Face it. Not everyone can be a nurse. And not every nurse can work in the emergency department. The chaos, the rush and the constant change do not appeal to some people, and some are not equipped to deal with it. Nevertheless, a special few thrive in rapidly changing clinical situations: the few who welcome instant decision-making with very little history or background, and for whom the adrenaline rush is an elixir like none other.
   
A Natural Fit

Meet Timothy Van Pelt, RN, CEN, who works in the ED at Santa Monica-UCLA Medical Center and Orthopaedic Hospital. His career is somewhat unusual in that it is his second. He spent several years as an EMT in the Air Force and then 20 years as an actor — think “The West Wing,” “The District” or “The X-Files.”

He was drawn to the emergency department because of the immediacy, the thrill of needing to “get to it” and the opportunity to say, “I’m going to solve this problem.” For him it has always been a natural fit. While in nursing school at Santa Monica College he worked in the 24-bed department at Santa Monica-UCLA, drawn to the wide variety of clients and the rapid turnover of seeing close to a hundred patients a day. “You are really always on the move.”

Van Pelt points out emergency nursing also calls on those soft skills that come with time and experience: the ability to comfort distraught families, not take things personally, and the wisdom to understand that you may not be able to fix everything. Trickier still, nurses who choose this specialty need to fight cynicism; some patients do try to “play you.”

You can manage all this as a new nurse, and most hospitals hire new graduates into the ED. Still, nearly everyone agrees that it’s easier if you have some experience.

Floating Into it

Terri Byrant, RN, had plenty of experience and, unlike Van Pelt, she did not set her sights on ED nursing while still in school. She worked two years in med-surg, then 13 years as a critical care nurse. One day, on the verge of burnout, she had the opportunity to float to the ED. She went citing multiple “disclaimers”: She only knew critical care, she’d never done it before and so forth. It was exciting and scary at the same time. Nevertheless, the experience whetted her appetite, and when the opportunity arose five years ago she moved to the department permanently.

Now a charge nurse in the Level II ED at Good Samaritan Hospital in downtown Los Angeles, she thrives on the fast pace and the “need to always be thinking on your feet.” Because of the location of the hospital, Bryant says the staff sees a tremendous variety in the client base, from homeless people to sport fans and athletes from the Staples Center. The mission statement of the hospital dictates that all patients must see a physician before there is any inquiry regarding insurance.

Any given shift is apt to bring, well, anything. “There is no template for the job,” Bryant says. Each day and each patient brings something new. She says there is one fact nurses considering this field should know: There is no routine. You don’t need to thrive on constant stress, but you do need to be able to handle the level of responsibility inherent in the job — and you need to be able to adjust to patients and families that are always in crisis mode. Often, a calm, unhurried approach is the last thing they want.

Not only does the patient census reflect the neighborhood, it can also be a mirror for what is going on in the larger society. Bryant has noted a definite increase in the number of patients who appear in the department with serious economic-related depression.
   
Minor Emergencies

Robin Wood, RN, BSN, of Childrens Hospital Los Angeles, would agree. Dealing with a system that, despite people’s best efforts, can’t meet the needs of the patients is frustrating to her and others in the frontline specialty. There is so much you can’t do or can’t fix.

Parents who have lost their jobs and lost their insurance need to use the emergency department rather than a primary physician for their child’s basic care. In the case of CHLA, the triage system selects children needing urgent rather than emergency care to receive assistance in the Kids Care unit, which operates on site. But the inability of patients to access continuing or follow-up care is simply part of the job’s limits. 

However, Wood is quick to mention the upsides of her job. “Children are so different from adults. They will not complain; they just want to get up and play again.” Many of her team members commute long distances to work at CHLA, and their esprit de corps is a wonderful support, especially when things do not go well. New graduates must show exceptional credentials to earn a slot, but mentoring continues through a Versant residency for an extended period.

As a Level I trauma center, a facility designated as an Emergency Department Approved for Pediatric and a tertiary hospital, the acuity is high. When might they see their greatest influx of patients? During the hours youngsters are walking to and from school.

One of the biggest challenges is time management: setting priorities that acknowledge the needs of patients and their families. With a pediatric patient, the family is part of the unit. Another constant consideration is the developmental stage of a child. What is normal, what is not? Wood considers the ability to listen as the single most critical nursing skill for this specialty.

And, because it is an emergency department, there is always the unexpected — like the occasional baby that is born in the ED because the parents went to the wrong hospital, or the adult visitors who need emergency services.
   
What to Expect

Most emergency departments schedule 12-hour shifts, and many stagger starting times so that, for instance, dinner and breaks can happen without diminution of staffing levels. Breaks are especially important with a job that requires constant motion. Have you ever seen an ED nurse sit down to take a history? And — “Nurse Jackie,” and her colleagues over on “ER” not withstanding — there really is no time for recreational drugs or sex!

An ED can be organized in a variety of ways. Most use a formal triage system that allows the sickest patients treatment first while still addressing the needs of those with lesser problems. Van Pelt says Santa Monica-UCLA recently instituted a fastER system that allows patients within certain diagnostic categories — a sprained ankle, for instance — to be in and out of the department within an hour. Pretty good when you consider that three hours is about average for U. S. hospitals; and the most recent CDC survey reports that, across the country, some 400,000 patients per year wait 24 hours or more.

All emergency departments participate in a level system, ranked one through four and determined by resources, such as availability of trauma surgeons and other specialists, volume, educational facilities and research. Based on that level they receive certain types of patients by ambulance. Of course, anyone with anything can arrive on his or her own. By definition, a Level I trauma center has 24-hour coverage by trauma specialists and can accept paramedic transports of any type. Level IV departments are usually rural facilities and, by contrast, have no on-site physician.

Although nearly every hospital sees children, not every hospital has the ability to serve critically ill pediatric patients or earns EDAP designation, so all of these distinctions help determine what type of patient makes up the patient load.
   
How to Get There

Emergency room nurses need certificates in advanced cardiac life support and pediatric advanced life support. Wood, who is working on an MSN at Cal State Fullerton, teaches the Emergency Nursing Pediatric Course and the Trauma Nurse Core Course offered through the Emergency Nurses Association. Both are often part of the credentials sought. Many ED nurses also achieve certification through the Board of Certification for Emergency Nursing, which offers testing in emergency nursing, flight nursing, pediatric care and ground transport emergency nursing.

In general, emergency department nurses earn the same as nurses in other units. There is no differential for the toll this specialty can take, though some hospitals provide clinical ladders with added compensation based on experience. It is a type of work that only talented, dedicated and energetic nurses do well.  

Sidebar

Is It an Emergency?

• Non-urgent: needs medical care within 2-24 hours
• Semi-urgent: needs medical care within 1-2 hours
• Urgent: needs medical care within 15-60 minutes
• Emergent: needs medical care within 15 minutes

Did You Know?

• Emergency rooms endure 120 million visits per year.
• Volume increases throughout the day starting at 8am, with a peak time between 4pm and 8pm.
• Children under 12 months and adults over 75 make up the largest group of patients.
• Emergency rooms are the entry portal for more than 50 percent of hospital admissions across the country.


Elizabeth Hanink RN, BSN, PHN, is a freelance writer with extensive hospital and community-based nursing experience.