ER/ Trauma vs Trauma ICU

DayDreamin ER CRNP · Jul 15, 2017

Depends on whether you want the patient straight off the street or from the ER. Kind of depends on whether you are willing to wait the two so years it will take to be the nurse to take the "big bed" when that trauma rolls in. Most L1 ERs will have a dedicated L1 room and will only be assigned to someone on the trauma team which usually take at least a year or more to earn that spot.

Same is really true in the ICUs I've seen. A new nurse won't get thing those super critically ill patients right off the bat. He/she will usually have to put the time in with the more minor ill patients to start.

I've never known a SICU/STICU not be attached to a L1 center. That is part of the criteria to even be considered a L1 center anyway. Maybe I misunderstood the question.

Alexxoxox, BSN · Jul 15, 2017

Depends on whether you want the patient straight off the street or from the ER. Kind of depends on whether you are willing to wait the two so years it will take to be the nurse to take the "big bed" when that trauma rolls in. Most L1 ERs will have a dedicated L1 room and will only be assigned to someone on the trauma team which usually take at least a year or more to earn that spot.
Same is really true in the ICUs I've seen. A new nurse won't get thing those super critically ill patients right off the bat. He/she will usually have to put the time in with the more minor ill patients to start.
I've never known a SICU/STICU not be attached to a L1 center. That is part of the criteria to even be considered a L1 center anyway. Maybe I misunderstood the question.

How long do the trauma patients usually stay in the ER? How many traumas come in each day (on average) at a Level 1 Trauma Center?

DayDreamin ER CRNP · Jul 16, 2017

How long do the trauma patients usually stay in the ER? How many traumas come in each day (on average) at a Level 1 Trauma Center?

Less than an hour. Goal is 20 minutes from ER to scanner, unit, or OR but that can vary based on what all needs to be done.

We are a 800+ bed L1 hospital with six trauma rooms in the ED - one is a dedicated L1 room. We have seen up to 27 traumas to include 4 or 5 L1s in a day. I think the most L1s we had in a day was 10 or 12. I cannot remember. I've had 4 L1s in one day but one really wasn't a 1. I've had that room and never saw one single patient all day. It just varies.

Wolf at the Door, BSN · Jul 16, 2017

Former Level 1 Trauma ICU RN here. There was a separate trauma ER from the medicine ER where I worked, two totally different parts of the hospital. Trauma Bays, Trauma ER, Trauma OR, Trauma PACU, Trauma ICU & Trauma Stepdown. Burns had there own ER, OR, ICU, Stepdown.

Summer is Trauma season so it is really busy. It depends how many trauma centers are located in your area.

Alexxoxox, BSN · Jul 16, 2017

Former Level 1 Trauma ICU RN here. There was a separate trauma ER from the medicine ER where I worked, two totally different parts of the hospital. Trauma Bays, Trauma ER, Trauma OR, Trauma PACU, Trauma ICU & Trauma Stepdown. Burns had there own ER, OR, ICU, Stepdown.
Summer is Trauma season so it is really busy. It depends how many trauma centers are located in your area.

Does it usually take an RN a few years to get into the trauma part of the ER? Do trauma ER nurses, or trauma icu nurses get more trauma experience?

Wolf at the Door, BSN · Jul 16, 2017

Does it usually take an RN a few years to get into the trauma part of the ER? Do trauma ER nurses, or trauma icu nurses get more trauma experience?

Yes, you should at least wait a 1.5-2 years before picking up shifts. Trauma ER is just trying to stabilizing the patient for OR. Then OR rushes the patient to ICU so that patient does not die in operating room, or the patient is actually ready to be sent to ICU.

ICU gets more experience due to whatever was happening in trauma er (volume replacement & coding) continues on in trauma ICU and more lots more. Trauma ER stitches patients and a few other task that does not go on in trauma icu.

I convinced allnurses to create a trauma speciality a few years back. There was a Trauma and Trauma ICU category if I remember right. I battled a few members over the need of the trauma category. I assume due to lack of traffic it failed and was removed. General specialities exist lol, oh well, I still think trauma is needed.

Non Sequitir · Jul 16, 2017

It's basically the same difference between the ER and any other floor. The ER stabilizes with the goal of 'how quickly can we get this pt to where they need to go', the floors treat with the aim to fix the problem. That's a gross oversimplification but serves this particular example well. Hospitalist/inpat docs who cover the ER can be absolutely terrible because the frame of reference for treating patients is much different. The ER needs to maintain open beds, the floors need to continue the work that the ER started.

Wolf at the Door, BSN · Jul 17, 2017

If you want to see the gore right in your face trauma er and circulate in the trauma bay. Trauma ICU we get them bandaged.

Kristenlaurenw · Aug 16, 2017

I work in the ER of a level 1. We don't have dedicated trauma nurses. We go to huddle in the morning and get our assignment (acute pods, fast track, triage, float, critical/trauma) and it changes each shift. Our critical pod gets all of the traumas. We have 8 beds. When they call a level one, surgeons are standing outside the doors from trauma, neurosurgery, vascular surgery, ortho surgery, etc go see who is needed). In a lot of cases with hemorraging level ones we start a massive transfusion protocol which means we literally get coolers full of blood to infuse immediately, and a lot of the times I end up having my patients in the OR in the first 30 minutes and then they go to shock trauma ICU. As an ER nurse, it's all hands on deck to keep the patient alive for that 30 minutes or so(which us why we chart traumas on paper). The STICU nurses usually get them in a mess and never complain. They are amazing! They transition them from being covered in dirt and leaves and grass to being presentable for families all while managing the vents, drips, chest tubes, foleys, art lines, etc. that we just started in the ER and took off running down the hall with!

nightbrightener · Oct 2, 2017

Even a level 2 trauma center will get you exposed to a variety of patients. We ship out bad burns, pediatric neuro and pediatric cardiac, occasionally a dissecting AAA, everything else stays in house to the OR, ICU ,TNU, or IICU. Level 1 handles everything but even a level 2 can see you cracking chests in the trauma bay, depends on the hospital and patient population. Like earlier posters said, ER is rough and ready, many go on to NP and trauma NP, but TNU or ICU will see them longer and be more involved in the healing or resolution of their injury, until they get stepped down anyway. The big thing is that regardless of level 1 or 2, you will be primarily an ER nurse who after a year or 2 does traumas in the bay, if you are lucky. So for immediate exposure TNU/ICU may be better. Decide why you like trauma and what part you want to be involved in, then take it from there.

bgxyrnf, MSN, RN · Oct 3, 2017

If someone were interested in trauma, should they work in a Level 1 Trauma Center, or a Trauma ICU ( that receives traumas from level 1 center)? Just curious about this field of nursing.

As you've probably realized by reading the replies, "interested in trauma" is an incredibly broad statement and covers the spectrum from the medics on scene all the way through PM&R.

Generally speaking, it goes like this:

Medic: On scene, begins care even prior to extrication at times, suboptimal conditions... rain, snow, mud, wind, spectators... primary goal is to get the patient to definitive care as soon as possible. They utilize various interventions... IVs in any vessel they can find, IO lines, needling the chest to evacuate air, intermediate to advanced airways (king tubes, combitubes, LMAs, and ET). By design, they should have the least contact with the patient and aren't worried about much beyond the ABCs.

ED: A full assessment of the patient including bedside ultrasound, imaging (you'll get to know your CT techs very well) and labs, as well as some invasive procedures like DPL (I know, I know... I've only seen two but we still stock the trays...)... The conditions are much better than the field but remain suboptimal for what's going on... The ED is the bridge between the field and the definitive care that happens in the OR and the ICU (which goes by various name... STICU (shock/trauma ICU), TICU (trauma ICU), SICU (surgical ICU)). Interventions in the ED are generally pretty limited and focus on the time-critical things needed to keep the patient alive long enough to make it to the next stage (for example, blood, TXA, fluids, chest tubes, advanced airway management (ET or surgical crich), EVDs ("brain drain"), or the big Kahuna... a crash thoracotomy ("cracking the chest") or a crash c-section). Generally antibiotics are started in the ED as soon as possible (peritonitis kills and osteomyelitis debiliates).

OR: Pretty self-explanatory... initially, it's not terribly delicate... it's mostly focused on control of bleeding, relieving pressure on the brain, and cleaning (be it dirty wounds like mangled limbs or perforated bowels). Often, trauma patients require multiple surgeries.

ICU: Now here is where it all starts to come together. This is the destination from the ED and the OR. Now the patients are starting to get cleaned up, get their pain consistently controlled, and the fine-tuning of treatment. The full range of treatments are now instituted and managed and now begins the transition from trying to keep 'em alive for the next 30 minutes to the next couple of hours to the next shift to the next day then week... Things are much more controlled in the ICU... well, right up until they're not. All the badness that can happen in the ED can happen in the ICU, and then some. And my ICU colleagues don't have the luxury of thinking, "we just have to get 'em upstairs" like we do in the ED... until the patient stabilizes, they're going to make it or break it in the ICU. While we tend to thrive on chaos in the ED, chaos in anathema to my ICU friends. That's why people are *either* ICU nurses *or* ED nurses, not generally both. ED nurses are looking to manage the chaos, ICU nurses are looking to avoid the chaos. In the ICU you may find patients with so man tubes and lines and monitors that you can hardly find the patient in the midst of all of it... picture a patient with six chest tubes, ten surgical drains, a couple of wound-vacs, external hardware holding their broken bones in place, a central line in their neck, a large line in their femoral vein, 4 peripheral IVs, an arterial line, a drain to their stomach, 8 IV pumps, two drains coming out of their skull, a catheter from their bladder, and monitors tracking: arterial bp, central venous pressure, intracranial preressure, heart rate, respiratory rate, end-tidal CO2, oxygen saturation, noninvasive bp, and perhaps the pressure in a mangled limb or even in their belly. In addition to all that, these patients probably need regular dressing changes that can take hours... They may be on a large bed that spins them like a pig on a bbq spit. They may have RT coming in to do aggressive chest physiotherapy and they may be on advanced ventilators giving them gasses besides oxygen and air and perhaps high-frequency, low-volume ventilations... they may also get regular dialysis if they started w/ kidney disfunction or if their kidneys were trashed due to the trauma or the treatment.

Wards: From the ICU, the patient will transition to the trauma ward (or the morgue) where things are more laid back because the patients are stable... or they're *supposed to be*... or they *were*... a lot of rapid-response calls go to the ward because the patient crumped after leaving the unit or they never went to the unit but probably should have or they just crumped because patients crump sometimes, no matter what you do. Now the issue on the ward as opposed to the ED or the unit is one of resources... in the ED, there's always a doc nearby, even at zero-dark-thirty, and you've got carts ready for all of the crash procedures, you've got a rapid infuser or three standing by, bedside ultrasound, nurses and RTs abound, and you're generally as close to the CT scanner as anybody and the surgeons usually answer your pages in a hurry. Same thing in the units... they have even more equipment and carts staged for immediate use and the docs, while they might not be physically present, will certainly recognize the call-back number and call back or show up very promptly. When a nurse calls from the ICU, the docs are pretty sure it's something that needs immediate attention. Some docs are less respectful of calls coming from the wards. When things take a crap on the floors, it's a big problem because they're not generally well set up for crash interventions because they don't happen all that often so when they do, their resources are stretched very thin.

PM&R: And here is the grossly overlooked and under-respected part of the system because it is these folks who will be responsible for getting the patient back to whatever level of function they might be able to achieve. As with all of it, it's really a continuum that starts in the ICU and continues to post-acute rehab, but these folks on the back end don't get much glory but they are every bit as vital as everybody else. They won't see as much gore, to be sure, but they do have patients with chronic wounds (fistula, anyone?) and some pretty impressive ortho hardware (the orthopods were the kids with the amazing collection of Legos and erector sets).

So, what's your interest in trauma?

If you want to see misaligned bones, internal parts on the outside, blood all over the floor, mangled flesh, ruptured eyeballs, what the internal anatomy looks like through gaping wounds... if you can handle screaming and flailing and an element of personal risk, the ED may be your thing. If you like hustle and bustle, here's the place. You best not have thin skin, though, because it can get a bit heated in the midst of the chaos. You need to have the confidence to perform when seconds and minutes count. You need to be able to prioritize like a quarterback and be able to identify issues and act without having to be told to... this is no place for people who haven't found their voices because it can be challenge to be heard when others have tunnel vision. If you're ADD, this is for you.

If you want a great view of internal anatomy, the OR is the place. If you can handle being around some of the most... emmm, self-confident and directive... personalities, the OR is a good fit. If you are meticulous, the OR. If you don't particularly like to interact with people outside of your small circle, definitely the OR. If you don't want to see the emotional damage trauma causes patients and families, for sure the OR.

If you want to marvel at the amazing abilities of modern medical/surgical technology, the ICU is the place. You need to be able to sit/stand in one place and focus on one patient, and sometimes just one part of one patient, for hours and hours. It's all about attention to detail and fine control of a multivariate, incredibly complex and dynamic system (that's my engineer-self speaking). If you're OCD, welcome to the ICU.

If you can handle seeing the same person for days and even weeks, the wards might work for you. If you're empathetic and can help people make peace with a new reality of a missing limb or organ, the wards may be a good fit. If you don't want to see the gore or don't feel energized by chaos, the floor can be a good place. If you are articulate and persuasive, the floor can certainly use someone like you for those 0200 calls to a sleeping doc who needs to get off their kiester and deal with developing situations. You need to be comfortable living with ambiguity because some of these patients "sorta" look bad but not "that bad." You'd best have great assessment skills because these patients can be hard to categorize along the scale of "sick or not sick." Being on the floor, it's helpful to be a 'people person' because you're going to be seeing folks at their worst. However, if you like to see daily progress and improvement, you'll probably see it here more than anywhere.

Finally, if you have the patience of Job and take the long view, PM&R could really use you. If you're a natural coach and encourager, the kind of person who can get someone to do those last couple of push-ups that they don't think they can do, PM&R may the place. If you abhor the word "can't," PM&R. If you're the kind of person who embraces the term "differently abled" instead of "disabled," PM&R is in need of people like you.

Now, beware that these are all generalities and (obviously) based only on my personal experiences (Level None, Level 4, Level 2, and Level 1) on the floor, in the ED and floating through the various ICUs.

Also recognize that while the goal is to get trauma patients out of the ED as quickly as possible, sometimes that can be hours and hours so even in the ED you may move out of the chaos stage and into the early ICU phase.

So, jprn2018, you need to ponder what it is about trauma that interests you and what are your unique attributes that would help you be exceptional in one or another of the zones along the trauma continuum.