PeakRN

Just for perspective I have found essential hypertension in otherwise healthy 2 and 3 year olds several times in the ED. While the ED is not the kid's primary care, that may be the only medical provider they see for months or years. These kids could easily end up with long term kidney disease if they weren't completely evaluated during their visit.

When we hire in my center we typically favor critical care over floor pediatric experience. Unfortunately adult med/surg is unlikely to give you either experience, but you also have to start with the job you can get. If you are willing to relocate there are often programs where you can start as a new grad in a large ICU.

The ICU book. The Ventilator book.

Query: Professionalism.

One of our PICU intensivists loves giving haircuts to the long term kids.

Reducing dislocations. Instantaneous gratification.

While I agee with some of this I would like to clarify a bit. I was a messy medic. The floor and bench of my bus were a disaster by the end of my call. That was because we thoroughly cleaned the back after every call. Also since we only us a few calls a day it want a big deal to clean after the call, had I run a 911 system that is constantly churning volume I’m sure that would have been different. Cleaning your workspace type habits were a big change for me.

You seem to have a bit of a chip on your shoulder. Why did EDs start hiring paramedics? Simply put they are cheaper labor than registered nurses. Paramedic and nursing education is not the same, I’ve done both. Paramedics are taught the technical skills in order to manage patients outside of the hospital. They perform high risk interventions with less training than those who would typically be performing them in the hospital because the risk is outweighed by the benefit on the street. In the hospital we can lower that risk though by having specialty trained staff perform those interventions. Nurses are instead taught a general basis of care across many care environments and then specialize when they start working in a specific area. The shortest paramedic course is 3 months in the US, the shortest RN are about 16 months but requires a prior bachelors and prerequisites.

In my opinion your ED has not provided adequate training. All of our new grads must have ACLS, PALS, TNCC, ENPC, NIHSS as well as complete their online ED modules and all of their staged orientation (which would include things like gastric tube placement, sedation management, invasive line management, vasoactive drug titrations, et cetera) before we allow them to come off of orientation. If my new grads can’t get the appropriate learning opportunities in the ED by the end of their orientation I will send them to one of our adult or pediatric ICUs to get that experience.

We never furloughed anyone, but we did cancel every traveler and PRNs have been removed from the schedule. We did rotate a lot of nurses with adult experience back to the adult world. PICU nurses back to adult ICU, peds onc to adult onc, peds floor to med/surg, et cetera.

I’ve taken care of more famous people and their families than I can count. Professional athletes, national media reporters, politicians, several heirs to european monarchies, CEOs who’s names are nationally known, and so on. We are a bit well known amongst those circles for not caring about anyone’s celebrity status, and treating everyone equally.

No offense but if you have nothing to do as a nurse on a peds unit for several hour you aren't really a peds nurse. There is always a kid that needs help with homework, another disease to be studied, an infant that would benefit from holding, and so on.

For something like a glucose check I don't understand why you would really need to use the limb alert arm. In the unit we stick patients every hour when on IV insulin, often (repeatedly) on the finger of their choosing.

I'm fortunate to have the perspective of having worked with adults and peds in EDs and the units. Life is unpredictable, it isn't fair, and not everyone gets dealt a good hand. I've had plenty of kids with poor outcomes from heart disease, the flu, and just about every other thing possible. It exists in adults too. It exists in the EDs, adult ICUs, NICUs, floors, and so on. I think that in order to survive critical care you have to come to terms that a lot of patients are going to have poor outcomes, and be able to not take it home. We are able to recover many more patients, and give lifetimes back to so many of our kids and their families. Over the years I've worked with a lot of nurses who don't ever really handle the stress well, and ended up leaving the units or EDs. It isn't natural to see death and suffering like we do everyday, and they found that another care environment ended up being much better for them. If you do choose to leave the PICU don't think of it as a failure or weakness.

I think that it's just part of the business for hospitals that have unions. There is probably variation based on union contracts and state laws, but if your union has the right to strike then is it egregious that the hospital has the right to hire temporary workers? That's kind of the point though, you hope that you are valuable enough that the hospital will take you seriously and the you use that as negotiation leverage. But if the ask is too great or the value compared to temps isn't worth it then it is up to the hospital to decide whether to keep or fire the union nurses.

Do you have TNCC and ATCN?

I did the hour commute (a decent bit more than an hour actually) for almost two years. It wasn't fun but it can be done. Some HCA hospitals have a very poor reputation, some have a good reputation. Magnet status does not guarantee a good manager or a good learning environment. Also several HCA hospitals have magnet status. It's really hard to give good advice without knowing specifics of the who hospitals. A couple of things I would recommend thinking about. Which hospital provides a better learning experience for new grads. How easy is it to transfer to the ICU from the PCU unit. Who's hospital actually sees sick patients in their ICU, especially cardiac and sick fresh post ops?

It depends on the matrix but if we are down one nurse (as long as it is a float/resource) position and not a patient assignment we get your normal pay (1.5 for overtime, regular pay if under 40 hours, etc). If we are down two nurses they offer $10 an hour, down 3 or so $20, 4 or more $30. The powers at be of course have the ability to offer more or less bonus depending on if they think they can or can't get nurses. We are also offered credit for the cafeteria, movie/basketball/baseball/hockey tickets, and all other kinds of incentives if they think it will bring in staff. I wouldn't come in for $2 an hour, I could easily make more picking up a PRN shift in another facility.

The society of trauma nurses has a study guide.

Because the expectation of parents and family are just that. They aren't going above or beyond, but rather to not be present is to do less. When you become a parent the bar is set at the top. This isn't to say that the family doesn't have a hard go at it, but that is part of having a kid. Also you're the one who referred to "miracle baby stories."

I don't say this as an anti religious statement, but those aren't just miracles. Those kids are the result of the hard work, perseverance, and love from their nurses, docs, therapists, pharmacists, and every other member of their care team.

The hard thing about premies is that their NICU course may have little to do with their eventual outcomes. I have taken care of 23 weekers that code 5+ times and make it out without any serious deficits. I've taken care of 'healthy' 32 weekers who end up neurologically devastated. Recently I got to take care of a preschool aged ex 22 weeker who came in for an injury after playing. Neuro intact, no respiratory disease, no eye problems. If we hadn't always had a birth history I wouldn't have guessed he was a NICU kid, let alone a kid who was born under 500 grams. The record holder for our lowest birthweight kid is thriving and doing great. The assumption that premies are universally going to have poor outcomes or full term kids will all do well is incredibly flawed. And regardless we should always have compassion for our patients and their families.

Know your limits, know your emergency drugs and procedures, learn when to say no. Take advantage of every learning opportunity. Don't be afraid to ask questions. Don't be afraid to talk to the Docs. Don't get abused, but don't immediately withdraw from the harsh advise of the old-timers.

Another thing to consider is the massive difference in independence in between the NICU and PICUs, even if the latter cares for preemies. We will take premies as long as they present with serious congenital heart disease, but our management is very different than in the NICU. In the NICU small details are held with more importance than in the PICU, which often means that you have to talk to the NNP or Neonatologist before something so minor as even starting a new IV. Whereas in the PICU nurses have a lot of independence. We have very extensive standing orders and may have replaced several different electrolytes, transfused multiple products, titrated or started multiple pressors, and even runt the first several minutes of a code without a provider. More than just a matter of skill, the NICU and PICU have very different nursing personalities. Not only would I think about whether you could do NICU, but also consider if it is even something you want to do.

If an ED has ESI 2 patients waiting in the waiting room for any amount of time, but especially over 10 minutes, the leadership needs to restructure how the department flows.