Ep 5: Emergency Nursing Explained with Jessica Smith Dos Santos

In this episode of My Nurse Specialty, I talk with Jessica Smith Dos Santos about her path into emergency nursing and what it really takes to succeed in the ER. Jessica shares how she entered the specialty unexpectedly after another unit closed, and how what started as a default move eventually became a role she grew into and learned to love. She also speaks honestly about how overwhelming the ER felt in the beginning, including the steep learning curve many nurses experience when starting in this fast-paced environment.

Jessica explains that not all ERs are the same and why understanding the different levels of emergency departments matters. She talks about the difference between high-acuity trauma centers and lower-acuity community ERs, and how that can shape a nurse’s experience, especially early in their career. She also shares what certifications are helpful, what nurses should know before applying, and why it is so important to be honest about the kind of pace and pressure you want in your work.

We also talk about the many directions an ER nurse can grow within the specialty, from trauma roles and triage to charge nurse, leadership, freestanding ERs, and education. Jessica gives a realistic but encouraging look at the specialty and offers valuable perspective for nurses who feel drawn to emergency nursing but want to understand the reality behind the role.

In This Episode, You’ll Learn

• Why not all ERs offer the same experience.
• What new nurses should know before starting in emergency nursing.
• How ER nurses can grow into leadership, trauma, and education roles.

About My Guest: Jessica Smith Dos Santos is an ER nurse and nurse educator with a background in telemetry, pre- and post-procedure care, and emergency nursing. Over the course of her career, she has worked in different ER settings, including high-acuity trauma environments and lower-acuity emergency departments, and has also developed experience in pediatric emergency care. She now supports nurses as an emergency room educator while still working per diem at the bedside to keep her skills sharp.

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Transcript

SPEAKER_01 0:02

Welcome to My Nurse Specialty, a podcast for nurses who want a clearer view of what's possible in this profession. I'm Rebecca, a registered nurse, nurse career strategist, and someone who has spent decades working across different nursing roles. Nursing School teaches us how to pass boards, but when it comes to careers, most of us are introduced to only a handful of specialties. It just depends on who you talk to after you get out of school or while you're in school. And then we're expected to figure out the rest on our own. That lack of awareness is where confusion and misalignment begin. This podcast exists to expand that awareness. Throughout this podcast, you'll explore nursing specialties, some you've likely heard of, and some you may not even know exact, along with the insight and helps you understand what's best for your career at any stage. This is my nurse specialty: real nursing, real stories, and real possibilities. Hi everyone, and welcome to the My Nurses Specialty Podcast. So tell us your name and what is your specialty?

SPEAKER_00 1:17

Hello, everybody. It's so great to be here. My name is Jessica Smith dos Santos, and my specialty is ER. I am an ER nerd, and I'm so grateful to be here to share more with you guys.

SPEAKER_01 1:29

I'm so happy that you're here, Jessica, because so many nurses, that's where they say they want to start. So I want to talk about, you know, how you got here and what it was like for you. Starting out in that, but when you started that specialty. So, first of all, did you always know when you got to the ER that's where you wanted to be?

SPEAKER_00 1:51

No. As a matter of fact, I got to the ER kind of by default, and we can talk a little bit about that. But I kid you not, I cried almost every shift for like a year. Most of our I decided I was gonna be okay and made the decision that I was gonna master every role there was to master and really settled into enjoying it. So that's a good ad.

SPEAKER_01 2:13

I mean, it's a lot of newer nurses. I think that's pretty typical that they get into something and it can be overwhelming. So, you know, the learning curve in ER is probably fast-paced and so much to learn. So, you know, that's understandable that that happened, but you know, it's not everyone's journey, but it's thank you for being so transparent about that. And you got there by default. So tell me a little bit about what that default looked like.

SPEAKER_00 2:44

Yeah, absolutely. So I had been a nurse for five years. I had worked on a telemetry unit, and then I went to a pre and post procedure unit. If I may put in a plug for Telly, I think Teli is a great foundation for a brand new nurse. Like it's enough to teach you those like time management skills, and the patients are just complicated enough to like grow your knowledge and your practice, and it's an amazing foundation. And then I went from there and I went to a pre and post-procedure unit. It's actually a really simple like prep and recover. It was busy, but not a lot of acuity. It was a great place to get a bachelor's degree and make two babies, which is exactly what I leveraged uh that season in my career for. And they actually decided that they were going to be shutting that department down. She was right in 2010, because it just wasn't making money for the hospital. But they wanted to retain us. And I was very big pregnant with my second baby. And they were like, We would like to retain you. Where would you like to go? And I said, not even realizing that RER was 95 beds. It was a level two trauma center, like super high acuity. We were the stroke center, the trauma center, and the heart cardiac uh heart attack center for northern Nevada, Northern California, and parts of Utah. So I raised my hand for a really intense ER, huge pregnant. They told me in one day that I was losing my job. I had an interview set up three hours later, and like an hour after that, they told me I was hired and I could have any shift I wanted. Of course, I chose day shift, but it should have been a red flag because I'm like, I have no critical care experience. I'm about to have a baby. I've been in this like super easy, cushy, you know, job role for the last two years, and you're like, awesome, you have an RN behind your name and a pulse. Come on down. They had just had like a mass exodus, and I knew not what I was signing up for. Oh wow. That is like a problem for sure. Yes.

SPEAKER_01 5:04

But you know, you do bring up a good point because um I yeah, I've talked to so many nurses that, you know, just getting in and also a lot of us that have been around for a while, and sometimes we do talk about those opportunities that just kind of show up, you know. And like recently there was a nurse that was a door was open for her, and she just wasn't sure if she wanted it. But her and I had spoken, and sometimes when those opportunities show up, if you don't take it, you don't get it again. So even though it started off on a rough road for you, sounds like at that point too, you could have picked somewhere else as well, but that's how it worked out. So that does happen in nursing. I actually was involved in that myself, where I was working a unit, and they said, Where do you want to go? And I actually went to case management. And I I know actually a nurse who just retired. I remember she was a colleague, friend of mine, and she picked recruiter. And she became a nurse recruiter, just retired as a nurse recruiter after 30 something years. So those opportunities do happen in nursing. And so kind of maybe be ready, like, you know, where would I want to go if I if this unit was to close down in this hospital, right? Because things shift.

SPEAKER_00 6:28

Well, and also be ready for like my sister's story is a little different. Like, she's a labor and delivery nurse, but had no interest and no intention of ever being a labor and delivery nurse, and just ended up in a small community hospital, and that's what they needed. And she was new, and she's like, sure, why not? And she's been in love with it ever since. So, I mean, there's also those surprises where you're like, no, but okay.

SPEAKER_01 6:53

Yeah, that's good. Those are those do happen. So be prepared. But you're in a very good position to talk about what you think would have been helpful for you in starting for the ER, or for a nurse who wants to go into the ER, that's really where they want to go, what they should know. Yes.

SPEAKER_00 7:14

So, what I have learned since then is that there are different levels of ER. So there's like a level one or level two trauma center that or a level three trauma center, like they take in all the gnarly stuff, right? Like, figure out what kind of experience you want. Like, are you a trauma adrenaline junkie? Do you want to be dealing with a lot of colds, a lot of heart attacks, a lot of stroke protocols? Like, it's like drinking from a fire hose, stepping into that environment as a brand new nurse. And I trained a lot of brand new nurses in that environment. It is not easy, friends. It's it wasn't easy for me, and I had five years of experience. And some of it was on telemetry. There's also, I ended up leaving nursing for five years. I got really burned out, and I was like, I am done with this profession. And then five years later, the ER is like, hey girl. And I had a girlfriend, I had actually trained her as a brand new nurse, and she was now a nurse educator in an ER near where I had moved. And she's like, Hey, we have a day position open, why don't you apply? And so I got back into nursing. That ER was not a trauma center, it was not a stroke center, it's not a heart attack center, it was not a baker act receiving facility for those psych receiving patients. And it was a much better experience because I got to like relearn that patient flow, and there were just enough high acuity patients to like really stretch me back into those high acuity skills, but not on a day-to-day like in the trauma center. I I mean I participated in a code at least once a week, and I only work three days a week, right? Whereas in the other place, I worked there for a year and I participated, I think, in five codes in a whole year. So there are very different levels of ER. And if you are brand new, I would recommend seeking out sort of a lower acuity, non-trauma, non-heart attack to get your foot in the door and get one or two years of good experience there and then make that leap into that higher acuity because it's it's difficult no matter how much experience you have, and especially if you're brand stinking new. I would say the only caveat to that is if you're already a paramedic or a firefighter and you're running on a rig, and now you've been a tech in an ER and now you're getting into nursing that way. I'd say that would be the only sort of caveat that would be an easier transition.

SPEAKER_01 9:51

Yeah, definitely good points. I know too, working at a teaching hospital is different than you know, a smaller community hospital or even a university, you know, hospital that they do have a lot of residents and interns that float through. I know there's a lot of spotlight right now on the on because of the show called The Pit. So yeah, have you seen that?

SPEAKER_00 10:16

Full transparency. I watched like the first three episodes and I'm like, oh hell no, I am not reliving this in my living room. Like they did a really good job. It was quite realistic, and I was like, no, I'm good. Been then done that.

SPEAKER_01 10:31

Right, right. No, and it's different than a lot of the medical shows that have been on TV. And you I did the exact same thing as you. I actually watched a couple episodes and I had like PTSD and I had to turn it off. And then my kids started watching it, and so I started watching it with them, and then I was able to watch it, and so I did get through the first season, but I was telling them, you know, this is not every ER. And so it's good for people to know because if yeah, if you got young nurses or people who want to be nurses or say one day they want to be in an in an ER, it's good to know that there are different levels of ER, and that that one is a university teaching hospital, which has a lot of pros to it as well. Especially let's if you did want that and started there, you know, like which you did later, moving into a different level afterwards would be easily able to do. It's important to know that yes, there are different levels that are out there. You not one ER is the same as another ER. Correct.

SPEAKER_00 11:36

And also recognizing that if you get into one ER, like I ended up falling in love with pediatric ER. When I went back after my five-year hiatus, there was an opportunity to grow my pediatric ER nursing skills. And I remember the first time the doc was like, hey, I need you to start a line and draw labs on that one day old. And I was like, excuse me. I was like, I know about I can drop a 16 in an IJ in a hot second. Uh you want me to do what with that little thing? So I mean, I got that opportunity to really lean into like pediatric ER nursing, and I just found that I fell in love with it. And I just I found a whole nother groove that I didn't even know that I didn't know. And it was a really cool experience.

SPEAKER_01 12:26

That's great. I that's another again for you know, nurses to know that sometimes you don't know you don't love a place until you really kind of got into a place, right? So, you know, especially I know people that work with adults and then switch over to kids and vice versa. You know, maybe because you haven't been exposed to it, you just don't know. So sometimes allowing those opportunities is a good reason to see whether you really love it. It's really hard as a nurse trying to figure out where you want to go, which is the whole purpose of this podcast. But because we'll tell you, shadow. Well, I've shadowed before in areas and got the job and hated it. So, you know, that isn't always even going to be a good true indicator whether you're gonna like something or not.

SPEAKER_00 13:19

Yeah. My friend Kelly and I, we kind of have a professional rule for ourselves that when we get into a different role, we give ourselves a year because it gives us enough time to get over that hump of like, this is uncomfortable. I'm new, I don't know what I'm doing, I don't like this skill. And then you kind of settle in and you're like, okay, I'm over that, like, I'm new hump. And then by the end of that year, like you've mastered some things, and then you can really decide like, is this for me or not? Because you can toggle back and forth, like, I hate this, but why do I hate this? Do I hate this because it's pushing me and it's uncomfortable? Or do I really like this is not a good fit for me? And it it takes time to really figure that out. So if you're gonna commit, I would say commit for a year. Plus, it just looks better on a resume when you give a place a full year rather than jumping three months and six months and nine months, and it just shows people you're not dependable. So you can speak to a year saying, I gave it a full year and I discovered that it just wasn't an alignment for me, and I'm looking for my forever fit. That looks a lot better on a resume.

SPEAKER_01 14:29

It does, but I do know that there are nurses who absolutely know they can't do an area, and that year just seems like forever. And so I think you really do have to weigh it. Like, can you do a year or can you really not do a year? And if you can't do the year, you know, I think that you can maybe not even, you know, really talk too much about that job. Just leave it off the resume. Yeah, just leave it off if it was a couple weeks, you definitely don't need it on there, right? Yeah, it's harder to explain a six-month, you know, type of or even a three-month, but you know, when you have a gap in employment. But yeah, it is good, but it I think what really what you're saying too is really deciding why you don't like it. Because you'd mentioned that. Is it a skill? Is it, you know, what is it that I don't like about this that I cannot do that year? So there are those, you know, there are situations where don't do the year if it's through mental health, right?

SPEAKER_00 15:40

Absolutely. Absolutely. And and then that becomes a conversation of like, let's get really intentional about why you're choosing what you're choosing to begin with. I think that's a that's a whole other conversation.

SPEAKER_01 15:53

Is there any like if somebody, you know, really does, let's say, like you said, you know, maybe they they did the EER when before they're became a nurse, you know, in some kind of tech capacity or something like that, or you know, or someone who just really knows they want to get into the ER and their brand new nurse, maybe worked a year in some other area and they but they still want to get into the ER, what certifications would you say they should get prior to applying?

SPEAKER_00 16:21

So this day and age, a lot of ERs will take you and give you 30 days to get what you need. And it depends on what type of ER you're applying to. So if the uh ER takes care of pediatric patients at all, you do have to have either POWs or ENPC. Most cases accept POWs, you do have to have ACLS and BLS. If it's a trauma center, you are going to be looking at getting your TNCC or trauma nurse certification at some point. That's going to be important to be a part of a trauma team. Every ER has to do specialized stroke training. So looking at that NIHS training and a lot of places, they will provide that training for you and they give you a certain timeline. So I remember when I first started ER, I had ACLS and BLS. They gave me like 30 days to get my POWs, but they offered it through the hospital. And then I started trauma training. So then I got my ENPC and I got my TNCC, my trauma nurse certification. And then I took the professional aspect to a whole new level and did go on to get board certified as an ER nurse. That is not required, but it's also an additional level of once you've decided where you're going, consider getting certified in your specialty, because it'll just take your professionalism and your knowledge kind of up that next notch. So those are kind of the few things initially that you would need depending on what ER you're in.

SPEAKER_01 17:58

Yeah, and those are really good things to mention that certification too, that like all the specialties have certifying that you are an expert in that specialty as well. Definitely it's great for if you wanted to move up within the ER. So tell me a little bit about opportunities that you got to the ER, you're working in the ER for a while, and you want to stay in the ER, but you don't want to just stay being on the actual ER, just being being the nurse in the ER.

SPEAKER_00 18:25

What other opportunities are available to a nurse who gets into the ER and has opportunity to move either laterally or uh so initially when I finally decided that I was staying, I was like, okay, what are all the different roles within our ER? Because that ER had a yellow pod, which was more like kind of our urgent care, like our fast track area for people that, you know, had a stiffly nose or a stem toe, you know, those kinds of things. We had a green pod, which was more psychiatric specific, plus a little bit of medical stuff sprinkled in, but lower acuity medical stuff. And then we had our blue pod, which was our trauma pod. So they would come in as a trauma, go through our trauma process in the trauma bay, and then they would be delivered to the blue pod after that part. We had the red pod, which was our high acuity pod. So lots of codes, lots of intubations, lots of sepsis, really, really sick patients. So our ratio was a little bit lower. It was like a one to three ratio versus blue pod with a one to four, green pod was a one to five. So they looked at that. They also had the triage role. So being out front and like accepting those patients coming in. And then they had the trauma roles, so they had a trauma team lead, but then they also had a trauma team that would respond to those traumas. So all of those roles are kind of lateral within the department that you could consider mastering. Oh, and they also had a pediatric ER. So you can kind of look at doing all of those things in the ER that I started in in terms of lateral moves, but then you would look at that additional training to become a charge nurse. So a trauma team lead was a step up. A charge nurse was a step up. So being in charge of a 95-bed ER and all the traffic and all the staff challenges that come with that. That ER also had a leadership structure where they had a few supervisor positions, a couple of manager positions, and then a director position. So those were all like climbing up that ladder of hierarchy. So those are all of the things that were available in terms of the ER. And I just decided once I decided I was staying, I decided I was gonna get good at all the lateral things. And then I was gonna go for charge nurse and see how it went.

SPEAKER_01 20:55

Yeah, and you always still have options, and it's just if you decided to stay in ER, where would you go? And it can also be ER is a good stepping area for other opportunities as well. I think we have what flight nursing, I think sometimes is is a good spot for that. Or do you know any other ones?

SPEAKER_00 21:13

Flight nursing is good. I know that depending on the area you live in, they have concierge medicine, they have sports medicine, they have rodeo medicine. So it's more of like those trauma-based nursing roles for um events. Like those are all things to consider. Another thing to think about is a lot of ERs these days also have an off-site freestanding ER. So the the first hospital that I worked at didn't have that, but the second ER that I worked at did. And it was a freestanding ER. So it had uh CT scan, ultrasound, x ray, lab, EKG, all available on site. And then we had the ability to transfer to our main hospital. Hospital for admits. And that's an interesting beast all in itself. Like it's less staffed. Like the one that we ran had 10 beds and it was staffed with two nurses, a doctor, and a tech. And so, you know, I walked in one morning and there's a patient having an FT elevation MI who looked absolutely horrendous. And they were like, oh, we're we're waiting on the transport. They're gonna be like 15 more minutes. And I picked up the phone and called 911 and the fire department can get him. So it's it's a different, it's just another aspect of that emergency medicine.

SPEAKER_01 22:35

Wow. Yeah, that's a lot to opportunities that you can do with it with that. Because I you think about it, yeah. So many. Right, so many. Okay, is there anything you want to add that we didn't talk about?

SPEAKER_00 22:48

Yeah, sure. I would also say now I am per DM bedside ER, like a couple of shifts a month to keep my skills up. But now I'm an emergency room nurse educator. So that's a completely different role. I don't do patient care in that role. My my role is more of supporting the nurses with their competencies or if they're making errors, like what's going on and how can we support them in being more successful. For the new ones, it's like helping them, you know, at the bedside and helping them with their knowledge and just helping them grow that critical thinking. So it's like an ER adjacent, right? It's still ER, but it's another role that you don't think about when you're thinking, I want to get into ER.

SPEAKER_01 23:35

And I'm sure that your certification really helped you with getting into that position too. It did.

SPEAKER_00 23:42

It was something that was on the resume, but I didn't keep it up. So I could say I was board certified at one point, and now I'm actually looking at going for board certification as an educator. Okay. So something different.

SPEAKER_01 23:56

There's always something with nursing for sure. Absolutely. Okay, so for fun, I kind of like asked asked this last question. And it's so I'm just gonna have you finish the sentence.

SPEAKER_00 24:05

And so it is my nurse specialty is great for nurses who who like high adrenaline, who have high energy, who love to learn at a fast pace, and who are willing to hit the ground running every single day. Ready or not? Ready or not. Okay. Well, thank you so much. Is there anything else you want to share then? What I would say is if you are considering emergency nursing and you are a brand new nurse, I think it's really, really exciting. And it's a steep learning curve. And it can feel like you don't know what you're doing for a couple of years. So if that's the route you choose, it is entirely possible. But be prepared to feel like you don't know what you're doing and to be challenged every single day for at least a couple of years, if that's the road that you're gonna take.

SPEAKER_01 25:04

Yes, that's so important. I'm so glad you couldn't mention that because I'm sure that when you're a new nurse, you're going through this. And to know that that's actually normal to feel like that for possibly two years. That's we we I always used to say, or I do say, that there are certain things that you can only do by going through. You can't go under the experience, you can't go over the experience, you have to go through the experience. And just know that you are you are in the current stage of experiencing it in a new specialty that you want to be in and thrive in.

SPEAKER_00 25:43

No, yeah, just setting that realistic expectation. Be prepared to do hard things, and it's possible.

SPEAKER_01 25:50

And you can love it if you decide that's where you want to be.

SPEAKER_00 25:55

It took me a year to decide I loved it. And I'm not prepared through the tears. Yes, even through the tears.

SPEAKER_01 26:03

Yes, exactly. Exactly. Okay, thank you so much for being a guest on the podcast. I'm sure that you have helped so many nurses that are excited to actually probably hear this episode because they do want to be an ER nurse. And it's I'm really happy that you shared, you know, some of the pains that go with it and what you need to do to be in the specialty.

SPEAKER_00 26:26

Yeah, absolutely. It was my pleasure. And to all of you out there listening, best of luck to you. You are our future, and we are so incredibly excited to welcome you into our profession.

SPEAKER_01 26:37

Yes, yes. All right. Thank you again. Thank you for listening to my nurse specialty. I hope what you heard today gave you real insight into the specialty and helped you see what's possible for your nursing path. If you're watching this on YouTube, please subscribe. And if you're listening on audio, follow the show so you don't miss what's next. If you know a nurse or even a student nurse who's learning about their next steps, tell them about the show or send them a step out. And tell me, what specialty should we feature next? If you're a nurse in a unique specialty that you'd love to share, apply to be a guest on my website. I'm Coach Rebecca. Until next time, keep exploring.