Rural Hospitals

[Darkfield]

I live in the sticks but because I am an adrenaline junky and love high accuity, I work in a large hospital in a city. Sometimes we get transfers from other places to our ICU for higher level of care, and I start to wonder exactly what is going on out there.

What is it like to work in an ICU in a small hospital? Do you feel like you lose your skills because the bad stuff goes to bigger hospitals, or do you feel more competent because you see a wider variety of conditions (lack of specialty ICU's) and there aren't services for every condition known to man in your hospital? I am just curious.

We get funny things sometimes-we had a pt flown by helicopter to us-he was DNI/DNR. We often get people on propofol for sedation and dopamine for the propofol (running through a peripheral, of course). We once got a filthy, confused alcoholic whom the nurse insisted was on peritonial dialysis. When asked where his catheter was, she pointed to the fistula in his arm.

Of course, we have also gotten some very sick patients who have received more than competent care from their hospital, and especially from nurse in transport.

Anywho, just wondering what it is like in smaller hospitals.

[DixieJeanne]

I've worked in a small, rural facility. We always said we were "a jack of all trades and a master of none." YOu don't get to see enough of the same thing to become an expert, but you do become great at saving lives for a few hours.

We had the patient for 2-3 hours waiting for planes/helicopters to get there (the next closest town was 130 miles away and our hospital service area was just less than 10,000 sq miles). We had to manage to keep them alive without ANY specialists, special equipment, or experts in any field. Heck, we didn't even have ultrasound capability on weekends or evenings. No FAST scans for us. Our family practice docs and all the RN's did hte best they could with limited resources. I was very impressed with the care we did provide, even if it wasn't the best that could have been provided (such as if they were at a Level I Trauma Center, etc.)

When it snowed, it was even worse - waiting 5 or 6 hours for transports.

But the nurses there could work in any field if they chose to move. We would have to cover ICU, Med/Surg, Peds, OB, PACU, ER, and Cardiac - sometimes all in the same day. 16 bed facility with 5 ER beds.

So did I lose my skills? Yes and No. Did I gain invaluable skills? Absolutely. I always challenge people now who poo-poo on rural nurses to image stepping out of the ER and going to do a shift in OB. How comfortable is that for most of you (general you)? For a rural nurse, it's a weekly occurrence.

[RN1980]

i work in both kind of facillities, rural and larger city type. i use way more of my skills and exp. in the smaller rural icu, mainly because you will tend to lack the support staff that you will have in the larger type icu's. often during a critical moment or a code resp may not be able to respond and you may have to control the airway and even run the codes in the unit and floor until a doc gets in from the clinic or makes it up from the er (which may take awhile). as far as putting in lines, often it really take pulling teeth from some small town docs to drop a aline or central line in pts, so you may end up becomming pretty good at jugular and art line sticks yourself.

[Darkfield]

Nice! we can't put lines into anything but arm veins. That is something that is sort of suck about where I work; we see everything you can think of, but because it is a teaching hospital, we have to let the residents do everything. They run the codes; anesthesia intubates, never respiratory, although that is changing.

Thanks for your replies.

[RN1980]

i know it, i use to work a weekend prn shift at our state teaching hospital, i found myself becomming a fancy operator and go get'er during the codes and rapid responses cause of the residents. one day during a rapid response on one of the med floors, i was lucky enough to place a ej iv site on a chf woman, much to the suprise of the 1st and 2nd yr residents and med students. they inquired where/when i learned to do that skill, i told them about 3 wks into my nsg program..i left them with their jaws wide open. after much proding by the residents that weekend i finally relented & told them our anesthesia dept taught us and checked us off on yrly competent evals.

[rgroyer1RNBSN, BSN, RN]

I do EJ IVs all the time in our ER and TSICU, but then again Im one of the shift coordinators and charge nurses so Im always called for the difficult sticks even though its a teaching hospital and level 1 trauma center, but I still use my skills regularly.

[Crispy Critter]

I have worked in both large teaching hospitals and small rural ones. I agree-in teaching facilities, there's always a resident jumping in to do the good stuff and ancillary departments also horn in on the fun. In small ERs and ICUs, you have to work twice as hard to keep someone alive or from crashing-because it's all you, baby! I have intubated, run codes, placed EJs, ECGs. Sometimes it's scary when the helicopter is delayed. But all the rural ER nurses I've known have been very sharp with a wide range of skills.

[TylerDurdenRN]

I agree with everyone above, I work in a facility south of multiple Level 1 hospitals and a major University teaching hospital. I admit we do send a lot out to them by helicopter and ACLS ground transport due to lack of specialty surgeons and limited weekend MD's for specialty cases. But when these "tough" patients are at our unit, we are basically left doing ALL the care, running the code, assisting or placing lines (we do have training), intubation, everything you can think of. So I have to know at least a little of everything.

On the other hand, we don't see they crazy stuff as much as the big facilities for the same reason, so although I may see a little of everything, I don't get to have it everyday and thus I don't get to really master everything I perhaps could at a larger facility.

So really, although we both are ICU RN's, its a different kind of nursing, while being very much the same. Both are extremely highly qualified. In fact at this time I'm looking to get into the major hospital to increase acuity to sharpen some of those skills while remaining at the rural contingent, which will help me, and my co-workers as I can bring back my learning and teach them, helping us and the patient.

[RNforLongTime]

I work in a small community hospital ICU. We have 6 beds. The entire hospital is licensed for 200. There are two floors for psychiatric patients, a 6 bed OB dept, a 10 bet acute detox unit, a 38 bed general med-surg ward, a Transitional Care Unit and a special elder care unit.

I work in a general ICU so we get a little bit of everything. GI bleeds, overdoses, bowel resections, R/O MI's and whatever is deemed necessary. Sometimes we get patients that really don't need ICU but the floor is 'too busy" so they send them to ICU instead.

There is always at least an ER dr in house as well as a first yr Intern House Officer. I work night shift so I am Respiratory Therapy on night shift. I draw and run my own ABG's. I run my own vents. I put in IV's, run drips, etc. We don't do a lot of Swan's and definitely no CRRT or IABP's. So, while I've lost some skills, I've gained others.

We also do not have any ancillary staff so I am also the Unit Secretary and Nurses Aide...i.e. I provide total care to my patients.

There are two larger hospitals within a 5 mile radius of where I work. We transfer patients out to those facilities often, i.e, for positive trops that need to go to the cath lab STAT, Brain bleeds as we don't have a neurosurgeon available. We dont' have a Peds ICU in my town at all so there are times where kids have to be flown to a Childrens Hospital.

I have been cross-trained to OB and have assisted in deliveries in an emergency situation, like a mother coming in dilated to 9cm and ready to push within 10 minutes of arrival and the on-call OB nurse(there is always ONE in house at all times--same as when ICU is closed, there is always one ICU nurse in house) hasn't made it in yet, I've gone down to help out in a pinch.