As I said last month, we are searching for a new location to be closer to my wife’s job. I am also tired of things where I work:

  • I was suspended without pay for a week because of a pending investigation when a delusional patient accused me of trying to kill him.
  • An incident just after New Year’s day where a patient threatened violence.
  • Three different incidents in January where patients either attacked or threatened to attack me.
  • My hospital claims to want 4 to 1 nurse to patient ratios* in the ED. That is rare. Now it’s usually 6 to 1. On one recent shift, I had 5 patients, but 2 of them were on ventilators. One of the other three was a sepsis patient who went into cardiac arrest just after EMS brought him in. The work load there is just too high.

So I also want to change jobs. Career specialists say that you should change every 2 to 3 years, so I think now is a good time to do so. I think we are close to answers on both.

We found a builder that will build us a 5 bedroom, 4 bath, 2900 square foot house for less than $190 a square foot. The place is gorgeous. Here are a couple of pictures from the model:

Master Bedroom
Living Room

Construction should take a bit. In the meantime, my wife’s job is moving in the fall, so if the house isn’t done by then, she will have a 45 minute commute. We are negotiating terms now.

On the job front, I just negotiated with a potential new employer. I spoke with people I know who work there, and they say it’s a good place. It looks good:

  • Patient to nurse ratios in the ED of 3:1, with occasional jumps to 4:1. I confirmed with friends that they aren’t blowing smoke with this claim.
  • Better neighborhood, so less of the violent psych and druggie patients.
  • A $12 per hour raise over what I am making now
  • Getting a $10,000 recruitment bonus for a 2 year contract doesn’t hurt (payable in 4 semi annual installments)

The downsides are twofold:

  • Because this hospital is properly staffed, there are no shift bonuses for pulling extra shifts. Of course, my hospital stopped paying them in September, so no real loss.
  • I can’t be PRN at the new place. I have to work full time for the time being. That’s OK, this will enable us to pay for this new house in 8 years and still keep the one we live in now as a rental.

The new hospital has sent the offer, and I have conditionally accepted for an August start date. (when the wife’s new job location starts) I should get the actual contract to look over some time in the next week. If it looks good, I will sign on. Hey, closer to the new place, less workload, and more money.

Explanation of the importance of patient/nurse ratios:

For those who don’t know, each patient needs to be assessed at intervals, plus needs medications, tests, and other related things coordinated. For “routine” patients on a medical floor, a nurse can handle as many as 6 or 7 patients at a time. The more things that are wrong with the patient, the more time it takes to care for them, so task loading becomes an issue- a nurse can only do so much without increasing the risk that they will miss something important, or make a mistake because they are pressed for time and rushing high risk tasks like selecting and dosing medications. For this reason, the sicker the patients, the fewer that a single nurse can effectively handle.

Some patients are so sick that they take up all of your time. A patient on a ventilator is one of those. In general, having two patients on a ventilator is all a nurse can handle, because those patients are also usually receiving a list of medications that are high risk, and this combination means spending a lot of time with that patient. This is why the more acute the unit, the lower the ratios need to be. In the ED, patients in general shouldn’t be more than 4:1 to the nurses, unless you want to compromise patient safety by not monitoring the patients closely enough. For that reason, the ICU is usually 2:1, the “step down” unit is normally 3 or 4 to 1, and so on.

This is why the ED usually has a unit called “fast track” where patients are less sick with things like toothaches or broken fingers. In fast track, you will see ratios of 6:1 because the patients require far less of the nurse’s time. Fast track is usually a separate subunit within the ED, usually staffed with a nurse or two and a midlevel practitioner (a PA or a nurse practitioner), and the goal there is to clear out as many low acuity patients in as short a time as possible, thus leaving the sicker patients (who take up more time and resources) for the doctors and the nurses with lower ratios.

Categories: Me


Anonymous · February 14, 2023 at 6:47 am

Good luck with all the new!

Aesop · February 14, 2023 at 7:09 am

Great for you.

When people ask me why I’m in CA, one thing I point to is a mandatory 4:1 max ER staffing ratio, and 2:1 for critical patients.
I had as many as 79 patients (no shit!) at once before the staffing law passed overwhelmingly in this state.
Still the only one to do so.

Your OTJ story is the poster child for why I’d never leave before retirement under any circumstances.

Best wishes with your move.

    GuardDuck · February 14, 2023 at 9:40 am

    A bill was just introduced in Washington to mandate a max patient ratio. My wife is conditionally hoping it passes. Her fear is a poorly written law causing unintended consequences.

    Apparently you like the law down there? Any drawbacks?

      Aesop · February 16, 2023 at 3:27 am

      Sometimes hospital manglement (not a typo) thinks it’s like the Pirate’s Code (merely guidelines) rather than black-letter law of the land, so they try to “selectively ignore” it.

      Keeping certain Sacramento offices on speed dial cuts down on the problem tremendously, but the main problem is that deliberately ignoring the law should be a reportable criminal offense, with prison time for admin types who do it.

      Then it’s not so funny any more, and a lot less optional.

      FWIW, the rule of thumb hereabouts is
      ICU: 1-2 patients
      ER: 4 patients, and ICU pts. in the ER count as 2
      Tele: 6 patients
      Med-surg: 8 patients

      When TPTB can ignore a rule, they will. And when it’s pt’s lives and your own license at stake, you tend to want to kill people for putting either one at risk.

Jonathan · February 14, 2023 at 7:30 am

Good finds, I hope the job and house turn out to be what you want.
How do you budget for moving costs, redecorating, and time off for both?

Anonymous · February 14, 2023 at 12:12 pm

You might consider building construction variations which are better fits for a second world country where maintenance is harder to get: 1. Drastically more insulation so you don’t have to spend as much on A/C. 2. Higher wind load so you can stay in place during hurricanes without the evacuation mess, and short of a tornado you won’t need an immediate serious structural repair. Window shutters, either hinged or roll-down.

West South Africa · February 14, 2023 at 12:57 pm

Move before the affirmative housing HUD acts passes.
As the competent staffing crisis intensifies, there should be wage increases for those who are competent.

grump · February 14, 2023 at 4:10 pm


Strictly looking at what you posted, IF you wanted to work PRN in surrounding areas, you could…..but with a $12-hr raise, you may be able to enjoy y’alls time off together……

TheyCallMeGrumpy · February 15, 2023 at 10:31 am

Would love to know the name of the builder. We were looking at Floriday, but the builders were loosing their minds and charging $225-$240 per sf.

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