Ambulance Nursing: Interview with Lorraine Estronick, RN, BSN, CCRN, TNCC

My Specialty

Ambulance Nursing: Interview with Lorraine Estronick, RN, BSN, CCRN, TNCC

Providing critical care to patients outside a hospital setting

By Keith Carlson, RN, BSN, CPC, NC-BC
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Lorraine Estronick, RN, BSN, CCRN, TNCC, PRN Ambulance, LLC, Southern California  

What led you to nursing?
My mom is a nurse. When I was little and she was going through nursing school, she would have me study with her instead of hiring a babysitter. She would go through case scenarios at the dinner table (much to my father’s chagrin, due to the gory details) and she’d ask me what I would do in that situation. Based on my response, she’d then teach me what the right course of action would be. I would go through her study flash cards with her. By the age of 8, I had learned my ECG rhythms after a lot of repetition.

Share with us the trajectory of your nursing career.
I started out as an EMT and worked for PRN Ambulance throughout nursing school. Once I was licensed as a nurse, I worked in a GI lab at a local hospital for a year and then transitioned to the ICU, where I still work full-time. After two years of ICU experience, I started at PRN Ambulance as a part-time nurse. I’ve been there for a little more than a year now.
Was becoming an EMT the first step you took towards becoming a nurse?
I was trying to find a position that would allow me some downtime to study for nursing school while at work. As an EMT, I was on a CCT (critical care transport) rig throughout most of nursing school and I had time to study between calls.

The nurse and the other EMTs on that team were very helpful. When we had a patient to care for, they would quiz me on what should be done. They’d use those moments as teaching opportunities. The on-the-job learning was a big help in nursing school and beyond.  After having my mom and my coworkers as excellent teachers, I naturally try to do the same by passing on knowledge to the EMTs and nurses I train. I also teach trauma classes and precept new grads in the ICU.

Once you were a nurse, were you certain that the ambulance was the place for you?

I knew I wanted to do critical care of some sort and the ambulance is a very different form of critical care than the ICU. In the unit, you have at least four other nurses working nearby, so if something happens, you have them there to help you stabilize the patient. In the back of an ambulance, you’re on your own. The EMTs are there, but they have a limited scope of practice, so you have to figure it out yourself. I like the challenge and the autonomy.

What lights you up about the autonomy?
It makes me sure about my ability to take care of patients under any circumstance. Every time I provide care for a very sick patient on the ambulance, it helps me to grow and learn as a nurse. It's wonderful to work for a company that’s so supportive. PRN provides everything that you could possibly need to succeed. My manager and supervisors are always there for me when I need them.

How long are shifts? What happens in the course of a shift?    
Our shifts are 11 hours and they’re staggered, with teams going out at 6:30 a.m., 7:00 a.m., 8:00 a.m., 1:00 p.m., 2:00 p.m., 3:00 p.m., 7:00 p.m. and 9:00 p.m. We don’t work from the base; we’re scattered throughout L.A. County so that one of our rigs will be within a short distance of most calls.

Once you’re working on a patient in the ambulance, there’s always the option to redirect to the nearest hospital if you run into trouble and need help. We can always upgrade the call and activate the lights and sirens. During a shift, you’re out in the community. We get to talk to people and see how all of the facilities in the area function slightly differently from one another.

The human interactions are interesting and some scenarios are harder than others. If things are chaotic at the scene, you find the calmest family member and delegate calming down the rest of the family to them. As the nurse, I delegate to the EMTs and focus solely on the patient.

Who comprises the different ambulance teams?
On a basic life support (BLS) rig, we have two EMTs. On the advanced life support (ALS) rig, there’s an EMT and a paramedic. On critical care transport (CCT), there are two EMTs and a nurse.

Nurses have the broadest scope of practice of anyone on the ambulance teams. We can even run vents, so we function like respiratory therapists on the rig. I can run any drip as well as an intra-aortic balloon pump. (This isn’t common on ambulances, but PRN provides a higher level of care.) If we’re transporting a patient who is at great risk for major complications, we might have a physician on board as an extra layer of clinical expertise.

What kinds of standing orders does an ambulance have?
We have everything needed to run a code, including a signed standing order for all of our ACLS meds. It’s pretty much what you’d find in a crash cart. Otherwise, if it’s the standard of care within your scope of practice, there’s probably a policy for it.

What does a nurse need to do in order to work as a CCT nurse?

She or he needs two years of experience in the ER or ICU. Any advanced certifications (like the CEN or CCRN) will help expand the nurse’s knowledge base. I personally recommend working as independently as possible within the hospital setting. If you always need help or backup in the hospital, you won’t be able to handle the ambulance, where you’re on your own.

Seek out the sickest patients with the most complications and ask as many questions as needed in order to understand what’s going on. Take classes to expand your knowledge and become more and more confident. If you question yourself in the back of the ambulance, it could be dangerous.

Once you’re hired for an ambulance position, you’ll be teamed up with another nurse until you’re comfortable on your own. When I train new nurses, we run through different scenarios and practice starting up the vent. Doing this in a safe environment in different settings allows the nurse time to understand how to safely do it in any situation. Simulation labs are becoming more common, but on-the-job training is really the best way to learn.

What makes this work so satisfying for you?
First and foremost, it’s the autonomy. The critical thinking that’s called for on the ambulance is vastly different from the hospital environment. If you respond to a patient who’s injured at home or on the street, you have to use your assessment skills to intervene and stabilize them with whatever you have on hand.

What would you like to see happen in the next five to 10 years of your career?
I’m working on my master’s in nursing administration. From there, I plan to apply to the DNP program at Cal State. I’d like to work as an ICU intensivist.

If you become an inpatient NP intensivist, would you miss the ambulance terribly?
I’ll probably never leave the ambulance service completely. I’ll keep a part-time position, continue to hone my skills and stay connected to the outside world.   

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