ER/ Trauma vs Trauma ICU

roj2220082 · Jan 9, 2018

This reply was ahhhhmazing!!! Between this reply and talking to an ICU and ER nurse tonight, I have so much more clarity!

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.