Am I thinking this through properly? New grad ICU/ED

[TammyTho]

Hello all, I need to make sure my heads on straight and I'm not missing any aspects of this so I came here :).

Little background, 42 mom, grandmother, have owned businesses, managed companies and now that my kids are out doing their thing, I have finally gone back to school and graduated with my nursing degree. I have been working as a tech on a med/surg floor throughout nursing school and while my manager has offered me a position, I know that is not where I want to be as a nurse, it's just not me. I have also been a float tech and worked in the ICU where I am amazed at the acuity and knowledge base there is to soak in and an ED tech and love the hustle and bustle and unknown of the ED.

I have been offered two different positions in the last two weeks, both full time midnights, different hospitals - one in a level 2 ED where I haven't worked but have heard amazing things about the manager and staff, they have offered extensive ED internship/training and one in a step down/ICU overflow floor with a manager I know and respect (and who loves my work) who has also offered extensive ECCO training as well as additional orientation time in the ICU so I can eventually pick up shifts there.

This is where my brain waffles and I need your assistance. Part of me wants to take the ED opportunity, to soak in the crazy and either thoroughly enjoy it and know I've found my place or at least get it out of my system. I enjoy being busy, the unknown, the traumas that come in and the team work of the ED. The other part of me wants to take the stepdown/ICU overflow position to be part of the long term care, take excellent care of those who need it most (and their families), soak in the details of the different disease processes and continue to expand my knowledge base. I enjoy researching the details of what is happening with my patients, the whys, the hows, the what ifs. I honestly love the idea of both of these decisions and don't know how to decide. Right now (at this moment as my mind changes moment to moment) I am leaning hard toward the ICU as I believe that if it ends up to not be my place it would be an extremely marketable skill to have in the search for where I belong while the ED may not give me the same marketability if I find that isn't my place.

Thoughts? (other than start med/surg first because I'm not doing that :))

A million thanks in advance!

[HakunaMatata10]

Congrats! This is a good "problem" to have.

Its important to note that you seem to use "ICU' and stepdown interchangably---these two enviornments/units are VERY different (Ratios, level of nursing care, aquity, etc)--I would HATE for you to think you were starting in the ICU and end up on a stepdown unit.

I am an ICU nurse at baseline and also serve as the Code Blue nurse for the entire hospital.I cant give you a recommendation but I will share what those two units are like vs. ED, pros/cons.

Stepdown/progressive care: Ratios are typically 3:1 or 4:1 depending on aquity/staffing. If its anything above that, run far away. You will have a mix of stable patients on the upswing and patients that skimmed by getting and ICU admission with the potential of taking a turn for the worse. It will always be busy and these patients tend to be the most "needy" (Disclaimer: As an RN prefers intubated and sedated patient's--I have a lot of respect for stepdown nurses and how they deal with the walky-talkies, they arre saints!) On stepdown, if a patient decompensates, you have to recognize and then help get them to ICU. You wont care for actively dying/ life support-requiring patients on stepdown. Just to clarify, in an actual ICU you would have fewer patients but a higher aquity (i.e. patients on the ventilator, multiple vasoactive drips to titrate, CRRT, ECHMO). ICU nurses tend to practice at a wider scope and utilize more nursing-based protocols. With that comes accountablity and liability. Pros and Cons. Obviously, more codes, deaths, etc. A pro of step-down vs an ED or ICU is the ability to see the "end result" more often. In the ED, you help save many lives but nce they are sent to the ICU, you dont know if they actually made a recovery or ended up dying. ICU is similiar. You may be 1:1 with a patient and bust your butt to save them. The patients often leave before they have "come to" really so we dont usually know what the big picture outcome is. On stepdown you will be with patients/families as they come out of the fog and be able to share/expierence thier gratitude. You will be able to see a patient walk out at discharge after coming in in cardiac arrest. Sometimes those moments help in the "why do I even do this" times.

The ED gets the whole spectrum from not sick patients, med surg level, stepdown, and crit. You will work in every "section" of the ED, meaning one day you will have to take the "common cold" and "toe pain" patients and the next shfit you will get to take care of the trauma/code/shock room patients. Evry hospital rotates differently. I have never worked ED but I have old coworkers than went to ED and coworkers that came from ED--Some love it, some hated it. Goal of ED is to stablize the patient and get them to wehre they are going (home or admitted). Goal of IP is to treat/heal the patient. A lot new grads think ED will be constant Codes and trauma--typically not.

I have found that ED nurses tend to be less Type A, becasue they have to be flexible. If you are someone who cannot fathom the idea of lose ends and constant multitasking, ED is not for you. As you said, you will see crazy--but atleast it is only for a few hours. On stepdown, you will do total care for the patient. You will get to know them and thier family--This can be beautiful and intimate with some patients...it can be a nightmare with others.

This is just a few of the pros/cons. Hope it helps! Congrats again.

[akulahawkRN, ADN, RN, EMT-P]

I'm an ED RN and that's what I've done for my career thus far in nursing. I also have experience as a Paramedic and as an athletic trainer. Here's the thing about the ED. You have to be pretty much "squirrel" wired because you're going to be constantly prioritizing and reprioritizing your tasks with your patients. Most of the time you start with little known about the patient and you begin working up the patient and as the info trickles in, you have to adapt to what the data shows you. You have to basically be a jack of all trades, master of none (or at least only a very few), flexible, adaptable, and inventive.

I work with pretty much everyone that comes through the doors, sometimes from the first minute of life or someone that's about to have their last... and I have to be able to deal with pretty much everything in-between. Here's the thing, and it's been mentioned above: my job is stabilization and triage. I deal with people that sometimes are crying their eyes out because they have a hangnail or a papercut, people that think none of us exist and nothing exists, people that are too drunk or high to safely send home, people that ignored a stubborn cough and now have pneumonia to the point where they're septic, to massive intracranial hemorrhages, to people that are either having a heart attack or they think they're having one.

Most ER's that I've ever been to have areas that they try to dedicate to certain acuity levels of patients. "Fast track" basically deals with large volumes of low acuity patients that come in, get seen, maybe get an intervention, a med, a prescription (if necessary) and back out the door. There's often an area that deals with the generally sick. Those patients will often be in the ER room for a few hours because their workup and needs are higher. Sometimes they go home, sometimes they get transferred, sometimes they get admitted. These are great rooms to start out with because you get to see different patients and they're sometimes "sick enough" that you get to learn and see how things develop and sometime those can become very high acuity. Another "area" deals with the very sick. Sometimes they call those rooms "Code Rooms" or "Trauma Rooms" and the nurses there usually are very experienced in dealing with those sick patients. Many of those patients end up going to ICU or a SDU because they're too sick for a Med/Surg or a Med/Tele floor... or they die.

The name of the game in the ED is throughput (or flow). It's all about triage - sorting the patients and getting them to the care the patient actually needs. The ED is a very poor substitute for primary care and while it can "do" Med/Surg, Med/Tele, SDU/ICU, and Psych, it doesn't do any of them anywhere nearly as well as floors/units that "do" those things.

If you really want to get some ED experience, I would suggest spending some time getting experience on a Med/Tele floor, SDU, or ICU first. You'll get your basic assessment skills down solid, you'll have a good experience base for what happens after the patient leaves the ED, and you won't have to learn the basics of being a nurse in an environment where things can be as fast-paced and just plain weird as the place can have you running around much like a squirrel on meth.

Now then, I'm in California, so I get the benefit (so to speak) of having a 1:4 ratio. Other states don't have this so it's possible for you to have a higher ratio. You should pay attention to those ratios...