look so weak, so bony thin.

When 10-year-old Juliana Jones says hello, Schwartz smells a sharp odor, like fruit gone bad, on her breath. It suggests acid buildup in her body, which likely means a dangerous complication from undiagnosed diabetes.

"My sniffer is pretty good," he says. "It's where I think we are headed."

Work in the ER is like that, drawing on basic senses beyond medical skills as nurses confront infections, trauma, mental illnesses and chronic diseases. The jack-of-all-trades nature of the job, combined with the stress and occasional conflicts with distraught parents or delirious patients, makes it one of the hardest to fill in Minnesota health care.

Children's launched a campaign to hire 176 more nurses by fall, because parents are bringing more and more children to its hospitals, but it fell behind on recruiting for its emergency departments in 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 all areas because they see everything," says Yinka Ajose, a Children's clinical director leading the hiring campaign.

Schwartz, 27, was destined for pediatrics as the son of a Children's Minneapolis ER nurse. He worked in child care and children's programming at a fitness club before joining Children's as a clinical assistant and finishing nursing school on the side.

"[Helping kids has] always been a passion of mine," he says.

It's 11 a.m. when Schwartz wheels 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 for 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. Then comes the 5-year-old sporting leopard-print pajamas and clutching a stuffed hedgehog in room 22. She is suffering the double insults of strep and influenza.

"We've been seeing that a lot lately," he says.

Then comes the rambunctious 6-year-old with strep who can't lie still. Schwartz guesses he is still infected because he skipped antibiotic doses and is simply restless after being stuck in bed for days. His mother worries he might have PANDAS, because she read how the mysterious condition causes bizarre behavior after infections.

PANDAS is rare, but listening and ruling out possibilities is part of Schwartz's job. He gets down on one knee to look at eye level at his patient.

"He's been screened for ADHD," his mother insists, "but nothing like this. This is different."

The challenge by lunchtime is plain for the St. Paul ER. Eleven nursing shifts on a staffing sheet are highlighted with yellow marker, meaning they were open at the start of the day. Six remain unfilled. The number of patients in the ER has increased from three to 18 and will soon reach 23 — with five more waiting.

Staffing gaps usually get covered last-minute by nurses willing to work overtime, administrators who are still licensed, or expensive contract nurses. Clinical assistants can cover mundane tasks as well so that short-staffed nurses can take more patients. But those stopgaps might not last, Ajose says. Children's projected last fall that it would need to increase nurse staffing by 10% in one year to keep pace with demand.

Pediatric hospitals were so underused during the pandemic that Children's put workers on extended furloughs. Some retired. Now it's under pressure, partly because general hospitals are cutting back. Mercy Hospital in Coon Rapids is one example, converting its pediatric beds for adult use.

"During COVID times, there was nobody that waited in our waiting room," Schwartz says. Now, four- to six-hour delays aren't surprising.

Juliana's arrival has created a buzz. A charge nurse takes on the case of the restless boy so Schwartz can focus on this frail girl.

Blood tests are needed urgently, Schwartz tells the upset mother. Juliana lost weight amid school stress, but the whole family is thin and her mother didn't suspect problems until her daughter threw up.

"We are worried about her," Schwartz says, "and we want to get this stuff started quicker than later."

This is the third IV line Schwartz has threaded in patients' wrists today so they can receive fluids and medicine, but none more challenging. The acid smell suggests the girl's blood is flooded with ketones, which convert fat into energy when people haven't eaten. A lack of insulin in people with diabetes tricks the liver into overwhelming the bloodstream with these acids, sometimes fatally.

Juliana's veins have receded due to dehydration and illness. Schwartz is struggling to find one to draw blood.

"What's your favorite thing to do with your kitties?" he asks as a distraction.

"Cuddle them," the girl replies.

"Oh, puppy and kitty cuddles are the best!"

Schwartz works in the ER some days but on others he is a charge nurse or trains new hires.

On this day he is shadowed by Shanna Jorgenson, who left an administrative job at a competing hospital to return to hands-on nursing. She feels the urgency and is helping, but can't find supplies Schwartz needs in an unfamiliar cart.

"It's there — the white packaging," Schwartz says, directing her to a compress. "Right, right ... Right below your hand!"

Schwartz hustles to a trauma bay to find a scanner that will analyze the acidity of his hard-won blood sample. The first scanner is out of power, so he searches for a second.

"Do you have it?" Jones' doctor asks about the result. "Still cooking?"

"Another 100 seconds," Schwartz replies.

They are concerned. This didn't happen overnight.

"She had to be losing weight for a lot longer," Schwartz says.

ED nursing can mean celebrating small successes without closure. The readout confirms the suspicion, and Juliana is prescribed insulin to undo the harmful chemical reaction in her body.

Diabetes specialists at Children's Minneapolis are ready to take over care, so medics whisk the girl back through the door she entered hours earlier.

Schwartz may not see her again, but then there's the next patient — a newborn needing X-rays to check for a bowel obstruction.

"I tell anybody who is on the outside looking in, the ER is a different beast," Schwartz says. "Ultimately you'll know that you're cut out for it by the end of your first week. Usually."