Travel Nursing Agencies

Allied Resources Medical Staffing, 4949 Liberty Lane, Allentown, PA 18106, (610) 841-0210 – Great organization to work with – especially if you are just starting out. They were a subcontractor agency on my first assignment. After they had submitted my name for my first contract, I found an advertisement by the primary agency where I could have received more pay. This is how I discovered the differences in pay depending on which agency you go with. They weren’t able to make up the entire difference for me, but they did bump the pay slightly to help me out. Also, when I needed some employment verification for insurance on short notice they were extremely accommodating. Referral bonuses of $500.

Concentric Healthcare Staffing, 4250 North Drinkwater Boulevard, Suite 100, Scottsdale, AZ 85251, (855) 466-8773 – This is one agency I won’t be going back to anytime soon – and not because of the recruiter. I’ll tell you about the quality of her service in the following post. No, it was the account manager with whom I had a problem. The agency wanted me to talk to the client Director of Nursing to iron out the details of my contract. I did this, and one of the things we agreed on is that the only place I would be pulled from the ICU was to the ED. I went back to the agency and let them know everything was worked out. They sent me a contract with a general pull clause which would have made it possible for me to be pulled anywhere in the hospital. I asked them to change the contract to reflect the negotiations they told me to accomplish. I was told the legal department wouldn’t allow modifications to the wording of their contracts. I asked to speak to the account manager. I received a call from the account manager – a guy by the name of Nicholas Jimenez – who was absolutely rude and, in my opinion, unprofessional, and I told him so. He very quickly told me I was free to seek employment through another agency. Which I did, and I’m now getting $200 more a week than what Concentric was going to pay me for the same position. Mike Sherk, mnsherk@gmail.com

LRS Healthcare, 1120 North 103rd Plaza, Suite 3, Omaha, NE 68114, information@LRShealthcare.com, 800-811-0064 – Highly recommend. Current contract through them. Very smooth process from first contact to execution of contract. Mike Sherk, mnsherk@gmail.com

Maxim Healthcare Services, 7227 Lee Deforest Drive, Columbia, MD 21046 (with many satellite offices), 410-910-1500 – Good agency to work with. My recruiter was one of the nicest guys you will ever work with. But there are some shortcomings in my opinion. Their payroll department couldn’t tell me initially if my withholding would be for Pennsylvania, Maryland, or possibly both. Also, they seem to have a free-for-all with their recruiters. I’m constantly getting calls by new people. If I contract through this agency again, I want to use the same recruiter I had in the past and don’t need solicitation calls from others. Mike Sherk, mnsherk@gmail.com

Medical Solutions, 1010 North 102nd Street, Suite 300, Omaha, NE 68114, (several regional offices) info@medicalsolutions.com, 866-633-3548 – my initial recruiter with Medical Solutions was incredibly motivated – until I sign the contract. Then it became increasingly difficult for her to respond to any form of communication. See my comments in the appropriate following post. As an organization though, not bad to work for. If you want a contract in Washington, DC or Baltimore this is one of the agencies that you should look at. They seem to have, at least for the time being, an inside track to MedStar Health facilities. Mike Sherk, mnsherk@gmail.com

SnapNurse, 675 Ponce De Leon Avenue NE, Suite 8500, Atlanta, GA 30308, 844-804-7627, Text 844-804-7627 – I traveled with SnapNurse to the Ft. Lauderdale area in the late summer of 2020 to assist the Florida Department of Health with COVID-19 testing. This was a pretty good gig which paid pretty well. BUT SnapNurse will typically If pay your travel to the work area and your lodging. This means you won’t be getting any tax free lodging stipend. Also, they don’t give you the stipend for the meals and incidentals. You have to pay that out of your own pocket. Like I said, a pretty good gig. If you’re just starting out and don’t want to deal with the logistics of traveling this may be a good way to go. If you have experience and are comfortable setting up your own travel and lodging you may want to look elsewhere in favor of maximizing your tax free income. Mike Sherk, mnsherk@gmail.com

Please contribute to this post by leaving your comment below or by emailing them to me. As I receive your information, I will update this post with your comments and arrange the content in alphabetical order by agency name.

As always, please share below on the platform(s) of your choice, hit that like button, leave a reply if you’d like to share your thoughts, and check the boxes if you would like notifications of new comments and/or posts. Finally, if you are moved to support my efforts in publishing this blog you are free to make contributions via Venmo @nursinginthetrenches. Thanks! See you next time.

Travel Nursing Fundamentals

A little over 2 years ago when I started this adventure of travel nursing I was uneducated about the system/process, looking to land a job quickly, and went with the recommendation of a friend for the agency I used. I have absolutely no complaints about the agency, my recruiter, or my first assignment. But there are some things I have learned since then that I think every traveler should know.

Contract Hierarchy

If a recruiter ever tells you all agencies pay the same call bullshit immediately!! The expression of nursing needs, advertisement of openings, recruitment, and contracting of travel nurses is a multi level, nested, contractual and subcontractual nightmare if you don’t have some idea of how things work and how you can be affected. Generally a hospital has one of two options when they decide to seek staffing assistance from travel nurses. First, they can contact a recruiting agency on their own. Another method for them is to hire an agency (not sure what they call these organizations) who will receive their needs, put them into some type of industry acceptable advertisement form, and then approach recruitment agencies. Know this; every organization that puts their fingers into the pie is going to take a piece. The more levels of contractors and/or subcontractors involved in the contracting process the less you will get as a travel nurse. Your goal is to get as high up the food chain as possible. You want to try and find, as an ultimate goal, the primary contract holder for the hospital where you want to work to ensure for yourself the highest pay possible.

So with that in mind, if an agency texts you or in some other way contacts you regarding a position your initial reaction should be to do an online search to see if anyone else is advertising that position at that hospital and compare the advertised pay. Never be afraid to shop around.

When to be Loyal

This will be short and sweet. The only time I would recommend loyalty to an agency, in contrast to the advice I provided in the previous section, is when you are in need of benefits. Whether it be health insurance, retirement contribution, or something else, if you don’t have a source of benefits outside of your employer then you want to consider tenure with an agency so that you can qualify for their benefits. The one piece of advice I would offer here is make sure you do some due diligence and shop around to find the agency that has the best benefits for you.

Hourly Rate vs Tax Frees

So many nurses I have run into, when beginning their journey as a travel nurse, are hyper-focused on the hourly rate that they can get. This usually results from them having been a staff nurse and the only basis of comparison is hourly rate. This is not what you want to concentrate on primarily. Instead, you want to look at your tax free stipends. This is where you can make bank. In the following section I will show you how to double check that you are getting the maximum allowable lodging and meals stipends allowable by law.

Verify the Tax Frees

Do yourself the absolute biggest favor you can by going to the site listed below and checking the allowable tax free stipends when you’re negotiating your contract.

State Income Taxes

If your tax home and place of employment are in different states you’ll want to pay attention to your state income tax withholding and be aware of what your state tax liability will be. Generally, the income tax is withheld by the state in which you are employed and then when you file your tax return with your home state you will get credit for the tax paid to state in which you are employed. Communicate with your tax professional for the details on your specific situation.O

Here’s a useful cite to reference the income taxes for each state:

One place where this can get a little difficult is if the state in which you are employed does not have a state income tax. In this case, you will not have any taxes withheld unless you direct your employer to withhold income tax for your home state. Again, please talk to your tax professional so that you don’t get yourself in a financial bind come April.

Compare Notes

Don’t be afraid to share, in private, the amount of your contract with other travel nurses. When multiple agencies are filling vacancies at a hospital there can frequently be a disparity in pay between nurses. Sharing of information between travel nurses is a great way to take care of yourself and take care of your fellow travel nurses at the same time. Don’t be afraid to help each other!

Referrals

Another great way for travel nurses and nurses considering traveling to take care of each other is through referrals. Please consider leaving your contact info with your comments – if you choose to respond to any of the future posts I cite in the next paragraph. If you’re looking at a particular agency and don’t know anyone who has traveled with them consider reaching out to and using one of the people in the post as your recommender. An extra couple hundred bucks from a referral can go a long way sometimes.

The next four posts will only become a resource if you, the reader, contribute. These posts will be continually updated based on comments received and will be for evaluations and suggestions regarding travel nursing agencies, travel nursing recruiters, hospitals where travel nurses have worked, and places to stay while traveling.

As always, please share below on the platforms of your choice, hit that like button, leave a reply if you’d like to share your thoughts, and check the boxes if you would like notifications of new comments and/or posts. Finally, if you are moved to support my efforts in publishing this blog you are free to make contributions via Venmo @nursinginthetrenches. Thanks! See you next time.

Additional Thoughts on COVID-19

Wow! I can’t believe my hiatus has been over a year. It’s good to be back. And welcome back to all of my half dozen (LOL) readers!! I’d like to offer some additional thoughts on COVID-19 and the pandemic before transitioning into the subject of Travel Nursing.

First, in my experience treating ventilated COVID-19 patients, providers seem to be very stingy regarding the doseage of sedatives necessary to achieve adequate sedation. Please remember, if a intubated patient isn’t adequately sedated they will eventually be bucking the vent. We all know the outcome if this happens and remains uncorrected.

A more extreme example of the need for adequate sedation is when paralyzing patients in preparation for and during proning. Can you imagine how tortured and terrified you would feel if you were paralyzed and awake to experience it?? What if you were in pain or had some other physical need, were awake enough to experience that pain or recognize that need, and were unable to communicate your condition(s) to your nurse?? You MUST be a stalwart advocate for your patient in these situations. If not you, there may be no one else!!

Also, with severe COVID-19 pneumonia patients we are obviously very concerned about patients not oxygenating adequately. To combat the inflammatory wetness in the lungs we sometimes see providers ordering large doses of diuretics in addition to steroids. Monitor your patient’s fluid status carefully! If they have a central line you may want to setup CVP monitoring. There is a transition point where output will start to fall in response to the same amount of diuretic. This is when it’s time to really pay attention to intake/output, blood pressure, and heart rate. I have seen multiple patients over-diuresed to the point where they are then given bolus(es) to restore fluid balance and guaifenesin to mobilize secretions.

Regarding this next point, I’ve had several fellow nurses chastise me because of “advocating the use of alcohol”. Yes, I am advocating the use of alcohol since it is the only antiseptic that we can safely (in small, limited quantities) ingest. But I am not advocating the irresponsible use of alcohol, merely the minimal use for medicinal purposes. Last year I remember reading several papers stating that the coronavirus may colonize the oropharynx before it is carried into the lungs. The same papers stated that when this happens the virus generates a sore throat in its hosts. This is how the disease process started in me in January when I contracted COVID-19. The morning after I developed the symptoms of malaise and aches and pains I awoke with the worst sore throat of my life. In an effort to keep the infection from progressing any further into my body, specifically further down my respiratory tract, I used a modified “oldie but goodie” home remedy.

For generations some combination of whiskey, honey, and/or lemon juice have been used to treat sore throats at home. I have never cared for whiskey so I used 1 shot of tequila, 1 shot of honey, and 1 tablespoon of lime juice. I thoroughly stirred this mixture and, taking a small sip at a time, used the entire glass to gargle. After I gargled with each sip for a minute or two, I swallowed the mixture. By the time I was finished with this glass, my sore throat was gone. The next morning I awoke with just a slightly scratchy throat and repeated the gargling procedure again. My sore throat never came back and I never never developed a lung issue from my COVID-19 infection.

Warm salt water can help relieve the symptoms of a sore throat also, just not as effectively in my opinion. The reason I believe it’s not as effective is because you shouldn’t swallow salt water or any other typical gargling solution, but rather spit it out, because of the adverse effects on your stomach. So why do I think it’s so important to be able to swallow the antiseptic solution you are gargling with? Because the action of gargling forces air out of your mouth while you are holding a solution at the back of your mouth, gargling is only effective down to the level of the open epiglottis (figure 1):

So no matter how effectively you gargle, there is still a portion of the oropharynx between the level of the open epiglottis at the top and the level of the closed epiglottis at the bottom (figure 2) which could remain relatively untreated and potentially contribute pathogens to your lungs during inspiration of air. The only way to expose this area to the antiseptic affects of whatever you are gargling with is to swallow. Again, if you use this recipe it is not meant as a method to abuse alcohol, but a method to most effectively sanitize the oropharynx and possibly help protect your respiratory tract from infection.

One final item. Please DO NOT simply discard your habit of wearing masks in public. If you are vaccinated you still have the ability to act as a carrier. If you have had COVID you are not necessarily immune to the variant you experienced and not necessarily immune to the other COVID-19 variants. I believe, just like with the Spanish Flu of 100 years ago, we will be hit by a third wave – possibly by the more contagious Delta variant or a different variant. The possibility exists, if vaccinations are not available/ignored and masks are cast away, for this pandemic to keep going a while longer. Probability dictates if the pandemic can continue there is a greater chance of new variants developing through mutation.

At this point, as I said, I’m going to transition to several upcoming posts regarding tips for travel nurses based on my experience traveling over the past two years.

PPE Part 2 – Gowns and Eye / Face Protection

This post will certainly not be as involved as PPE Part 1 – Masks and Respirators, but the remaining parts of adequate PPE to care for COVID-19 should be addressed. One of the PPE items we are probably most familiar with is the isolation gown. We generally think of these for protecting us in contact and droplet precautions, but they are also valuable and necessary when entering an airborne precautions room. The gown will minimize the chance of airborne particles settling into the fabric of your scrubs.

Isolation gowns seem to be made of one of two types of material although sometimes you’ll see a gown made of both materials. On the left is a polyethylene gown. On the right is a spun polypropylene gown. Both types of material do an adequate job of protecting you. The major difference here is the breathability of the gown. If you are in a room for an extended period with a polyethylene gown be prepared to sweat. The polypropylene gown provides for more air circulation and, in my opinion, is much more comfortable.

Next we have the cap and booties. Really not much to say here, but I did want to show them. Caps usually aren’t part PPE on the floor and are generally seem in perioperative environments. You won’t see booties very often on the floor either. Again, they are usually seen around the OR.

Eye and face protection are much more important in airborne isolation than most people realize. Both tuberculosis and COVID-19 can be contracted through the eyes. Therefore, if you are caring for COVID-19 patients and develop conjunctivitis (pink eye) get yourself tested! If it gets in your eyes it can get in your sinuses. If it gets in your sinuses it can get to your throat. And we know where it goes after that.

Eye and face protection comes in three general types – goggles, face shields, and safety glasses. The most commonly seen types are the face shields and the safety glasses. Both of these provide adequate protection against splashes and droplets. Unfortunately, they are not totally effective in an airborne precautions environment. They allow air circulation to the face which could result in contamination of the eyes by an airborne pathogen.

Goggles, on the other hand, can be more effective for airborne precautions. The goggles pictured in the upper left seal to the face and have very small vents along the upper edge. The goggles in the upper right will fit over eyeglasses. This type has four vents (the white circular appliances) – one on each side of the goggles and one over each eye. Although the goggles minimize circulation compared to the face shield and safety glasses, it would be nice if the vents contained some N95 or greater filter media.

As I promised, pretty short and sweet. I hope there was something here for you to take away. Everyone please stay safe out there!!

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Homemade Mask Designs

Masks are in short supply in the hospitals and there is even less availability for the general public. Recent directives to wear masks in public have left quite a few people at somewhat of a loss as what to wear. I’ve assembled three different designs for you as a suggestions. Also, please pay close attention to the ear loop size. Many of the homemade masks I have seen / tried on have very small ear loops and are hard on the ears. You may want to cut a piece of fabric the size of your finished mask, staple your proposed ear loops on, and try the mask on before you mass produce ear loops that are too short. And the key thing to remember is if the mask is only made of cloth it will not stop the COVID-19 virus.

The first design is courtesy of a high school classmate of mine. I know she has made quite a few for family, friends, and people in the community – and I believe she made some for the local hospital. The nice feature with these masks is they are designed with a pocket into which you can place a filter. If you want protection from the COVID-19 virus the filter needs to be a HEPA filter of some type. You won’t find any N95 filters out there. Oh, and be careful washing HEPA filters. Many of them won’t tolerate it. See my Re-Use of Facemasks post for an idea on disinfection using hydrogen peroxide.

This second design I found on the internet. It’s a different style mask and looks like it would be effective. This design also has a pocket for a filter. Remember the ear loops and the HEPA filter material.

Finally a copy of our “duckbill” N95 masks that we use in the hospital. Dr. Ryan Southworth presents, and his wife demonstrates how to make one of these masks out of a HEPA vacuum cleaner bag.

If you’re considering making some of your own masks I hope this gives you some ideas. Until next time please continue to practice your social distancing and isolating in place. Be safe everyone!

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Disinfection of Filtering Facepiece Respirators (FFRs)

I’m sure this post won’t appeal to all. While it is informational, it’s not a subject that those of us on the front lines deal with. The subject is more in the realm of sterile processing as opposed to nursing. I’ve put together a collection of items illuminating the recent developments / decisions regarding decontamination of FFR(s) for reuse.

July 2016 – I’m not sure if others have heard of the research conducted at Duke University. I had after talking to a 3M representative several weeks ago when I inquired about decontaminating N95s. What I didn’t realize until last night is the final report of that research (which of course includes recommendations for further studies) was finalized in July of 2016!! For almost four years there has been an effective method for disinfection of FFRs but we screw around until there’s a pandemic to finally approve it!

March 20, 2020 – After I spoke to the representative at 3M I was emailed the following Technical Bulletin. According to this document Ultraviolet Germicidal Radiation, Ethylene Oxide, and Hydrogen Peroxide Vapor (HPV) treatments all resulted in no “observable physical change” to the FFRs. There was, however, no findings regarding the fit or post-treatment filtering effectiveness of the FFRs. Consequently, 3M could not endorse any of the methods.

March 27, 2020 (Based on document date) – Another paper from Duke University building upon the previous research. They showed the HPV method was feasible using commercially available equipment. They also performed fit tests on humans rather mannequins to verify facial seal of the FFRs.

March 29, 2020 – USA Today article regarding the FDA upgrading their partial emergency use authorization for Battelle – a Columbus, Ohio non-profit company – to increase the number of FFRs they may decontaminate each day. FFRs decontaminated in this manner are reportedly reuseable 20 times! With this “full” emergency use authorization the FDA is now allowing Battelle to process 10,000 FFRs per day when the company has two machines in operation – each of which can process 80,000 FFRs per day! Really?

March 30, 2020 – Webinar produced by Duke University regarding HPV decontamination of FFRs.

April 9, 2020 – CDCs latest information on Decontamination and Reuse of FFRs. HPV method is at the top of the list.

I hope you got something out of this and I didn’t bore you too much! Please click the comment button below and share (I’m not sure why there’s not a share button visible from the start). Also please feel free to leave comments and use the follow button in the lower right of your screen to get email updates of future posts. Stay safe and well!!

Comparison of pandemics: COVID-19 and the “Spanish” Flu of 1918-1919

A collection of three articles I found online. Some striking similarities between our current COVID-19 pandemic and the “Spanish” Flu pandemic of 1918-1919. The similarities are not only striking, but in a few cases disturbing. In my opinion there are two main things we have to realize as a society. First, just because we may experience a brief drop in “the curve” doesn’t mean we’ve reached the peak. Secondly, there may just be more than one peak to the curve and, like the “Spanish” Flu pandemic, a subsequent peak may be higher.

Please click the comment button below and share (I’m not sure why there’s not a share button visible from the start). Also please feel free to leave comments and use the followbutton in the lower right of your screen to get email updates of future posts. Be safe!!

Another Disagreement Over N95s

I have to ask myself if hospitals truly do not have the N95 masks so staff can have proper PPE or if they are holding them in storage based on the misinterpretation of the pathetic CDC guideline revision for PPE.

And now the CDC has changed that web page again. The strategies they discussed incuded using an N95 for multiple days, sterilizing the N95s for resuse, and rationing N95. But in no version of their guidance did they recommend withholding N95s fron the healthcare providers that need them. Come on hospitals! If you are short staffed now (and most of you are) can you afford to lose people to walking off the job because they don’t feel safe? Can you afford to lose them to quarantine because they become symptomatic? Can you afford to lose them if they end up becoming a patient? No, you can’t! So why don’t you get your priorities in order! It’s time to stop treating your staff like yesterday’s newspaper!

Please click the comment button below and share (I’m not sure why there’s not a share button visible from the start). Also please feel free to leave comments and use the followbutton in the lower right of your screen to get email updates of future posts. Be safe!!

What Would the Greatest Generation Think?

Whenever I see an article like the one I have featured below I can’t help but being taken back to my childhood. My maternal grandmother wasn’t the kind to save everything, but there were some things she did keep. One day while I was helping her in the attic I ran across my grandparents’ World War II ration books. Curious, I started asking questions about them. Grandma told me to set them aside and take them along downstairs when we were finished. Finally downstairs after what seemed like an eternity, grandma and grandpa sat me down at the dining room table. The books they had were almost identical to those shown in the picture. They proceeded to explain to me the process of rationing during “the War”. They told me that within each book were stamps for things like bread, milk, sugar, vegetable oil, and gasoline. Each time they purchased one of these items they had to present a ration stamp to be allowed to make the purchase. Also, there were only so many stamps for each item in a given month so they had to learn to do with less than they were used to. If they ran out, they were out for the month.

For at least three and a half years after rationing began, my grandparents’ generation had to do with less of most of the necessities they used on a daily basis. Now here we are, in this now entitled United States of America, and we can’t go one month without grumbling, groaning, and demonstrating. What would the men and women of the military services who fought in World War II think? What would the greatest generation as a whole think? What do you think this behavior says to the healthcare workers fighting on the front lines of the pandemic? Here’s what John Pavlovitz thinks:

Re-Use of Facemasks

I received some feedback that my Masks and Respirators post may have been a tad too long. Sorry about that, I just wanted to give as complete a picture as possible. But from now on I’ll try and limit my posts to a length which is a little more easy to digest.

In response to the shortage of N95 masks we are experiencing in fighting this pandemic, the CDC issued guidance entitled Strategies for Optimizing the Supply of Face Masks:

Among other things included in this document is guidance for the limited re-use of facemasks. I’ll let you follow the link above and read this guidance for yourself. What I wanted to point out is the guidance states the “mask can be stored between uses in a clean sealable paper bag or breathable container.” I’ve seen all the brown paper bags taped to walls in the hospital and I’m sure you have also.

My first thought with this technique was how do we keep the clean side of the mask from getting contaminated when we are taking our mask in and out of the bag. I’m not sure if this is the best idea to prevent cross-contamination. The video below, by Jason Rozinka, RN, came across my Facebook news feed last week. I think it’s a very good idea to minimize cross-contamination:

I’ll get into this more in depth in another post, but there’s research out there showing hydrogen peroxide is a suitable (and approved) disinfectant for the N95 masks. So I’m thinking why not disinfect my mask while I have it in storage between uses. This is what I came up with:

As you can see, I’m using the same container Jason describes – a 5 cup / 1180 mL Ziploc storage container. They are available in a pack of 3 which cost me right around $2.00.

First, I applied squares of heavy duty, double-sided mounting tape to the corners of the bottom of the container.

Next, I folded a shop grade paper towel to fit in the bottom of the container. All folds are down so no part of the towel will stand up into the container.

Finally, I added 8 caps from a bottle of hydrogen peroxide. If you use a regular paper towel you may need to use less. You want just enough to saturate the towel.

And here’s the end result. The mask is suspended above the hydrogen peroxide saturated towel. This works with the “cup” style and Aura masks. The “duckbill” doesn’t maintain its shape well enough, flattens out, drops, and touches the bottom of the container. If you decide to use my method remember to keep your container in the dark as hydrogen peroxide degrades in the light.

Please, if you choose not to use an alternative to the brown paper bag be careful that you don’t contaminate your hands when getting your mask out of the bag.

Remember, to don one of these masks you hold it against your face with one hand and pull the straps over your head with the other hand. I you glove the hand you will hold the mask with and use that hand to retrieve your mask from the bag or container you should minimize contamination. I would then discard that glove before applying the rest of your PPE.

Hope this helps. Stay safe!! Please click the comment button below and share (I’m not sure why there’s not a share button visible from the start). Also please feel free to leave comments and use the follow button in the lower right of your screen to get email updates of future posts.

Look for my next post on sanitizing methods for masks and filters.