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Emergency or Trauma Nursing?
This month’s Nursing Notes newsletter takes a look at the fast-paced field of emergency nursing including sub-specialties in trauma care. I got a chance to sit down with two experienced emergency care nurses to talk about the differences between emergency department nursing care and the specialized emergency field of a trauma nurse. Paul Bond is an emergency nurse with over 20 years experience in the field. He’s also the host of a bi-weekly online radio show found at EmergencyNursingToday.com. We were joined by Susan Cox, a trauma nurse at Rady Children’s Hospital in San Diego where she is Director of Trauma and Volunteer Services. Susan is also the President of the Society of Trauma Nurses.
Interview with Paul Bond and Susan Cox on Emergency and Trauma Nursing
Jamie: Susan and Paul, I’m happy to have you on the show here at Nursing Notes Live. I’m excited mostly because I think it’s important to draw distinction between the specialty of emergency department nurse and the subspecialty or its own specialty in its own right of trauma nursing. So Susan I thought I would start off with asking you, what do you see is the key differences between being a trauma nurse and perhaps being an ER nurse?
Susan: Yes. I’d be glad to help with that. Actually trauma is a subspecialty of nursing. It is specific to the phase of care that you’re talking about. The emergency department or the emergency center phase of care is one phase of care in trauma nursing. So there are people who work in the emergency department. Sometimes all of the people who work in the emergency department function as trauma nurses. But there also trauma nurses in all of the other phases of care in the hospital or outpatient setting. We have trauma nurses who function on our floors. We have trauma nurses who function in a radiology department and our critical care units. They are all caring for trauma patients and have a subset of clinical expertise and knowledge that is specific to trauma patients and anticipatory knowledge and expertise in anticipating what might occur ongoingly with the trauma patient related to mechanisms of injury and what has happened to the patient. So the difference between an emergency department nurse and a trauma nurse is basically that a trauma nurse can be an emergency department nurse but there are also trauma nurses in many other phases of care in a hospital.
Jamie: It’s interesting that you say that, Susan, because I didn’t know that the trauma nurses extended beyond, say, a specific trauma center or beyond the emergency department setting but that’s very interesting that they extend into other realms.
Paul: I really didn’t either, Jamie. I understood that trauma nurses were not just in the emergency department. But my understanding was more the critical care post-ER like in a trauma ICU or those types of things – the OR. I didn’t realized that they went into radiology and the regular force too which I think was great because trauma is its own continuum of care. Since the ‘60s with the advent of the Golden Hour and everything that R. Adams Cowley did through shock trauma, we’ve noted that there’s a major difference in how you care for trauma patients versus medical patients or simple trauma patients, if you will, somebody’s just had a broken leg as compared to somebody who was stabbed or shot or fell of a building or whatever it may be. There is an entire continuum of that patient’s care related to the trauma as compared to just the ER which is how it originally was. It was trauma with trauma. Once you got out of the ER it was just general nursing care or just general medical care. I’m glad to see that the specialty has blossomed, if you will, into the other realms of nursing – critical care as well as radiology and out on the floors after they come from the ICU into the Step-Down units. I think that’s great to have that care all the way through to discharge because, truly, trauma is – just as Susan said, it is a sub-specialty of its own but it’s a very specific specialty that has a lot of information that you need to know. Kind of like an ER nurse, it’s almost the same but it’s different in that an ER nurse has a lot of things that they have to know very specifically for right-now but doesn’t necessarily have to know anything for two, three, four days or a couple of weeks’ out. Whereas trauma nurses have to know the right-now with trauma but also a month down the line what to expect with what’s going to happen after the patient. Somebody that has massive barotrauma, let’s say, they may end up going into ARDS and that could be two to three weeks’ out from the trauma. To know those types of things and to have that specialty, I think is a wonderful way of handling it.
Susan: Right. It works really well. I think one of the really confusing things for our public, for the citizens, is that with the advent of so many emergency department-based shows on television and so much drama around the trauma that happens on those shows, people really have trouble distinguishing between an emergency department and a trauma center. They think they are the same thing. The whole continuum of care is what’s really interesting to people when you sit them down and talk about it. That the emergency department is one phase of care and that in our – I work in a pediatric hospital where we don’t get a lot of acute-status patients, you know, knives and guns club types of patients – so we don’t have a lot of really seriously injured kids who come into our emergency department but those who are seriously injured spend the least amount of time in the emergency department. They are expedited either to the operating room or to the ICU or to imaging, the CAT scanner. So the phase of care is really different depending on the acuity of the patient and the perception that all of the operations and all of the diagnostics go on in an emergency department for most hospitals is really confusing to our citizens.
Paul: Right. I have to agree. Susan, I work in a community hospital so we’re not a trauma center. The traumas that we get, that come in, most of everything you’re talking about actually happens through the ER prior to us transferring them out. We work with two trauma centers, they are relatively close. One is about thirty miles away which is a level two trauma center and one is about 70 miles away which is a level one trauma center. Speaking with those nurses and in dealing with them over the years, what you’re saying is exactly true. A trauma patient or a trauma stat patient when they come in will spend no more than 30 minutes in the ER and then they’re gone. But the trauma care continues on and the trauma nurses continue that on. The ER nurses only do that first 30 minutes of initial assessment, maybe starting IVs, hanging some blood, whatever the case may be to move them on to the OR or wherever else they need to go.
Susan: Correct. I think something else that’s really confusing too – even professionals who don’t really spend time thinking about the difference between a trauma center and an emergency department, really don’t understand that there is a huge number of patients who come in as injured patients into emergency departments, even emergency departments of trauma centers who are not trauma patients. In our hospital 90% of the injured kids who come in are not trauma patients. They are managed by the emergency department or they’re managed by our clinics, especially orthopedic clinic and never rise to the level from a mechanism of injury or acuity point of view to a trauma status. So the whole continuum of injury is confusing to people also even our own profession don’t get that. There are injured patients but then a subset of those injured patients is trauma patients.
Paul: Right, I agree. Right now, we’re going through some of that same type of learning with not only the nurses that I work with in my emergency department but also the more of the two local trauma centers. Florida, originally when they setup the trauma system, had set it up based on the ACS criteria which included mechanism of injury. But within the past, I’m going to say, ten years – I don’t know what exactly the time frame is – the state had decided to take that out of the trauma stat criteria because of the push from the trauma centers, because they were getting so many patients that were coming in a trauma stat. So instead of going back and saying, “Okay, they may not be trauma stat but they can still be considered trauma patients that you go to your ER” being a trauma center, the state – because there was a crisis at that point, all the trauma centers were threatening to drop their certification which meant Florida will have no trauma centers at all. They moved that out of the trauma stat criteria. So now it puts the burden back on the paramedics to make a decision based on things other than MOI which, as you know, plays a big role in trauma patients. Trauma patients for the most part are young and healthy so they manage very well and they can maintain for a longer time until all of a sudden they’re not maintaining at all. That MOI, I think, needs to truly be in there because if somebody falls from twenty feet, they may be fine for an hour, but an hour and ten minutes later, they’re crashing.
Susan: Absolutely. That’s really where the whole concept of trauma centers came to be. I live in San Diego where we’ve had a trauma center for about 26 years but I was a nurse in our pediatric ICU before we had a trauma center. It was very frustrating for all the clinicians in our center to see kids come from small community hospitals that really didn’t have the resources to adequately manage critically-injured patients who tried for a couple of days and then realized they went over their heads and then transfer the kids. So we got kids with not only what’s called “primary injury” but also secondary injury – swelling and bleeding and things that could have been prevented had they been in a trauma center which is the concept of the “Golden Hour” and trauma center system. It’s getting the patient to the right place. Our county of about 4,000 square miles, we do use mechanism of injury as a determinant because kids can compensate very well for a period of time and sometimes to the uneducated eye or the more naïve clinical eye of a paramedic or young paramedic, the child can look perfectly fine and be compensating for a critical or really life-threatening injury that’s internal and not readily apparent to somebody who doesn’t do pediatric care all the time. Depending on environment, and San Diego is kind of a combination of urban and rural, mechanism of injury does enter into our definition of the trauma patient and I think we just have to as regions decide what makes sense for our own areas. But certainly we have understood and have greatly appreciated the ability of a small child to compensate for a very serious injury for a period of time and look pretty good.
Paul: Right. I think if you talked to most ER nurses who have been in the emergency department for a few years, and paramedics the same way, if they’ve been on a bus and then the streets for five years or so, they’re all going to tell you the same thing, that they have seen these patients that looked fine and all of a sudden they weren’t fine. So they understand and I think that’s a good thing too in that although it may have happened haphazardly, a lot of people who are in the community facilities that aren’t a trauma center now realize that this person, although they look great, they really need to go to the trauma center to be checked out a little bit more definitively because we can’t handle it. Right along the same lines, I’m glad to see the CDC pushing the full ACS criteria as the trauma stat criteria now that’s been backed by seventeen different agencies. I’m hoping that that’s going to come around nationwide as one set criteria.
Susan: Exactly. One of the things that I thought that might be helpful to talk about, you’re probably confronted with this also, is the new generation of nurses, the young nurses are all really anxious to get where they’re going in a hurry. I get a lot of phone calls and a lot of people coming to me and saying, “I want to be a trauma nurse.” They have a month of nursing experience or they’re right out of school. I think it would be helpful to talk about – so what does it take to really be a trauma nurse or experienced emergency department nurse that deals with trauma in a really effective clinical way, what do you think about that?
Paul: I think that’s a good idea too. As a brand new nurse coming in to the emergency department especially if you are a grad nurse, it can be very overwhelming because you think that you got a handle on things coming out of nursing school and all of a sudden, you’re thrown into a completely different environment that that’s – I don’t want to say “uncontrolled” but it’s controlled chaos. As you know, an ER is not anything like the floor. It’s a totally different animal. Nurses, especially new nurses, can be very overwhelmed with what’s going on in the ER and having to manage multiple priorities. I always tell brand new nurses that I think it’s a good idea that they start thinking about becoming at least a certified emergency nurse so they can start understanding what it is to be an ER nurse first and then if you say, “I want to specialize past that,” you’ve got that foundation of managing multiple priorities and dealing with critical patients and then move on from that.
Susan: Yes, I totally agree with that. I do think it is underappreciated by new nurses coming in to the profession, how much knowledge you acquire just by doing basic nursing care either in an emergency department or on a basic floor where you’re just honing your skills and moving from novice to expert and being able to look at a child or an adult. Really, with your gut, because of all the knowledge and experience you’ve acquired, be able to say to yourself, “This is a patient who is fine” or “This is a patient I’m really worried about.” That ability really requires a certain amount of in-the-trenches, basic nursing work where you’re just acquiring skills and learning from the people around you.
Paul: Right. I agree. It’s a shame that as nurses come out of school, they’re given the impression – and I don’t want to say that they’re told is – but it’s almost like they’re given the impression that they are nurses and they can take care of patients. To a point, they can, but I don’t think they realize that nursing school gives you the very minimum basics of what you need to become a nurse and then you have to start applying that and learning the nuances of the care, if you will. Like you said, once you see a lot of things you start getting that gut impression that “This person isn’t as well-off as they look.” That only comes with actually seeing it and doing it.
Jamie: You need a baseline. You need to have a normal to be able to recognize the abnormal. I run into this one. I educate students. I do a lot of EMS, paramedic and EMT education and they ask me, “Well, I need to know the different lung sounds are supposed to sound like.” And I said, “Well, you need to be assessing lung sounds on every single patient whether they’ve got a respiratory issue or not because how else are you going to recognize normal?”
Paul: Exactly. When I was a paramedic actually, when I have had new EMTs as a partner or any EMTs that had never been my partner before, I always make sure that they understood what normal sinus rhythm was on a monitor, what asystole was, and what Vfib was because past that, they don’t need to necessarily know. It’s good that they know but those are the three that they need to know. If they see it, they need to tell me right away. Everything else can kind of wait a second or two and you need to let me know if it’s not normal sinus. But those three were emergent things that I needed to know about right away. So it was still just the basics. One thing that has stuck with me for 28 years when I was in EMT school, was my EMT instructor told us that if you are going to go on to be a paramedic, you need to be a good EMT first before you can even think about being a paramedic because it doesn’t matter if you intubated the patient and did everything else correctly but you miss the fact that they were bleeding out from their leg. You need to do the basics first. I think the same thing is true for nursing. If you understand what the basics are, of the ABCs and what a normal person looks like, then you start getting the feel of what an abnormal person is. Even if you don’t know what’s wrong, you know something’s not right and that’s the important part.
Susan: Exactly. I think the other thing that is underappreciated by new people coming in to the profession – I don’t know about you but I can’t tell you how many times people have asked me why I didn’t just become a physician. Like if you’re really intelligent, you’re not going to be a nurse, you’re going to be a physician. I have made a point of having a conversation with those people to talk about the fact that I made a conscious decision to be a nurse. Nurses and physicians have different roles. The caring part of nursing is what really drew me to this profession. The caring part of nursing is something that you really have to learn. You can be a really caring person but the psycho-social aspects of being a nurse, especially a trauma or an emergency department nurse or a critical care or cancer nurse, it’s really a burden initially because it really requires acquiring skills that most people don’t have. The ability to talk about death and dying, the ability to talk about loss of function, the ability to talk to people about things that most people aren’t comfortable talking about is something that it takes time to acquire and you can’t fast-track it.
Paul: No. It takes a special type of personality too.
Susan: It absolutely does. That’s what I see is the real beauty and real satisfaction of being a nurse: is being at the bedside, caring for families and patients and really making a difference in their life not just technically, that’s a part of it, but if you ask families, they kind of weigh equally the caring and the technical. They want both and both of those are skills that take time to acquire.
Paul: Right. I agree. I’ve had the same conversations with people before too because, just like you, I’ve being this for a lifetime it seems and people will say, “Well, you’re so smart, why don’t you just go get your MD?” and I’m like, “Oh, I don’t think so. First off, I don’t want to be in that end of healthcare. I enjoy the fact that I can do a lot of medical things but also time with the patients.” Just like you, you can educate the patients about what’s going on or talk to them about what to expect and help alleviate their fears and you actually can interact with the patients a little bit more than what physicians can do. Especially nowadays, physicians are pulled in so many different directions more so than nurses, I think. Nurses are burdened with a lot of things too but we still have that expectation that we want to be at the bedside and we push to be at the bedside more so than physicians do.
Susan: Right. I think it’s a really exciting time. I know you’re probably seeing this in your organization also but we’re seeing a huge drive toward collaboration between the different organizations. ENA and STN have worked together for a long time, have been complementary to each other in educating and supporting our profession. What I’m finding in the last few years, and I’m really heartened by, is that the physician groups are starting to collaborate with the nursing groups in not only education which we’ve done I think pretty effectively for many years but also in pathway development, guideline development, injury prevention strategies, regulatory stuff, all the forums where we’ve kind of dabbled and touched on as nurses. Now we’re being seen as important partners in the discussions at the table and we’re being pulled in to the basic preliminary meetings to develop collaborative for many of these agendas that have heretofore been primarily physician-driven. We are now partnering with many of them and it’s an exciting time for young people to come into nursing because we build our systems on these shoulders of giants. We’ve had many nurses who are now retired, who have established some of these inroads to make this happen. This is not something that happened overnight. The new nurses coming in to what our profession now is going to benefit so greatly from all the hard work of the pioneers in nursing, we have slowly changed the culture.
Paul: I agree. I think too that one thing that both you and I can agree on is that with the years of experience that you have and the abilities that you have technically to be able to care for the patients and do the skills and do the assessment, that has allowed nursing to look better in the eyes of physicians because they recognize that nurses can do these things and they can rely on nurses for what’s going on and they can trust them. That has allowed nursing to actually get a seat at the table because physicians look at nurses more so now than they did even ten years ago as partners or as peers as opposed to a subordinate.
Jamie: Really quickly, Susan, what’s the advanced practice version of trauma nurses there – as a clinical specialist or is there an advanced practice, I don’t know, nurse practitioner in trauma care?
Susan: I think you see all three actually: physician assistants, you also see nurse practitioners and clinical nurse specialists. I think, for pediatrics, we have nurse practitioners who work in the critical care unit, who are partners with us on care of trauma patients. We have nurse practitioners in the emergency department who are partners with us and caring for trauma patients. We do not have a sustained inpatient census of trauma patients enough to support a nurse practitioner dedicated to trauma in our particular organization because our average daily census is somewhere between three and ten patients. But in an adult acute trauma center where their inpatient census is twenty or thirty, the nurse practitioner model of case management, of being a physician-extender or physician-partner is alive and well. One of the wonderful collaborations between physicians and nurses is caring as a team for a patient population. It works very well in the adult trauma centers. It actually started – one of the trauma centers here in San Diego started that concept many years ago and it works really well. It’s a great opportunity for advanced practice nurses to work in trauma but pediatrics is a little different. We just don’t have enough of the census to support it in our center at least.
Paul: Susan, I have a question for you, just along that same line, I know that some universities are now beginning to start nurse practitioner programs that are geared toward emergency medicine, so instead of getting an adult nurse practitioner or pediatric practitioner, you come out with a specialty in emergency medicine, are they doing the same thing for trauma nursing also? Have any university started that at all?
Susan: I think there are trauma nurse practitioner programs. I know there are. I think they are generalists, not specific to pediatrics or adults. I actually think that’s a very wise way to go because in our emergency departments, most emergency departments in our state, at least, are at least basic emergency facilities that care for both adults and children. Even if we’re a pediatric center, we do have adults present to us and we do take care of them. So somebody who has an expertise in both adults and peds, I think it’s really a wise approach especially with disasters kind of being very carefully planned for and have been a reality in our world, to have the ability to be able to be a generalist in trauma is a really good thing to do.
Paul: I agree. I didn’t know if there is a trauma specialty for nurse practitioner programs. I’m glad to see that there are.
Susan: There are. They are just becoming more available. I’m not sure how many there are in the country but I know there are at least a few.
Paul: That’s great. That’s awesome.
Jamie: Well, I think we’ve kind of gotten to the end of our time. I know all three of us could probably sit and talk about this for quite a while. It’s a fascinating topic. Susan, I know the Society of Trauma Nurses, at traumanurses.org, is that’s correct?
Susan: It is. Yes.
Jamie: Okay. There’s information if someone’s interested in what it takes to become a trauma nurse, there’s a lot of great information available on your website. I was taking a look at it.
Susan: There is certainly and it has a lot of contacts. They can get a hold of any of us and we’re happy to talk to people.
Jamie: Well, fantastic. Thanks a lot.
Susan: Thank you.
Jamie: And Paul, you have your show, emergencynursingtoday.com? You put out bi-weekly and just a great resource in emergency care and what’s going on in emergency nursing.
Paul: Thank you, Jamie.
Jamie: Yes. It’s great. So that’s one resource. Of course, ena.org for the Emergency Nurses Association also, a resource for people interested in emergency nursing.
Paul: Right. Thanks, Jamie, I appreciate being on the show.
Don’t forget to check out the entire February, 2011 issue of Nursing Notes, featuring a peek inside the specialized fields of emergency and trauma nursing. You’ll find links to resources like the Nursing Campaign’s “A Day in the Life” video which follows emergency department nurse Laurie through her day while she balances family, hobbies, and a second career as an ER nurse, and the Emergency Nurses Association’s latest set of Emergency Nursing Resources. You can read the entire issue online at www.discovernursing.com and don’t forget to catch our other Nursing Notes Live episode this month where we brought together a group of emergency and trauma nurses to discuss the unique challenges associated with their jobs. You’ll find this and our other podcast episodes at www.NursingNotesLive.com and in the podcast area in iTunes.