Aliakey

Type1Nurse wrote: "...level 2 and we're ALWAYS short staffed (typical RN to pt ratio is 1:12)..." 1:12??? I really have no idea how you folks do it. I was working in a financially-strapped, busy level 2 and could only hang in there for 6 months before I realized if I don't get out of there, I was going to kill a patient or more likely, myself. I went back to working as a paramedic with my busy 9-1-1 EMS and really could not be happier... I may have three patients at once in the rig, but usually only one needs more than basic level interventions. If anyone is receiving Cardizem, CPAP, or needs to be intubated, I will have only that one patient, lol! While I don't regret acquiring the massive amount of nursing education and still feel proud about passing both the NCLEX-RN and CEN the first time around, I do feel like a failure as an ED RN. Our ratio was 1:4; not sure if having the AMI, acute CVA, renal, and ventilator-dependent pneumonia patients all at once was the breaking point or not. Many techs were laid off, radiology was a skeleton crew, and a new computer EMR system in place seemed to generate more headaches than cures. Am I scared of returning to nursing? You bet. I am in no way trying to hijack the original poster's thread, but wanted to say I know how you feel and I also really appreciate reading the replies from others. Is the emergency department supposed to be a place where you test a 12 hour+ bladder, are running so ragged that you may get three quick sips of water in during an entire shift, and develop an interesting set of varicose veins to show off to friends and family? "Time management is the key"... been drummed into my head and was well understood. Too bad the nurse call buttons, pharmacy delays, and admitting docs never heard of that key. I really have a whole new degree of respect and admiration for emergency department nurses! Those are not easy shoes to fill!

Flightmed123, I do apologize for running off topic with my post above. I do admire your motivation and your desire to help others lead healthy lives, and do wish you the best of luck in the path you choose to pursue!

Horse excrement... where in the world did you get your ER RN perspective and information?!?!? I am an EMS paramedic (and happily remain so today). I am also a fulltime ER nurse. However, there was a serious "wake up call" when I started at our 40+ bed ED; no sir, your statement that "medics could do the same thing" simply does not apply. Paramedics are skilled in many things that works well in the emergency department, but the standard-issue paramedic is no replacement for an RN. I can only hope you posted all that to troll. While paramedics do tackle a lot of that initial critical medicine in the field and can work a code in the ER like no one else, we're horribly deficient in the meat-n-potatoes of nursing. Everything from patient education to a whole mess of medication administration to not letting the doctor accidentally kill the patient lies in the hands of the RN. If the doc orders an inappropriate medication or treatment and we don't catch it as nurses, we are just as responsible for that patient's demise. The emergency department physicians are overworked and they do make mistakes... daily. As an RN or physician, precious time is very limited, but the number of patients you care for at once is usually not. I'm sure I'll never change your mind, and that's really not my goal anyway. But this propagation of "nurses only wipe butts" mentality that seems to plague rookie paramedics and EMTs has no place. No wonder we earn little respect as paramedics when our own "professionals" are vomiting out false information.

About $8000, and that's with buying new textbooks (can't stand highlighter-painted pages found with used books) and living only a half-hour drive from my CPNE testing site. The CPNE was passed on the first attempt (so, no retesting fees), and I did purchase the practice exams for most of my EC exams. Paid all out of pocket, since I was shifting from EMS to nursing.

(Emphasis on "proving" is mine) Not to shoot off-topic, and maybe I'm reading into this too much. But, while I do see some "textbook smart" students struggling with clinicals from time to time, I don't see it as an accurate gauge to whether they will be the worst nurse. And vise versa. It really depends on the student's learning style, dedication they are willing to commit to learning the skill, and how the preceptor/instructor handles their style of learning. I have always been a visual learner... so much so that I simply "don't get it" if my only educational resource is a lecture or other auditory style of learning. I was horrible in my skills labs and patient care as an EMT-through-paramedic student; took me forever to finally get venipunctures figured out. I know I am not a kinestheic (tactile) learner, by any means. Luckily, I could basically zone-out during lectures as we had excellent textbooks to use, and I was also very fortunate to have clinical skills preceptors that knew when given enough time and practice, I was very capable of mastering skills. I doubled my paramedic rotation hours on the ambulance by my own choice in order to catch up on my skills... from 240 hours to nearly 600 hours (unpaid of course). I passed my skills exam for National Registry without any failures, and today I can competently perform skills at the level of any of my coworkers. As an EMT-P to RN Excelsior student, I quickly recognized the benefit this program offers to the more-visual learner. I was in my comfort zone; no lectures, and I loved my many 1000+ pages of textbooks. However, learning the skills for the CPNE and other areas of nursing was a bear, and I know it took me a lot longer than many students. I feel really bad for the traditional brick n' mortar nursing students who are not given SimLab time as needed (if available), and then are expected to master a skill and pass their clinical with some preset number of attempts. The skills can be mastered; it takes effort and patience. I've precepted enough dedicated "textbook-smart" paramedic students to confirm that this is very possible. I'm not trying to hijack the thread or start an argument; I'm just asking that as nurses and future preceptors yourselves, please don't discount the dedicated slower skills learner and assume that they will turn out to be a low-quality nurse because "they are only textbook-smart". The best nurse not only learns the skill, but also has the education and knowledge to know why he or she needs to use it. Physicians aren't perfect, and our education protects the patient from potential harm. Competency in skills protects the patient as well; the best nurse is competent with both. Anyway, just my inflated few pennies' worth.

There's been a few threads in the past about an RN to EMT or paramedic... unfortunately, I remember at least one getting kind of debated badly enough that I stopped reading. I hope this one doesn't go that way. I am a paramedic and an RN (paramedic earned first). I love the EMS side of the world, and yes, you'll have an abundance of knowledge as an emergency department RN that would be redundant in a lot of material covered by lecture. However, in all honesty, there are some things that cannot be taught by a lecturer or by books. The ambulance rotations are important, and on the paramedic level in our area, require many hours of your unpaid time (at LEAST 240 hours for our college). ACLS can be a beautiful sight in a hospital setting; it gets a little less perfect when working a cardiac arrest in a roach-infested crowded hotel room surrounded by burnt spoons, well-intentioned police yelling at the crazed meth-head, other "friends" getting in the way or adding to the chaos, poor lighting, intubating on that nasty floor with a cervical collar in place, and so on. On wrecks, I love having nurses on a scene if they happened to be a bystander when the wreck occurred and offer help, but like other bystanders on scene, their safety must be monitored. It's a bit of a different world. We have RNs in our area that need to at least earn their EMT-Basic (and preferably their paramedic) in order to work on a flight service, since they are considered as "air ambulances". Some really scoffed at the clinical requirements initially, but then after completing their hours noted that they saw it in a whole new light. Clinicals aside, you'll also have to consider the state's educational requirements as well as National Registry's, if your state uses it for initial and/or continued certification. The National Registry (NREMT-P) exam for the paramedic level is not easy; in my opinion, it was more challenging than the NCLEX-RN. I renew my NREMT-P by taking the exam every two years (you have other options as well, such as 48 hours of a refresher course, etc. instead of the exam), and that tacks on over $100 in test fees alone to my expenses. That doesn't include the state recertification fees I also have to pay every four years in addition to the exam fees. Also consider that you'll need to earn Continuing Education to maintain your EMT certification or licensure, which may be independent of your RN continuing education courses. However, we have a number of conferences that allow you to earn both in our area, which makes it easier. And finally, liability insurance. As a paramedic with no dings on my record, I paid HPSO $170 per year for coverage. As an RN and Paramedic, I now nearly double that payment to cover both professions. Not trying to scare you off from pursuing certification or licensure in the EMT field, but just wanted to shed some light on why I feel some areas of the education should never be shortchanged and also the extra financial and time obligations you'll incur with this profession, whether you're working as an EMT/paramedic or not. Hope it helps!

I was originally from California, but don't live in Austin or anywhere near it. However, I can offer some helpful comparisions with the cost of living for both states. In California, you pay a state income tax. Ouch. Also, property/home costs (the building and utilities) tend to be higher, and fuel tends to cost more due to the added environmental taxes. In Texas, there is NO state income tax (BIG savings there), but depending on the locale, property and sales taxes can either be equivalent to or a bit more than California. In my area (west Texas), the cost of living is below the national average, sales tax is 8.25%, property tax (county) is about 1.5% of the appraised value each year, and the average cost of a nice home with an actual roomy front and backyard (unlike California's postage-stamp lots) ranges from $120,000 to $200,000. I'm sure Austin's housing market is more expensive, but don't know by how much. But, try finding anything like that in the Golden State, lol! Food and other store purchases are about equal between both states, in my experience. Overall, I'm getting a better deal as a nurse here in Texas; clean air, open space, friendly people, a fair pay rate, and less bureaucratic hassle. The disadvantages I've found here in my area are the repercussions that may occur from that lack of regulation (still remember the bad massive tire fire at an alleged "recycling center", and yet I hear the operation continues as usual) and no oceans/mountains within driving distance of each other. I was from the Sacramento area, so that was an adjustment. Hope it helps!

I tested and passed my first time around in Lubbock last September. The examiners and Clinical Associate were all very fair and very supportive, and there was plenty of patient variety at the Covenant Womens and Childrens Hospital for testing. As you can infer from the name, you will have a pediatric patient (no adult substitutes); the hospital itself is very well maintained and updated. The skills lab is held in a different building a few blocks away that is associated with the Covenant medical system, and there was plenty of room to perform skills on Friday. Supplies are fresh... I heard some accounts suggesting that there were crunchy/crispy/crackly supplies (waaaaay over-expired) at a different CPNE testing site in the south. Not the case in Lubbock at all. The patients are not textbook perfect, but I personally believe part of your nursing exam should test your ability to handle little weirdnesses that can pop up, as long as they are fair and within the scope of the CPNE. All my patients fit within those constraints; some better than others I have to admit, lol! But again, you do have CAs and CEs that want to see you succeed, so I can honestly say they did everything they could within their power to make the exam very fair. However, they will not make the exam easier for you. You HAVE to know what you are doing, be flexible if something does not go quite as planned, KNOW how to build your nursing diagnoses and care plans, and most importantly, manage your time effectively. When I practiced on my dummy patient "Fred" at home, there was no time allotted for walking to the med room, preparing medications, assisting with ambulating a patient who had a mindset of beating her hallway distance record now (never later in the afternoon, lol!), and so on. Your patients are human, and you must know your stuff. I was the only one who passed in my group that weekend; all of us were first-time testers. Not bragging here, but just emphasizing the difficulty in the exam itself when working with live human patients that you do not personally select. Getting back to Lubbock... there's several nice hotels/motels within walking distance to the hospital and skills lab facility, and at least one does shuttle with a van for their guests (the one recommended by Excelsior in their acceptance letter to the Lubbock site). The weather is always changing, but usually dry and windy this time of year. Be sure to pack a coat/jacket. We had snow last week that followed with 80 degree temps and wind the next day. I live near Lubbock; please drop me a PM if you want any further information as long as the questions don't violate Excelsior's policies. :) Good luck!

I'm a paramedic and graduated from Excelsior in November. I really enjoyed all there was to learn from the Excelsior curriculum; never knew there was *so* much to learn about nursing until I really got into the thick of the program! There are some notable differences between paramedicine and nursing. As paramedics, we learn a lot about a very narrow segment of the healthcare picture... emergency medicine without the benefits of all of the diagnostic tools and such in the ED. As paramedics, there is a heavy emphasis in making as accurate a field impression as possible with information we can squeeze out of the patient. We can even blurb out ACLS, PALS, ABLS, and other algorithms in a drunken stupor off shift (okay, maybe that's a Texas thing). Paramedicine is a very important segment no doubt, but in nursing, now everything is far more detailed beyond the emergency setting borders. You will be expected to dip into the many jars of diseases, medical procedures, nursing expectations, pharmacology, etc., and while you are not expected to become an expert in mental health nursing, renal, etc., you will need to gain a solid understanding. I loved it, but it does require a LOT of reading and time to grasp the concepts. It took me nearly two years. Your mileage may vary. The transition from paramedicine to nursing was interesting in regards to the CPNE (your clinical exam weekend with real live human patients). As a paramedic, you should have no problem defining your priorities, asking patients the appropriate questions, and performing your assessments and medication skills. You've seen a lot of the "weird" stuff out there already, so a colostomy or recognizing an infected wound is not going to be a problem. Personally, what I found more challenging was the sterile field preparation (beyond what we do in the back of the unit for sterile suction), assessing the *entire* patient (not just a focused assessment), time management when caring for your patient, and most importantly, care plans. I never even heard of care plans when I began Excelsior, and that is a big component to not ignore. A number of my fellow CPNE testers (also paramedics) did not give serious time and practice to care planning, and it really hurt them during the CPNE. Excelsior is very doable, given time, plenty of studying, an open mind to the nursing process, and focus on the weaknesses (care plans). I also found the NCLEX-RN exam to be easier than the National Registry (if your state requires that certification); I took my renewal NREMT-P exam and the NCLEX-RN three days apart because I apparently like pain, and quite honestly, the NREMT-P seemed more difficult.

I've tried a couple of different browsers, but as of the time I write this, your strip is not being displayed (errors in the link?). Are you seeing predominately-negative complexes like those shown in leads II and III in this image below? In short though, you may find a predominately-negative QRS complex to be a normal finding in certain leads (such as aVR or V1). Or, it may suggest the presence of a new or chronic condition, which is why serial ECGs are so important. Changes in the axis also depend heavily on whether certain leads are predominantly negative or positive. A pathological left axis would have a predominately-negative lead II and III (like what you see in the image above), and I'd want to search more with the other leads or increase my concern if the patient is symptomatic. For example, a patient with a more predominately-negative QRS in lead II should have you looking for a qR complex in the leads I and aVL and also an rS pattern in leads II, III, and aVF (inferior leads). You are looking at a possible left anterior fascicular block in this case, which may be normal for an older patient with a chronic history of hypertension and coronary artery disease, or a younger patient with a cardiomyopathy of sorts. Or, in about 5% of cases, this can suggest an inferior myocardial infarction (usually if supported with signs/symptoms or other ECG changes). Without knowing which leads are involved, its hard to say whether the negative orientation is normal. Could also be something that is a face-slapper , like incorrect lead placement (for example, the normally-negative QRS of lead aVR is positive... may be a lead switch). Since I have no affiliations with this site, I hope it's okay to post this link to EMS 12-Lead: : Site Index : | EMS 12-Lead This site offers a wealth of practical ECG interpretation information geared towards paramedics (since we can't really consult a cardiologist in the field before initiating treatments ), but obviously great information for anyone learning 12-lead interpretation. Hope it helps!

As a poster who mentioned that I was the only one in my group that passed that weekend, I do want to add some additional information so that is not 100% discouraging to those considering the Excelsior route. Our group comprised of three working paramedics (myself included), and the others were LVNs. Only one person took a workshop before the CPNE... it wasn't me. However, he had nothing good to say about it. To be quite honest, I wonder if the other two paramedics spent much time with care plans or the details of the lab stations. We don't write careplans in our field (our documentation is very different) and there is the problem that since we often deal with IVs, injectable meds, and such with our occupation, we may not study the way it NEEDS to be done during the CPNE exam as thoroughly as we should. Add some nervousness and the timed aspect of the station, and that becomes a big problem. What I feel helped me pass: First off, I chose to take the EC Pathophysiology exam since I needed the units, and that helped A LOT with understanding the patient's condition and what would work as a nursing diagnosis. While taking the exam itself is not necessary, at least get a good handle on pathophysiology from your required nursing textbooks (Fundamentals and the Med-Surg books). Since the day I received permission to sign up for the CPNE, I visited the CPNE discussion forum on the Excelsior site several times a day to learn about careplans and CPNE tips. I submitted every practice care plan I could to the Excelsior advisors for their critique, and also submitted a few care plans to the discussion board for others' thoughts. I implemented the requirements of the lab/skill stations while I was caring for my patients on the ambulance at work (my EMS partner was very accommodating to my more time-consuming ways on our non-critical patients :) ). Almost every day for the last 3 months before the CPNE, I spent at least 30 minutes on a "mock patient" so I could know my critical elements inside and out. I bought the skills kit and set up my labs in the kitchen. And, I tried to think of "backup nursing diagnoses" and practice a care plan with it in case one of my CPNE patients was relatively problem-free, which helped with one of my adult patients during the actual exam. As a previous poster confirmed, the patients will not be textbook-perfect. But, *you* need to be. And, patients are human. Some patients will like you, and some will not. Some patients are enthusiastic about the extra care and attention they are receiving (and knowing they are helping a student nurse's education), while others require some creative interaction (my pediatric patient, for example). All this while being timed, of course. Back to the other students that weekend. One LVN only read the CPNE guide twice, and never set up a skills lab at her home. She never heard of the CPNE discussion board on the Excelsior site. And, the CPNE was the first time she ever laid hands on a piggyback infusion. However, I learned that this student passed the second time around; she took a workshop, set up a lab at her home, and practiced daily. Another student blew off the importance of the nursing diagnosis, not seeing the importance of it since he never saw it used in the emergency department where he worked as a tech. I don't know if he or the others attended workshops or passed on their next attempts. A long post... sorry about that. Just want to reassure that the CPNE is not impossible, but it's also difficult to offer a perfect exam situation beyond the skills lab due to the fact that we are dealing with live, human patients. And that imperfection can sometimes cause great students to have to retake the CPNE. It's the hardest practical exam I have ever tackled, but also gave me a hellava lot of respect for those nurses who graduated from the Excelsior program. The largest two hospitals in my area are very accepting of Excelsior graduates, and there was no problem at all finding my perfect job after I obtained my RN.

Just my humble opinion here: I'm an RN, a paramedic, and have worked as an ED Tech and yeah, there are bad apples that ruin the whole lot. The way this problem was fixed where I worked years ago was to clearly outline the expectations of the techs with chest pain patients, during a code, whatever. In other words, give them some sort of "protocol" and expect it to be followed. Protocols are a paramedic's bread n' butter, but our sense of autonomy in the field sometimes gets us into trouble in the ED if that clear direction and expectation to follow it is not offered. I'm not saying to treat the techs as trained monkeys, but looks like from the original post that there's some clear lack of guidance from the powers above. When my EMS Medical Director says you will not walk ANY chest pain patient in the field, we obey. Simple. The ED needs to offer these guidelines to their techs as their protocol, and respectfully enforce them. A few kind words to those techs who do abide by the guidelines goes a long way as well.

I'm sure you've already read through the author guidelines at American Nurse Today What I find strange is that while they are a peer-reviewed publication, they actually limit your reference citations to 5 or 10 as a maximum (depending on publication purpose/availability mode). Straight from their web page offered above: That is very unusual to me; I've never encountered such a strict limitation in well-respected journals. That actually makes your job more difficult, as you'll have less published expertise to lean on as support for your observations (I still can't get over that limitation ) While on the topic of references, I'm sure you know this already but would bear repeating for others considering publishing... go beyond the abstract. Pull the actual publication and read it. I have found more erroneous interpretation of results in the last decade that slip by and are published, although the abstract paints a glorious picture otherwise. Kinda scary. Good luck to you, and thank you for contributing to the knowledge base!

No question I would do CPR. No pulse. No DNR. I'm doing everything I can for you to offer that second chance in life. As an off-duty paramedic out of my region, my scope is limited to BLS unless ALS assistance is requested by the responding unit and approved by their medical director via radio. As an RN... far more limited, but I can still push on that chest. Even if good chest compressions offered only a 30% of the normal blood flow... it's *something* productive. Otherwise, I'm not sure how my ACLS medications are circulating, hitting the right spot with a non-shockable rhythm, and by some miracle, my patient regains a pulse before we even move the patient to the ambulance. Understandably, chest compressions are not the ideal, perfect treatment... but short of opening up the chest, its what we have and is far better than nothing at all. I'm not near the end of my life yet (I hope) and do not have a DNR. I would hope that if I hit the floor without a pulse, someone... anyone... would do chest compressions and if it happens, "break my ribs" (or whatever) to save my life, so be it. I'm recovering from 9 broken ribs right now and it's no cakewalk, but beats the heck out of decomposing six feet under any day :).

Absolutely. I just filled out my Press Ganey survey a week ago since I was recently hospitalized. I definitely remember the washing hands question... and it wasn't asking if the healthcare provider used a waterless cleaner, but if they "washed" their hands. That question kinda stuck with me for that reason. The hospital room I was in (med surg floor) had two sinks... one in the bathroom, and one just across from the bed. And the nurses, nurse practitioner, and patient care technicians all washed their hands as soon as they entered the room. Can't say the same for two of the physicians.