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The View from the Other Side

Editor's note: If you have been accepted into an undergraduate nursing program, have proof of at least one year of prehospital work experience, hold a minimum 3.0 GPA, and are a member of a professional Emergency Services Association, you could be eligible for a $5,000 scholarship.„Click hereto read more about the 2006„JEMS (Journal of Emergency Medical Services)/Elsevier Nursing Scholarship.

We_ve all seen the ads: ˙Nursing shortage,Ó ˙Hiring bonus,Ó ˙Relocation assistance.Ó The current nursing shortage is all over the news, and we hear about it from the ED nurses. The ˙benjaminsÓ are literally leaping off the page and into your wallet. JEMS even offers a scholarship to assist paramedics with nursing school. So is it worth it? Here_s what I learned from my experiences in the field and in two trauma center EDs.„

The first question I_m asked by most paramedics considering nursing school is: ˙What_s the pay like?Ó Very good, compared with most EMS wages. When I became an RN in July 2004, I was working for a busy county EMS agency making less than $9 an hour despite 17 years_ EMS experience and working a 56-hour week. In contrast, my first nursing job at a Level II trauma center ED paid $19 an hour and required only a 36-hour week. They also paid for my relocation from West Virginia to Colorado. Yes, the money is good compared with EMS, but you will earn it.„

Second, what does this ˙nursing shortageÓ we hear so much about really mean? It means as a new graduate nurse, you can now get a job in an ED or ICU, whereas the usual path used to be a couple years on ˙the floorÓ then to the ED or ICU. It means you can get a job in just about any area of the country. You will be in demand.„

So if you are considering the transition, what can you expect? As a new graduate nurse in the ED, I found that my assessment and IV insertion skills were much better than most new nurses and often better than many experienced ED nurses. Very little of what I learned in nursing school seemed applicable to the fast-paced ED environment. When I interviewed for my first ED job, the manager said she wouldn_t consider a new graduate who didn_t have an EMS background. This was a refreshing attitude. Unfortunately, management changed after I had been there for two weeks. The new manager displayed the attitude that if you didn_t learn it as an RN, then you didn_t know it. This attitude is common in nursing, but not universal. In contrast, my current ED management staff includes an ED director who_s a former paramedic and several charge nurses who are also currently practicing field ALS providers. The attitude is completely different now.„

The working environment is quite different from EMS. Being indoors has its advantages depending on the weather. Compared with EMS, the ED is less physically demanding, especially on your back. In general, the only lifting required is moving the patient from the ambulance cot to ED bed and to the X-ray or CT scan table. However, being on your feet for 12 hours at a time can be taxing and painful, even with good shoes. In addition, the current nursing shortage means most EDs are short staffed. You can frequently expect a patient load of three to five at any one time, often with no other nurses or techs to help you because they_re just as busy. Are these optimal conditions? Probably not, but it_s a common reality in the ED. Also, there is little down time. If you aren_t busy with your patients, you_re helping other nurses with theirs. Lunches and breaks are few and far between in most busy urban EDs. In general, I consider a 12-hour ED shift to be more tiring than a 10- or 15-call, 24-hour EMS shift.„

Autonomy, as EMS providers know it, is virtually nonexistent. The ED is a ˙Mother may IÓ system. After being a flight paramedic and working in systems where virtually all treatment was on standing orders, I found this arrangement to be frustrating and often inefficient. The ED ˙standing ordersÓ most often consist of IV, O2, cardiac monitor, ECG, draw blood and urine sample. That_s about all you can do without a physician order. In most cases, once the doctors get to know you, if you ask for something, you_ll usually get an order for it.

In the ED, nurses have little responsibility for airway maintenance, other than BLS. Intubation is done by the doctors or respiratory therapists. Ventilators are managed by respiratory therapists. The nurse_s job is more to maintain and protect the airway than to perform advanced airway maneuvers. This limitation can be frustrating, especially when watching a first year resident ˙gut tubeÓ a trauma patient you could have intubated in 20 seconds or less. Overall, the lack of EMS-type autonomy is not too bad once you become accustomed to the system.„

In general, my working relationship with most physicians has been good. As a nurse, you may have three to five patients. But when it_s busy, the ED physicians may have up to 10 patients, and the ED nurse is often the first to see subtle changes in a patient_s condition that require interventions. The physicians expect this sharpness in their nurses. Like a paramedic in the field, you_re still the ˙eyes and earsÓ of the physician as an ED nurse.„

After nearly two years in the ED, I rate my overall experience as neutral. It has been neither exceedingly great nor terrible. Nursing is a good career path with many opportunities other than the ED. I_m considering a move to an ICU position to accomplish my goal of flight nursing or critical care ground transport. Nursing is what you make of it. I acknowledge that your experience may be different from mine depending on where you work. As a paramedic and RN, you can keep a foot in both worlds. That_s my plan, anyway.„

Steven B. Pack, BA, RN, NREMT-P, is an emergency department RN in Roanoke, Va. His 18-year career includes ground EMS, air medical, wilderness medicine, search and rescue, and emergency nursing. Contact him via email at„spack171@yahoo.com.


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