ED vs ICU

NurseGirl525, ASN, RN · Oct 15, 2016

I would say a big chunk of nursing is supporting patients at their most vulnerable. I like icu over emergency because there is just too much madness in the ED. Not that I don't see craziness, but my patients are sick. Really sick. You get a cluster of everything in the ED. You get the sniffles, drug seekers, mental illness, mixed in with the true emergencies.

I'm still fairly new, but I love icu and I'm on a specialty icu which I really love.

adventure_rn, MSN, NP · Oct 22, 2016

I think one huge difference is the pace/predictability of the shift, time management, and prioritizing.

One thing I love about ICU (because I'm pretty neurotic) is that for the most part, I can plan my shift. Unless the patient is actively trying to die and you're mid-code, you can generally get a sense for when things will need to be done. Even though the plan may be altered if your patient is unstable, there's generally still a relatively clear sense of the plan (if not, it's going to be a rough shift). Maybe the sense of control is an illusion, but I feel like ICU is better for control freaks.

Meanwhile, there is no 'shift plan' in the ED; you never know who/what is about to come through the door, and you are constantly reprioritizing (you do that in ICU, too, but not nearly to the same extent). You have to become confident triaging and providing basic stabilizing care to every single type of patient and condition you may see (neonates to pregnant teens to folks in their mid-90s, asthma attacks to heart attacks to snake bites). By contrast, ICU nurses may be specialists (i.e. neuro, cardiac, neonatal, etc.) You can have an ED shift where all of your patients are low-acuity, and have illnesses that don't actually require an ED visit, a la urgent care (i.e. tooth pain, back pain, sore throat); that same shift, you may get someone spurting arterial blood from a wound. I once had an ED patient who was sitting up, filling out discharge paperwork, eating a ham sandwich one second, and coding the next. You have to be comfortable going with the flow, looking at the big picture, and making a new plan on the spot. As an ICU nurse, that thought makes my skin crawl.

On a similar 'control freak' note, ICU nurses usually want to know every minute detail about every body system in their patient, whereas ED nurses are more concerned with what is going on right at this minute as it pertains to the presenting problem. Neither approach is right or wrong, just a totally different mindset (which can cause some tension when ICU nurses are getting report for ED nurses, lol). Similarly, ED nurses will have a new set of patients every single shift, whereas you could have the same patient for an extended period of time on your ICU; consequently, you may get to know the patient, their medical history/assessment findings, and their family members.

A third 'control freak' element (man, I keep thinking of more and more!!) is your medical knowledge of what's happening to the patient. In the ED, you often have medical mysteries on your hands, which is one reason for the aforementioned 'lack of plan' situation; it's harder to make a plan to address an illness when you don't know the underlying cause. The plan for someone with a bowel perforation is very different from the plan for somebody with bad gas. Many ED nurses seem to think of it like a cool puzzle, and thrive on figuring out the root cause (kudos to them!) You get these mysteries in the ICU occasionally (in general, if you can't figure out why the patient is continually coding, it's going to be a rough shift), but more often, you've done enough tests that you know what is happening and why, and you use that info to create your handy-dandy plan. :up:

One thing I will say about (adult) ICU nursing: many of your patients will be intubated, disoriented, or exhausted (they are critically ill, after all), so you will be physically supporting them the greatest possible extent, but you may not be emotionally supporting them. One of the main reasons I chose to avoid adult ICU is that I witnessed many ICU patients who experienced a profound loss of dignity on the unit (not the fault of the nurses, but rather the nature of ICU care); that experience was very morally distressing for me.

If you can, try to shadow before committing!! That can help you clarify what each type of nurse actually does (i.e ED nurses are rockstars at starting IVs, ICU nurses may be great at floating swans), and how they go about doing it.

Best part: if you try one specialty and hate it, or if you're bored and want to branch out, you can always change specialties. That's the beauty of nursing

WKShadowNP, DNP, APRN · Oct 22, 2016

I love the unpredictability of the ED. There's a controlled chaos and then there's a category 5 hurricane of chaos but it is where I thrive. I'll post more when I've had coffee. It is time for me to clock in.

WKShadowNP, DNP, APRN · Oct 23, 2016

Now I've clocked out and driven the long drive home. I am pooped. But I got out on time (more or less). That's one thing I could not say as often in the unit. I almost always had to stay later charting because patient care came first. Charting is different in the ED in my experience because the focus is more concentrated on the point-of-care modality. While the whole-patient care aspect is not eschewed for quick-stop care, the need to be as meticulous is not as much a priority in most cases. The basics are addressed and the whole self is taken into account more like a ROS type of thing. Ok, pertinent positives are managed while all else is left for primary care.

GE90 · Oct 24, 2016

peds nurse on general peds coming in with popcorn expecting to watch a mma level kinda fight of "ED - the adrenaline junkiess vs ICU - the i'm an icu nurse and i know tons more than you"

That Guy, BSN, RN, EMT-B · Oct 24, 2016

peds nurse on general peds coming in with popcorn expecting to watch a mma level kinda fight of "ED - the adrenaline junkiess vs ICU - the i'm an icu nurse and i know tons more than you"

Ill give that to them, they do. But I like the fact I know a little about a lot. I don't specialize in one thing, I don't worry about the things floor nurses worry about I get to stabilize and scoot them out, up or down.

NotMyProblem MSN, ASN, BSN, MSN, LPN, RN · Oct 25, 2016

Now that these awesome nurses have addressed ED and ICU nursing, I'll chime in with my two cents and say that if you hold onto the mindset that you're "not concerned about pay or any of that rubbish", you will quickly see a payday that's more of a pay stub instead of a paycheck. Again, that's just my two cents.

adventure_rn, MSN, NP · Oct 25, 2016

It's amusing to me how many nursing students pose the ED vs ICU question, since the main thing they have in common is running a ton of codes. Otherwise, they're about as dissimilar as humanly possible.

I'd be curious to hear how ED vs ICU nurses' code experiences differ. I feel like outside of the delivery room (basically the NICU version of the ED), most of our NICU codes are surprisingly calm, quiet, and controlled. I only had one ED code experience (my aforementioned ham sandwich patient), but there was some yelling, a flurry of action, and at the end there was bloody vomit on one of the attending's open-toed sandals (He wore black socks with black teevas and thought nobody could tell they weren't closed-toed!! You'd think an ED doc would know better!)

Mad props to both specialties.

calivianya, BSN, RN · Oct 25, 2016

I don't think it gets much more vulnerable than ICU, if you like the thought of helping vulnerable people. Come a couple of months, probably 30/30 beds in my unit will have vented, sedated, unconscious people. Yay flu season! It doesn't get much more vulnerable than being unconscious with tubes in every imaginable orifice, and being tied down so that just in case you wake up a little, you can't touch anything connected to you. Not being able to talk, not being able to even tell someone you've got to poop, not even being able to scream. Yep, that's vulnerable.

That "patient contact" you mention, though - that's a double-edged sword. Yes, it's nice to see people get better. What I see way more often is someone getting better enough to get out of ICU, going to the floor, getting into respiratory distress, and bouncing back to ICU. The cycle repeats itself four or five times before the patient goes to palliative and dies. Few people truly have a better quality of life for having been in ICU, at least, few of the elderly, multiple comorbidies people I see the most of (the typical MICU patients).

And if the patient or his/her family are monsters... well, you're in for hell until the patient gets moved out, because you're right - you're dealing with the same people day in and day out. You don't just get to deal with the good ones over and over again. You get to deal with the worst of humanity too, and after your fourth day in a row of being cussed at by the same family member, or kicked by the same violent dementia patient, that whole seeing the same people day in and day out loses its glitter by quite a bit.

In fact, quite a few of my coworkers make sure to sign up for non-consecutive days, so they don't have to have their patients again.

Been there,done that, ASN, RN · Oct 25, 2016

Your salary is not "rubbish"... money is the reason we ALL work, self satisfaction for caring for "vulnerable" people will quickly wane. As all patients are vulnerable, why not go to hospice?

You cannot possibly find your fit in advance. You will not have your choice of job offers, find a job and learn from there.