Accepted to RN bridge!

VFlutter

Flight Nurse
3,709
1,230
113
The hard truth is that the vast majority of HEMS is not critical care nor provides critical care experience. You may get great critical care education and exposure but nothing that will substitute bedside experience or make someone exceptionally competent.

I know there are many bases that likely go a year without seeing any invasive hemodyamic monitoring, mechanical assist devices, titration of 6+ drips, true ARDS, etc. Flying a vented septic shock on Levo is the tip of the iceberg.

I've had flight nurse friends whom are prior ER nurses apply for CRNA school and be appalled to find out many do not consider it critical care experience. Most who went to an ICU to get experience were surprised the learning curve was much steeper than anticipated.

While I am on a soapbox I also think ER experience should be specifically level one or two (maybe)
 

Peak

ED/Prehospital Registered Nurse
873
478
63
I've had flight nurse friends whom are prior ER nurses apply for CRNA school and be appalled to find out many do not consider it critical care experience. Most who went to an ICU to get experience were surprised the learning curve was much steeper than anticipated.

While I am on a soapbox I also think ER experience should be specifically level one or two (maybe)
Having worked in Level 1s, undesignated centers, and about everything in between I strongly disagree that you get better experience at a level 1 or 2 center.

To start trauma designation does not correlate to medical acuity, states do not require you to see x number of sick medical patients to designate.

Trauma is also one of the easiest things we care for. Especially in EMS and in the ED trauma care is pretty straightforward.

Nursing in a large level 1 means that you do little more than charting and organization. A trauma (and similarly themed for a very sick patient or a code) gets you attendings, residents, fellows, PAs, and so on from the trauma service, general surgery, and the unit. Your ED techs are typically providing what is left of the ‘nursing’ care not done by an attending or medical trainee. Typically pharmacy is drawing and mixing at the bedside, lab collects and sends off samples, et cetera.

Location also plays a big role. A rural center that has high volume is going to likely provide a better teaching experience despite being a lower trauma designation than an urban level 1 where there are multiple centers and patients are quickly taken to OR. As a simple analogy I get a much bigger price of the trauma pie when I’m only sharing with 4 other people instead of 20-30. Also keep in mind that a large number of traumas seen in a level 1 are transfers and have already had a fair bit of stabilizing by the 911 agency, outside ED, and transporting EMS.

It takes much longer to make your way to the trauma bays in a level 1 than a lower designation. It is easy to get stuck in fast track and the medical pods for years before you earn the seniority to work the traumas.

To the ED versus Unit bit, both are critical care just in different ways.

In the ED or EMS the vast majority of patients are not sick, we just have to prove it so we can discharge/treat and release them. A small number of patients are sick, but as they are typically completely unstabilized rapid recognition and treatment is mandatory. Most patients do respond well with basic stabilization, even if they are very sick. I’ve certainly had some patients we end up maxed on 4+ pressors and aggressive vent settings in an hour or two in the ED, but this is incredibly rare.

In the unit patients are (usually) very sick, although also they are typically much more predictable and sudden unexpected decompensation is very rare. Typically I know much more about my patient clinically, and we usually have a pretty good idea of how to manage patients. It is important to remember that not all unit patients are on the verge of death, and there is a fair number of patients who can easily be tripled and still be a pretty slow shift. Like EDs various units will see very different levels of acuity, and depending on the nursing and medical structure can present very different learning experiences for nurses.
 

VFlutter

Flight Nurse
3,709
1,230
113
Location also plays a big role. A rural center that has high volume is going to likely provide a better teaching experience despite being a lower trauma designation than an urban level 1 where there are multiple centers and patients are quickly taken to OR. As a simple analogy I get a much bigger price of the trauma pie when I’m only sharing with 4 other people instead of 20-30. Also keep in mind that a large number of traumas seen in a level 1 are transfers and have already had a fair bit of stabilizing by the 911 agency, outside ED, and transporting EMS.
I do concede that is very much regional and not black and white however generally speaking you do not get the same exposure at a rural facility. You very well may get better experience stabilizing patients with less resources which is great. "Fair bit of stabilizing" is relative and again regional. Most rural ERs I have been to do not routinely place central and A lines, REBOA, hold ICU patients for hours, etc and transfer out patients as quick as possible.

To the ED versus Unit bit, both are critical care just in different ways.

Most patients do respond well with basic stabilization, even if they are very sick. I’ve certainly had some patients we end up maxed on 4+ pressors and aggressive vent settings in an hour or two in the ED, but this is incredibly rare.
In most cases there is a distinct difference between ER stabilization and ICU level care. Rapid recognition and stabilization is a key skill in HEMS the 4+ pressor patient experience is more heavily relied from nurses and the rapid stabilization is part of the medics wheelhouse.

Again, maybe I am biased as we do a heavy amount of high end critical care. ICU to ICU transfers are a large portion of our flight volume. Some bases primarily to scene flights and ER to ER which is less of an issue.
 

Peak

ED/Prehospital Registered Nurse
873
478
63
I do concede that is very much regional and not black and white however generally speaking you do not get the same exposure at a rural facility. You very well may get better experience stabilizing patients with less resources which is great. "Fair bit of stabilizing" is relative and again regional. Most rural ERs I have been to do not routinely place central and A lines, REBOA, hold ICU patients for hours, etc and transfer out patients as quick as possible.



In most cases there is a distinct difference between ER stabilization and ICU level care. Rapid recognition and stabilization is a key skill in HEMS the 4+ pressor patient experience is more heavily relied from nurses and the rapid stabilization is part of the medics wheelhouse.

Again, maybe I am biased as we do a heavy amount of high end critical care. ICU to ICU transfers are a large portion of our flight volume. Some bases primarily to scene flights and ER to ER which is less of an issue.
Most large urban centers are not routinely placing invasive lines either, those that are mostly a function of teaching residents not nurses.

What do you thing Level 1s are doing for most of their transfers that wasn’t done PTA? I’d say 80-90% of the transfers I saw were basically just a basic assessment, maybe a CT that hadn’t been done, basic X-ray, and sending them off to OR/unit/floor.

I’m instantly suspicious of anyone that tells me that they have performed ICU care because they have held ICU patients in the ED. Extended hold times are a reflection of poorly organized health systems who value keeping patients ($) over what is typically in their best interests (transfer to an outside hospital with open ICU beds). It also reflects that said hospital needs to increase bed capacity or improve throughput, but hasn’t for some reason.

I don’t disagree that most flight programs need the nurse to provide an ICU skill set more than ED, at least in systems that run medic/nurse.

There is going to be a lot of program variability, but most programs are not transferring the sicker ICU patients. When the sickest patients are moved it’s normally done with a lot of planning, a specialty team, and taking additional specialized staff.
 

Akulahawk

EMT-P/ED RN
Community Leader
4,550
966
113
I’m instantly suspicious of anyone that tells me that they have performed ICU care because they have held ICU patients in the ED. Extended hold times are a reflection of poorly organized health systems who value keeping patients ($) over what is typically in their best interests (transfer to an outside hospital with open ICU beds). It also reflects that said hospital needs to increase bed capacity or improve throughput, but hasn’t for some reason.
Then allow me... ;) Have I performed ICU level care in the ED? Yes, on the ICU hold patients we've had. Have I performed good ICU care? Not a chance. It's not that I'm a bad ED RN, it's that I'm not an ICU RN. That being said, I do the best I can to get my patient over to the ICU where the experts can provide the care that I am just able to muddle through. Thankfully we usually don't have extended ICU holds in the ED. Those few times we do, we actually try to bring an ICU RN to us. We're good at what we do, but we recognize that we're not an ICU.
 
OP
F

FiremanMike

EMS Coordinator
693
337
63
So I have to buy an $825 online textbook package that I bet I never use..

I'm not buying their "nursing equipment bag" complete with bandage scissors, hemostats, and a ****ty double tube stethoscope.. LOL

I am looking forward to wearing pajamas to clinicals though!
 
OP
F

FiremanMike

EMS Coordinator
693
337
63
Can anyone comment on how much nit-picking there is on these exams, or is that program specific?

I'm plowing through these chapters (9 chapters by Monday) and trying to get a feel for what I should highlight versus what I can skim..
 

MackTheKnife

BSN, RN-BC, NREMT, EMT-P, TCRN, CEN
530
139
43
Can anyone comment on how much nit-picking there is on these exams, or is that program specific?

I'm plowing through these chapters (9 chapters by Monday) and trying to get a feel for what I should highlight versus what I can skim..
I won't say nit-picking, but you have to change the way you think/approach questions. You might read a question and one of the four answers is the definitive answer in the mind of a medic. But you have to think like a nurse instead. I'm sure you've heard by now the acronym ADPIE- Assess, Diagnose, Plan, Intervene, Evaluate. Assessment is usually going to be the first thing you do, so that will be somewhere in the answers. And there is usually more than one correct answer, but only one is the MOST correct.
Good luck!
 

akflightmedic

Forum Deputy Chief
3,519
2,040
113
Select all that apply....can kiss my arse!!

Such a stupid, stupid question format. LOL
 

MackTheKnife

BSN, RN-BC, NREMT, EMT-P, TCRN, CEN
530
139
43
OP
F

FiremanMike

EMS Coordinator
693
337
63
So far the unit practice questions haven’t been horrible, some “check all that apply”.. most have taken more effort to decipher than much of my college up until now..

I don’t do well with questions like “what is the second step of the critical thinking process”.. I do better with “describe the importance of the critical thinking process”
 

MackTheKnife

BSN, RN-BC, NREMT, EMT-P, TCRN, CEN
530
139
43
So far the unit practice questions haven’t been horrible, some “check all that apply”.. most have taken more effort to decipher than much of my college up until now..

I don’t do well with questions like “what is the second step of the critical thinking process”.. I do better with “describe the importance of the critical thinking process”
Don't forget Maslow.
 

akflightmedic

Forum Deputy Chief
3,519
2,040
113
Yes....because the correct NURSING answer will cater to those needs prior to other needs we as Paramedics deem more important.
 

ffemt8978

Forum Vice-Principal
Community Leader
9,573
525
113
Yes....because the correct NURSING answer will cater to those needs prior to other needs we as Paramedics deem more important.
This point bears repeating.
 

Capital

Forum Ride Along
8
3
3
Also, remember that nursing school exams are looking for the answer that only works at NCLEX Memorial Hospital. You have to leave real world answers behind for now. So aggravating :confused:
 
OP
F

FiremanMike

EMS Coordinator
693
337
63
So I'm 5ish weeks in, this semester is a transition to RN and a pharm class.. So far it hasn't been terrible..

There are a LOT of homework and exam questions that are essentially "What about XXX order/med in this patient would require you to question the doctor on their order"..

Next semester begins my first clinical rotation (med-surg). Supposedly only one of the hospital systems opened up to students (3 in the area), and they're still not sure how it will all play out.

One interesting thing I found about nursing school vs medic school.. There is no actual required number of clinical hours in nursing school. Not that they would do it (hopefully) but I could technically have 0 hours of clinicals, the only requirement is that the nursing program attests that I am competent in a clinical setting.
 

Carlos Danger

Forum Deputy Chief
Premium Member
4,110
2,811
113
One interesting thing I found about nursing school vs medic school.. There is no actual required number of clinical hours in nursing school. Not that they would do it (hopefully) but I could technically have 0 hours of clinicals, the only requirement is that the nursing program attests that I am competent in a clinical setting.
Yep. I became an RN without a single day of nursing clinical, through the old Excelsior program. You did have to be actively employed in a clinical setting, and there was a 3-day clinical exam at the end of the program that was absolutely brutal. Most graduates at that time were LPN's, which I think is really who the program was originally designed for.

Maybe you'll get lucky and at least have to do less clinical than you otherwise would. Some clinical experiences aren't bad at all. There is plenty to learn from a good preceptor.
 

Top