nursenary57

Everybody here has made great points. I've only been in school for 6 months (about 130 cases so far) and there are definitely extremes. One day it is cysto after cysto (some done in 20 minutes, some up to 45) and then the next day is an open belly for a bladder tumor with creation of a new bladder from small intestine plus a prostatectomy. God only knows what else they did in there! The only time I have felt bored is on those all day cases where you have got your agent dialed in just right and VS are railroad tracks. To combat that I pull out my Mass Gen anesthesia handbook or whatever I've got with me and study up on something I haven't looked at in awhile. Of course I'm still watching VS, UOP, blood loss, end tidal CO2 and listening for any wayward expressions from the surgeon such as "Oh crap." Depends on what surgeon you are with you can learn alot about the surgery itself. I just finished a rotation at a large teaching hospital so he was already talking about stuff to the med student and residents. Learned a couple of things but not as much as I wished I had. I'm actually looking forward to the point where it becomes boring. Hopefully that means I won't be scared to death everytime I walk in there! When I got out of nursing school I would look at the older RNs and think "When am I gonna feel comfortable with my knowledge/skill/experience level where I can come in to work without being scared to death?" I feel the same way now. I'm sure it will be awhile before I get there.

Hey guys! I'm not dead. Brain dead maybe. Just finished week 3. Through 6 quizzes/tests I'm still clutching onto an A. Got two weeks left on this initial orientation period and then I'll be in the OR on 8/28. Thats when the fun starts. We average 4-6 tests/quizzes per week. Keeps us on our toes. The first two weeks were rough. We were in class 12 1/2 hrs one day. Spent at least ten hours in class on a few other days. Sitting there is mind and butt numbing. Regular class begins 8/28. Class is 1pm is Mon-Thurs. Class usually ends 6-8pm. In the OR Mon and Wed 6am-noon and all day Fri. The next week class is the same but I'll be in OR 6am-noon Tues and Thurs. It alternates like that so I get a three day weekend every other week. I've got to get back to studying. My machine check, RSI, Bier block, and spinal anesthesia checkoff is coming up. I'll check in soon.

I'll update you guys on the weekend. Kind of busy right now!

Hey guys, I'm starting my anesthesia program Monday, July 24th. To say I'm nervous yet excited would be quite an understatement. The percentages on each are variable, just like Owen Wilson said in the launch scene from Armageddon "I've got that excited scared feeling. But 98% excited, 2% scared. Or maybe its more, it could be 2, it could be 98% scared 2% excited. Thats what makes it so intense, cause its so confused. I can't really figure it out." Yeah, that pretty much sums it up for me. I'm attending Middle Tennessee School of Anesthesia in Madison. It is a 28 month front loaded program. First twelve months is majority of classes along with clinical 3 days a week. Last 16 months is OR all the time. First 5 weeks is an intense pre-OR orientation that introduces us to settig up the OR and the anesthesia machine. We also recert in ACLS, PALS, and 12 lead EKGs. If anybody out there is gonna be a classmate of mine, drop me a line. I'll keep you guys updated on how it goes. Good luck to those in or trying to get in.

I understand you getting upset about the difficulty of getting IVs in the "hard sticks". I used to work in a high volume Level 1 trauma ER. The hardest thing about that job was that we were incredibly busy and it sometimes took a lot of time to get an IV started on those spider veins in these patients. We have the same 2 sticks per RN protocol but unfortunately due to how busy we were that was not always followed. Even though it was a teaching facility our docs were reluctant on going forward with central/PICC access unless they were extremely sick. We didn't have anything like midlines but we were allowed to do external jugular IVs. Usually and 18 or 20 guage and it gave a great return and flushed well. No need for xray either due to the short catheter. But keep your head up and keep sticking!

Walec, No problem. I'm glad to help. PM me anytime if you have any questions. If I can answer them I will. If I don't know I can come up with a pretty good lie!

Walec1, I understand your nervousness, especially since I just went through the process in January. I'm very fortunate that I only had to do one interview and I start school in July! The key to getting through the interview for me was to overprepare. Probably not what you wanted to here. I talked to many people who had attended/was attending my school of choice (mtsa.edu). I learned about the type of interview that the school did and what they expected. Some of these people had interviewed at several schools and talked about the vast differences in style of interview. Some were basic meet and greets while they looked over your transcripts. The school I'm going to has you present a patient you have recently taken care of and they ask questions after that. My interview was 5 questions in 7 minutes. Yeah! A nerve-shattering time! Almost all of their interviews average less than ten minutes. So after gleaning all of the info I could from former/current students of the program I made out a study plan covering the things they mentioned. I wrote out answers to possible questions and reheorificed them over and over again. Whats funny is the best practice I had was when my roommate and I would toss the football around and ask each other random questions and practice our answers. Ex: What is the difference between Epi and Primacor? Why would they be used together? What are the parameters for weaning off the vent? If you see these Swan numbers what type of shock do you think the patient has? Blah, blah, blah. I could go on and on. This constant repetition of answering aloud is what got me over the fear (well, the majority of it anyway) of interviewing. So when I got in the interview and they asked a question my answer just flowed out because I had already practiced it a thousand times. So talk to people at the program your interested in and find out what the interview comittee expects. Mine was invasive hemodynamic monitoring, vent management, and vasoactive drugs. The drugs being the big deal. Had to know them to the cellular level. And I don't mean saying "Neo acts on alpha-1 receptors." That was just the beginning. It went way deeper than that. Try www.cvphysiology.com and www.cvpharmacology.com. Physiology book by Linda Costanzo also. To sum it up (finally), get the inside scoop on what type of questions they ask and write out your anwers to different scenarios. Have a friend throw questions out there for you to practice saying those answers aloud. Then do it again. And again. And again. After all that remember this: Repetition is the key to mastery. Good luck. You can do it.

Holy crap! I just figured out Artemis2 identity! I used to work with her! When I was waiting for shift change and I would see her walk through the door inside I would say "Thank God, someone who knows what they are doing and I can count on!" I learned a bunch from her and miss having her around. Thats why I tote around that bag full of books, because nursing school didn't teach me anything but Artemis2 did! Guys, you can ask her anything. I did get your email so check it when you get the chance. Great to hear from you!

Artemis, That was a great post. Wish you had been my preceptor when I got out of school. You took a complex process and made it simple. Or as I like to say "You rednecked it down for us commoners." You titrate by drops? Sounds like you've been in this game for awhile! I do have to disagree with one thing though: Levophed actually does have cardiac/inotropic effects. At lower infusion rates it has effects on beta-1 receptors, therefore causing increased cardiac contractility. I found this passage about Levophed on p.321-322 from Hemodynamic Monitoring: Invasive and Noninvasive Clinical Application by Gloria Oblouk Darovic: "Norepinephrine is a catecholamine with predominant alpha-1 and some beta-1 adrenergic stimulation. Norepinephrine causes constriction of all systemic arterioles except those of the coronary and cerebral circulations and produces direct inotropic and chronotropic cardiac stimulation. Uses- Norepinephrine may be given in the treatment of cardiogenic shock. Although the drug increases myocardial contractility, this effect is often offset by the systemic vasoconstrictor effects (afterload increase) that limit any rise in stroke volume. Increases in afterload may increase myocardial oxygen requirements, which may be a significant problem in ischemic heart disease." I learned about this when I was studying for my anesthesia interview. The unit I currently work at doesn't use Levo often so I studied up on it for my interview in case they asked. Before then I had no clue that it had beta-1 effects. Its amazing what one can find in textbooks!

I interviewed Tuesday morning around ten and they notified me Wednesday afternoon. That made my night at work go alot better! Most of the class (total 70) were accepted at early interviews last fall. There were 90 people for the last 23 slots. I agree with being sick of nursing theory but I'll jump the hoops if I have to.

Hey guys. I just found out that I got accepted to the 2006 class of Middle Tennessee School of Anesthesia. Just wondering if any of my future classmates are out there wandering in cyberspace. Good luck to all.

Browndog, You are right about Nashville pay ranges. I work at Vandy and Baptist. If you want to chat more about it you can get me at [email protected] I've got to work tonight but if you send me your email I will try to answer any questions you have got when I get home in the AM. Pyke

I did a 2 month travel contract in their ER last summer. Nice ER, good equipment and clean too. The staff I worked with was great. Out of all of the staff there were only two for whom I didn't care to work with (Sondra can probably name them). The charge nurses were on the ball but damn that place was unorganized! It is a level 1 trauma center and I have worked at another level 1 for two years prior to going there. To say there is a difference would be the understatement of the century. Let me put it this way, if I get injured in East TN, screw the golden hour and take the extra time to fly me to Erhlanger in Chattanooga. I want to make clear that I'm not downgrading or disrespecting the staff. There are a bunch of good docs, nurses, RTs, radiology etc. Most of these folks were knowledgeable and good at their job. But good God a mighty it was unorganized. I'm only gonna give one example (otherwise my BP will skyrocket and I'll be in the hospital on my only night off). At the level 1 trauma center I came from when we learned there was a level1 patient coming in (very unstable patient) this is the staffing we had to deal with situation. Primary RN, Secondary RN/EMT-P, RN to chart, Respiratory therapist, 2 rad techs, 1 ER attending, 1 ER resident, 3 trauma residents, 1 trauma attending, 1 trauma NP, 1 patient care tech, 1 social worker for family issues and CT cleared for the patient with OR notified to have a room ready. So probably 15 people within ten feet of the trauma bay ready to go. At UTMC the first level 1 I was involved with it was just me and a surgical resident. I could have bitten an oak tree in half with my orifice! That was the worst one. They had the ER set up better than Vandy but the trauma response was, once again, disorganized. In the ER they do team nursing which I grew to hate within about ten minutes of working there. If you don't know about team nursing, well, it isn't quite the same as teamwork. IMHO, it leads to screwups because continuity of care is compromised. I think they only had been doing team nursing for 6 months at that time. I only worked the ER so I can't tell you about the rest of the hospital. Once again, the people were great at their job and nice to boot, but disorganization hampered them. I won't pretend to know why they were disorganized. And if any of you guys from Knoxville are reading this, I had a good time and enjoyed working with you. Good luck with your move and decisions. Pyke

I work ER at Vandy and ICU at Baptist in Nashville. I would go to Vandy's med/surg floors. IMHO based on my experience you get better overall support at Vandy with patient's who take a bad turn on the floor and have to be sent to the unit. I have no experience with HCA hospitals except for a prn job in their psyche unit because I just couldn't get enough of the crazy stuff in the ER or my marriage! You might want to check out Metro General or St. Thomas. Did a clinical at MG and was a tech at St. Thomas for 2 years. I really liked St. Thomas, seemed like a nice place to work. Good luck with your decision. Pyke

I have experience in ER and SICU. My journey went like this - as a new grad I went to work in a level 1 trauma center ER. Scared to death of course but I learned more in my first three months than I did in nursing school. Full time there for two years and then PRN for the last 8 months. After I had been working for 18 months I applied for a PRN position in an SICU at a different hospital. Got the job but only a four day orientation! It is supposed to be longer than that but they kind of flung me to the dogs. I had taken a critical care course and did a lot of extra reading/studying before I applied for the position in order to prepare me for the transition. The ICU RNs would ask me what I knew about something (art lines, Swan numbers, ventilators, etc.) and I would tell them what I had learned from my reading. Their reply "Oh, you don't need any help, you know this stuff!." Hold up! I just regurgitated to you what I read in a book or heard in a class. I don't have the hands on or 25 year crusty nurse knowledge that I'm looking to get! Fortunately I work with some good people who helped me along. All that was to get along to my advice for the transition. I see everyone as an individual but I'm going to make some generalities here that correlate with my experience. So here goes... ER to ICU - In the ER you are a jack-of-all-trades. In general, you know a little bit about alot of different things. The big difference in going to ICU is the technical aspect. Swans, art lines, drains, monitors, balloon pumps, ventilators, etc. You will know a lot more about the patient's history and will come to understand pathophysiology because you will see these patient's with these conditions over a long period of time. (Notice how ICU nurses can be a pain in the *** about history when you call report with an admission...)The nurses who understood patho the best in the ER I work in used to be ICU folk. Be a bull about getting a great orientation. ICU to ER - You definitely learn ACLS (and PALS if you work with kids but it is a breeze compared to ACLS). IVs too. The big plus here is teamwork with docs. Don't have to worry about calling somebody and pissing them off at 3am when you just have to walk out of the room and there they are dictating. But the biggest change is pace. It is usually screaming along in the ER for almost the entire shift (once again my experience is working at 2 different level 1 trauma centers - I don't know the flow of a smaller hospital). Now the SICU I work in is in a large hospital and we get some pretty sick people but it is usually much slower pace. Usually. To help with your ER transition you have got to know where everything is because as long as you've got an airway box, ambu bag, suction, IV kit and some fluid you can make some magic happen. Or at least keep the grim reaper at bay for awhile. Going from one to other can be done. You just need a few things - 1) time management which ties directly into 2) critical assessment skills (in the ER you take a quick peek in the room and if they are breathing normally and not blue they can wait a sec), and 3) what the hell is this piece of equipment and how do I use it to make them better? Good luck on the transition. If you have any questions email me and I'll answer best I can. Nursenary57

Almost all units hire new grad RNs but I don't know about LPNs. Check their website out for current needs and their next job fair at www.mc.vanderbilt.edu Good luck! P.S. I'm pretty sure Baptist hires LPN new grads.

I celebrate this day by not going to work in that lovely hell hole this evening!

Interviewed there but didn't accept position. I work at Vandy and Baptist. I could probably answer questions about those places if you have any.

Interviewed there but didn't accept position. I work at Vandy and Baptist. I could probably answer questions about those places if you have any.

Etomidate and sux is what we use on nearly everybody. Not supposed to use sux on burns due to related hyperkalemia (sux combined with cell destruction increases K release 24-48 hours post incident if I recall correctly.) Etomidate is supposedly very good due to it's minimal effect on hemodynamics. Never used ketamine before. Need to learn more about it.

We have 3 trauma bays and we staff with 1 RN and 1 EMT-P (at least that is what it says on the assignment sheet!) When there are no trauma patients they float to the other assignments and help out with other patients. Of course if there are multiple trauma patients we pull from other assignments and do what you gotta to keep things going. Most traumas we have had at one time since I've been in the ER is seven. 2 were level 1s, 1 level 2 and 4 level 4s so it wasn't too bad. All from some interstate pileup. For the level 1s we have the RN/EMT-P or 2 RNs, a tech, a recorder, RT, ER resident and attending, 2 from xray, and the trauma service (1 attending, 3 residents and 1 NP). Quite a crowd. And another RN from ER lurking in the background to run the Level 1 infuser if needed. The trauma team doesn't use it much upstairs so most are not familiar with the operation of it. Unfortunately alot of the ER people don't know much about it either! I've probably used it 30 times max in 2 years. We definitely have room for improvement but I just finished a travel assignment where we had a level 1 trauma and it was only me and a surgery resident! Not their typical staffing but they were having a rough day to say the least.

I have been out of school for 2 years and I started out in a level 1 ER. It was the best experience that I have had. I learned more in my first three months there than I did in nursing school. I think being successful counts on 2 things: 1) You. Your attitude, willingness to learn and open to seeing how things are done by other RNs. After every shift I went home and studied the new things that I saw (I still do). I was one of five new grads that was in a new grad internship program and I am further along in my development than the other four because I did extra while they did not. For example, when we took ACLS I studied constantly while they spent their time hanging out laughing or *****ing about how hard it was. They were just happy to be out of school and when they went home they kicked back, had a drink and went shopping with their new paychecks. I went home, opened the ACLS book and studied for 2-3 hours. That doesn't make me smarter but it does make me better prepared. 2) Your preceptor. You have to have a good preceptor who is willing to train you, whether it be med-surg, ER, ICU, L&D, etc. A preceptor who remembers what it is like to come out of nursing school and being scared to death that you will do something wrong and unintentionally hurt someone. One of the new grads I started with had a preceptor who would chew her out in front of patients! "You don't know that? I can't believe they let you graduate without knowing that!" or "You never do that!" That is a horrible way to treat someone. The preceptor should know their pathophysiology, assessment, meds and procedures but none of that matters if they don't genuinely take an interest in your learning. I had awesome preceptors (3 different ones due to day/night shift and scheduling, all with 20+ years experience in ER ICU, L&D, OB, Cath lab, etc.) I can still go to them and ask about anything. And I didn't just stop at them. If I had a question I asked several nurses because they all have different experiences and learned different things. For instance, we have a large burn center so burn patients go straight there. I have seen 2 burns come in to the ED in 2 years. So how do I learn about burns? One of the RNs I work with worked burn ICU and she taught me a few things about burns. I took the Advanced Burn Life Support class by the American Burn Association. Now I'm going to work in the burn ICU to put the book knowledge together with the actual hands-on experience. Now I agree that experience is good and more experience is better. But that reminds me of a saying "Practice doesn't make perfect. Perfect practice makes perfect." You may choose the med-surg route and get stuck with ten patients with 15 meds apiece due at 0900 and an RN precepting because it is something she is required to do once a year. Or you may get incredible preceptors such as I did. I worked as a pharmacy tech for 2.5 years and I came out of school with a good understanding of pharmacology (though now I know what I really should have been asking the pharmacists). So I was ahead of most new grads in that area. But I wish instead that I had worked as a tech in the ER or ICU because I would have gotten more experience in the most important thing there is in nursing to know- seeing what a truly sick person looks like. Just like achieving any skill it requires repetition. Recognizing when someone is going down ("circiling the drain" is a term you will become familiar with) will put you a step ahead in knowing what needs to be done so hopefully you can initiate the right treatment to head off any problems. So I have no problems with a new grad being in the ER. Many factors will lead to your success or failure, with the main factor being you! ER may be right down your alley or you may realize that it isn't for you. Everyone has a niche. I wish you luck in your chosen path. If their is anything I can help you with just e-mail me - [email protected] and I will do what I can. Remember that preperation is key, because hope is not a strategy. Pyke