Jump to content

Are all ERs this horrible to work in?


Recommended Posts

Pre-Script: Sorry for the long narrative, and thanks to whoever takes the time to read and comment.

 

 

I started my first ER job in a typical, busy ER in a major North American downtown metropolis.  This is a (purportedly) “teaching hospital", complete with full cadre of residents, med students, pharmacy students, etc.

 

 

From the get-go, no one really ever told me how to act and think like an ER PA.  No Introduction to logistics of working with attendings and consultants, no tour of the hospital to get an idea of what the different units do, no orientation to where I fit into the ED and what would be expected of me. Far more significantly, no introduction to the general philosophy of ER medicine at all, no wisdom on the clinical mindset or medical art of the ED; a total void in place of any clinical preparation, the depth of which I cannot begin to enumerate here....all the little "ins and outs" of emergency medicine. Not a word, just into the fire on day one. Regrettably, my PA school ER rotations were lacking, and as such I was starting fresh.

 

 

The first months were treacherous, and emotionally trying. With no guidance whatsoever, I fumbled, faltered, and learned the hard way, but not without continually making a fool of myself and losing all confidence in the eyes of the rather cold-hearted attendings.  Rarely did any of the other PAs pull me aside to give me advice; this hospital was, as many are, overloaded and understaffed, and people simply did not have the time nor the patience to teach, guide, or help.  I learned fairly quickly that a "teaching" hospital means teaching the residents;  PAs were expected to immediately perform as well as PGY3s, and damned to hell was the PA who was not at that level on day one.  

 

 

I also learned that the EM attending crowd, at least here, was a very sad jumble of dysfunctional characters. To start, many employed (and enjoyed) rather malicious methods of "teaching” , sporting empty stares, looks of disgust, and lines of questioning that were sure, no matter what, to make one feel like an idiot.  This was not the pimping I experienced as a PA-student, one designed to help you think, with a little good humor; this was an emotional reaming, sometimes loud and abusive, for not enumerating in 30 seconds, with a report style tailored precisely the way that attending liked it, why a healthy teenage patient with an obvious viral URI was not having an MI or CVA.  It was endless, cold, emotionless rectal-ripping and sometimes outright abuse, gratuitous and ill-intended.

 

 

There were, of course, a few kind attendings, mostly the very senior ones or the very young ones, but the rest were a cast of nervous wrecks, egomaniacs, bipolar powder-kegs opportunistic abusers and backstabbers, smiling to your face but sparing no mercy behind your back.  

 

 

At no point did I ever feel like anyone really wanted me to succeed. It felt more like survival of the fittest – a philosophy of opening fire and seeing who is left standing when the smoke clears.  

 

 

At some point, someone took pity on me and pulled me aside, and gave me a long, detailed, heartfelt and comprehensive reality-check as to what I was doing wrong, what I was doing right, what to change, and so on...essentially "how to ER PA".    It was like water for the parched; I finally felt like I had some direction, and from that day forward I pulled my act together tight, and excelled. Unfortunately, it was too late...the loudest, most unstable and most cantankerous attendings made very clear I was a burden to them personally. No matter what I did, I was never smart enough, thorough enough, fast enough for them, and despite protests of other staff, I was told that I was just too much trouble to bother with.  With an administration just as dysfunctional as the ER itself, I stood little chance.  My ER career there was through.

 

 

Needless to say, this all left me quite burned.  I moved on and found work in Urgent Care, where, without the constant abuse and second guessing of the attendings, I see three times the patients than I ever saw in the ED in the average shift, and am blessed to have the personal respect of my staff and the clinical trust and confidence of supervising docs.

 

 

Part of me wants to return to EM...I would like to work in an environment with the clinical support and array of services of an ED, and further my knowledge of emergency care.  But if most ERs are anything like what I experienced, I never, ever what to go through anything like that again.  Perhaps it's just the wrong decade to work in an emergency room anywhere near a major city in North America.

 

 

Was my experience the exception, or is this the rule?

 

 

Thanks all for reading.

 

Link to comment
Share on other sites

I'm sorry you had such a bad experience. I'm sure you realize by now that you did some things wrong and sounds like you accept that. However, that environment doesn't sound exactly friendly or healthy. I have been fortunate to work in ERs or happen to have been with mentors that invested in me. Not all ERs are like this.

 

If you started in that same ER today (that you were at) you would have a different experience. Because you now have experience. You know how to present a patient. You know how to look stuff up and run something by an attending just to make sure you're headed in right direction - or maybe you wouldn't be nervous to run the first few cases by another PA to make sure any questions the attending might have you will readily know the answer.

 

If you want to get back into EM start moonlighting and picking up prn shifts. That gives you a chance to test the waters. Be warned though - a lot of ERs want you to focus on the fast track stuff and do workups only when the lower acuity patients are taken care of. And how many "low acuity" patients do I see that actually are higher? Lots.

 

You are probably always going to want to go back so go ahead and do it. If it would make you feel better go to an ER boot camp course. Again, I'm sorry it was so rough. My first job in cardiology was super tough and years later one of the docs told me that he was "one of the ones that wanted to keep you". Like that was supposed to make me feel better - I didn't know they discussed getting rid of me. Only when the group was divorcing did it come out. First jobs suck. They just do. I got my first ER gig in my hometown where I had worked as a tech and then had done my clinical rotation. The director was someone that had become my mentor and I wasn't afraid to ask questions. I'm embarrassed at some of the things I asked now looking back on it - and they didn't make me feel bad. I got my feet wet there. Mean people will always be mean people. I tried to be an asset to them and then when I was caught up I would ask how I could help them. So yeah I did the fecal impaction. The odd laceration. The abscess that had been waiting. We all helped each other.

 

So give it another try is my point

 

 

Sent from my iPhone using Tapatalk

Link to comment
Share on other sites

To answer the title question, horrible staff and management can make the coolest ER in the world the most hideous thing since scrofula.  I work in a dysfunctional one that is that way because regional management won't deal with the outliers that won't staff their departments and hospitals - we get our own patients AND everyone else's, something our place isn't equipped to deal with.

 

"BEATINGS WILL CONTINUE UNTIL MORALE IMPROVES".

 

sk

Link to comment
Share on other sites

Haha I love how much imagery you put into your writing - it is really fun to read!   But I am sorry for the negative experience you had.  To be honest, its stories like these (and there are a lot of them!) that was a significant part of what drove me to do a residency.  When I was in school, I thought to myself, "what are the things I want in a job?"  Well, I wanted to work in the main ED and have excellent oversight / dedicated teaching on everything you mentioned:  the philosophy of EM, the advanced procedures, the complex patients from pediatrics to OB to surgical patients, and the critically ill patients requiring resuscitation.  Sure there are some fantastic EM jobs out there that provide that for people new to EM, but when you apply around its really a gamble because its hard to know what a job will be like until you are thrown into it.  I think the ONLY way to guarantee that kind of excellent learning environment is by attending an established residency program.  With your experience now I'm sure you could do just fine with another job in EM, but you may also consider doing a 1 year residency program to get that training experience that you are looking for.  

Link to comment
Share on other sites

  • Administrator

"You own your own employability"

 

Pretty harsh-sounding words, but true: no one cares about your career but you. Don't wait for others to teach you, go learn.  Don't wait for people to tell you where or when or how you screw up, go find and fix problems proactively.

 

If you don't know how to act and think like an ER PA on day 1... why did you get offered the job, and, more importantly, why did you take it?  How did you get through rotations so mentally unprepared to work in a real high-speed, low-drag ER?  It sounds like it was a truly terrible experience.  Again, when I read one of these horror stories, I'm stuck thinking... how did your program not prepare you for this?  Did you not have an advisor to whom you could have reached out, even post-graduation?

Link to comment
Share on other sites

Thanks all for your replies so far! Specifically responding to rev ronin...I took it, because, ER is one of the few areas where this is simply, absolutely no way to learn to be an ER PA besides from being an ER PA.  I believed that then, and my experience only confirmed it.  Barring getting a shot at the dozen slots available nationwide for EM residencies (I tried multiple times), or having been a ER scribe,  there is just no way to prepare for it.   And, of course, more significantly, it was always my dream to be an ER PA, long before PA school  (was an EMT for many years).  In clinicals, sure, they let us hang around the ER and do a little of this and that, suture here and splint there, but being in an inner city they had even less time to care to teach a PA student, and at the time I was just trying to get though school like everyone else.  I was never given the opportunity to manage a patient from start to finish, chart and present myself, not once.  They let us learn plenty of skills, but little in the way of management and general ER workflow.  Post grad, everyone in this metropolis is on their own...tried reaching out to my advisors and got no response.  This is, again, a major city, and there is no time or plethora of help to go around....everyone is just trying to get by.  

 

But I truly feel, having been there, there is absolutely no way to prepare for an EM job...the nature of the job is such that there is SO much to learn that cannot be found in a book, even if you read Tintinalli end to end (I was/am in the process) and, it's probably the most light-speed clinical discipline out there....too much to learn, too little time, no one wants to share or care because of the pace.  There is no way to just "go learn".  Emergency Medicine in particular is far more a transmitted art than a book science.  You can't learn gestalt, gut sense, you just have to see ten of everything, and then you will begin to feel it (unless you lose your job when you've only seen about two of everything).  I listened to EM Boot Camp until i could recite it by heart, went to weekend EM CME conferences....but nothing is like the actual ER.  No book, tape or conference prepares you for the logistics of the practice.   Fixing problems proactively works when you have a basic paradigm, and good support, but you can't fix it if you don't know why it's broke.   EM Residents have the benefit of three years to screw up, but I certainly didn't. Either you get lucky enough to have a cheerful ER with great mentors, or you get screwed as I did.

Link to comment
Share on other sites

Haha I love how much imagery you put into your writing - it is really fun to read!   ...With your experience now I'm sure you could do just fine with another job in EM, but you may also consider doing a 1 year residency program to get that training experience that you are looking for.  

 

Haha thanks. I actually applied multiple, multiple times to the residencies, but there are just too few slots and the ones around my region seem to prefer young, fresh, polished grads, not older experienced folks...but in any case yeah I think I'm beyond that point, just would do well to find a supportive environment....

Link to comment
Share on other sites

......If you want to get back into EM start moonlighting and picking up prn shifts. That gives you a chance to test the waters. Be warned though - a lot of ERs want you to focus on the fast track stuff and do workups only when the lower acuity patients are taken care of. And how many "low acuity" patients do I see that actually are higher? Lots.

 

You are probably always going to want to go back so go ahead and do it.....

 

Yeah, perhaps that's an angle...haha actually I'm great with the fast track stuff, that's what I see in UC anyway.  And yup had my fair share of bad **** come through initially on the board as fast track ho-hum....full blown sepsis as "a fever"...was definitely interesting.

Link to comment
Share on other sites

Thanks all for your replies so far! Specifically responding to rev ronin...I took it, because, ER is one of the few areas where this is simply, absolutely no way to learn to be an ER PA besides from being an ER PA.  I believed that then, and my experience only confirmed it.  Barring getting a shot at the ten slots available nationwide for EM residencies (I tried multiple times), or having been a ER scribe,  there is just no way to prepare for it.   And, of course, more significantly, it was always my dream to be an ER PA, long before PA school  In rotations, sure, they let us hang around the ER and do a little of this and that, suture here and splint there, but being in an inner city they had even less time to care to teach a PA student, and at the time I was just trying to get though school like everyone else.  I was never given a patient to manage, chart and present myself, not once.  Post grad, everyone in this city is on there own...tried reaching out and got no response.  This is, again, a major city, and there is no time or plethora of help to go around....everyone is trying to survive and jobs are scarce.  

 

But I truly feel, having been there, there is absolutely no way to prepare for an EM job...the nature of the job is such that there is SO much to learn that cannot be found in a book, even if you read Tintinalli end to end (I was in the process) and, it's probably the most light-speed clinical discipline out there....too much to learn, so little time, no one wants to share or care because of the pace.  There is no way to just "go learn".  Medicine is far more an oral art than a book science, and that's a thousand-fold for emergency medicine.  I listened to EM Boot Camp until i could recite it by heart, went to weekend EM CME conferences....but nothing is like the actual ER.  No book, tape or conference prepares you for the logistics of the practice.   Fixing problems proactively works when you have a basic understanding, and good support, but you can't fix it if you don't know why it's broke.   That's why teaching hospitals exists, because residents are just as unprepared despite their time in ER rotations as I was (but teaching doesn't seem to extend to PAs at my place).  Either you get lucky enough to have a cheerful ER with great mentors, or you get screwed as I did.

 

Your program failed you.  Plenty of PAs leave school prepared to succeed in situations like yours.  You said your ER rotation was subpar and you had a misperception that a teaching hospital would extend to your position.  PAs aren't residents.  You can draw all the comparisons you want between the two, but the fact is that we aren't the same and no one has to treat us the same (or extend such 'teaching' opportunities to us).

 

If you want to go back to the ER, go.  Odds are 50/50 you'll have a similarly harsh environment.  In theory you know more medicine now and won't need as much hand holding and guidance and that alone may improve your experience.  Bottom line, though, you can't blame the whole experience on the ER.

Link to comment
Share on other sites

  • Moderator

Your program failed you.  Plenty of PAs leave school prepared to succeed in situations like yours.  You said your ER rotation was subpar and you had a misperception that a teaching hospital would extend to your position.  PAs aren't residents.  You can draw all the comparisons you want between the two, but the fact is that we aren't the same and no one has to treat us the same (or extend such 'teaching' opportunities to us).

 

 

 

 

I disagree with the "program failing" him/her- and maybe it's because their experience in PA school mirrors my own.  I could easily see a busy teaching hospital ER doing this to a new-grad PA- which is typically why these places have a minimum requirement of at least a year of experience before hiring

Link to comment
Share on other sites

No, not all ER's work that way. While my experience hasn't been perfect and there are some things our PA group still needs to fix and push for, I have found the MDs and the hospital to be supportive and welcoming of our role. The group sponsors and pays for an extensive training program that includes lectures and labs to help us mature as new grad PAs.

 

There is only so much that can be taught in 2 or so years in PA school, there has to be some level of OJT and orientation into what is expected. While we all practice EM, every ED is different and what we all do is slightly different, so it's not just the program's fault and even with a residency, one cannot expect to perform perfectly and to expectations.

Link to comment
Share on other sites

Your program failed you.  Plenty of PAs leave school prepared to succeed in situations like yours.  You said your ER rotation was subpar and you had a misperception that a teaching hospital would extend to your position.  PAs aren't residents.  You can draw all the comparisons you want between the two, but the fact is that we aren't the same and no one has to treat us the same (or extend such 'teaching' opportunities to us).

 

If you want to go back to the ER, go.  Odds are 50/50 you'll have a similarly harsh environment.  In theory you know more medicine now and won't need as much hand holding and guidance and that alone may improve your experience.  Bottom line, though, you can't blame the whole experience on the ER.

 

So you think 6-8 weeks of a EM rotation is enough to allow a new grad PA to function independently in a busy ED?

Link to comment
Share on other sites

  • Administrator

So you think 6-8 weeks of a EM rotation is enough to allow a new grad PA to function independently in a busy ED?

I don't think that's what anyone's saying, but yes, the ARC-PA required rotations should be enough for a newbie PA to know how to learn and develop.  I don't think ANY PA is ready to function completely independently on day 1, but it doesn't sound like that was the problem here--this colleague of ours doesn't appear to have been prepared to collaboratively learn in an unsupportive environment.

Link to comment
Share on other sites

"You own your own employability"

 

 

 

We had a similar saying in the Army - "You're your own career manager".  More often than not, you've got to go out and find your own education from the facility - not getting enough tubes, go chat up the anaesthetists, want more procedures, talk to surgeons, hospitalists, etc and ask them to keep you in mind if something neat comes up.

 

SK

Link to comment
Share on other sites

We had a similar saying in the Army - "You're your own career manager".  More often than not, you've got to go out and find your own education from the facility - not getting enough tubes, go chat up the anaesthetists, want more procedures, talk to surgeons, hospitalists, etc and ask them to keep you in mind if something neat comes up.

 

SK

 

 

This is something I have been wondering about for a while actually... once you are out in practice, is it appropriate/okay to reach out to the specialists and set up some kind of learning opportunities of your own?  For example, all of our medicine residents spend a couple of weeks on the liver service and they say that they learn a TON in a short period of time... we don't have that built in as EM residents, but I'm sure that if I wanted to (and if I had the time, which I don't right now), as a PA resident the liver service would let me join and function/learn like a student/intern at the very least.  I was wondering if I'd be able to do something like this when I get out into practice, if I manage to find a specialist who seems nice enough to take me under their wing, maybe spend several of my days off to go and round on their service with them (or practice intubations w/ anesthesia, procedures with surgery, etc as mentioned above).  I wasn't sure how appropriate that would come off to the specialists.  Any of you have any experience doing this, or hearing of something like this working out?  

Link to comment
Share on other sites

I don't think that's what anyone's saying, but yes, the ARC-PA required rotations should be enough for a newbie PA to know how to learn and develop.  I don't think ANY PA is ready to function completely independently on day 1, but it doesn't sound like that was the problem here--this colleague of ours doesn't appear to have been prepared to collaboratively learn in an unsupportive environment.

 

Thank you; this is what I was getting at.

 

Of course 6-8 weeks isn't enough time for ANY rotation.  But OP doesn't appear to have any inkling that that's how a busy ER/ teaching hospital would operate and where his/her place in that process would be - and, IMO, this is part of where the program failed.  Knowing how PAs are/can be utilized and to have a realistic disposition entering the workforce is part of the process.  

 

Of course there needs to be OTJ training but there is also a degree of personal responsibility to make sure that's happening and not just waiting for someone to hold your hand.  My program has made it very clear that once you graduate you aren't done studying and learning; in fact you may still be studying regularly initially.  You're just learning differently to apply the info vs being tested on it.  I certainly don't expect to walk off the graduation stage and just show up to work without any supplemental learning on the regular.

Link to comment
Share on other sites

  • Moderator

for folks without the benefit of a residency, it makes sense to work your way from lower acuity to higher acuity areas over several years. I was fortunate to have many years as an er tech and paramedic before pa school then in pa school I had 3 EM rotations (required, elective, peds em) and a trauma surgery rotation. I started out doing urgent care and fast track, moved to a community hospital seeing all comers, then a level 2, then a level 1, now entirely rural and mostly solo.

Link to comment
Share on other sites

for folks without the benefit of a residency, it makes sense to work your way from lower acuity to higher acuity areas over several years. I was fortunate to have many years as an er tech and paramedic before pa school then in pa school I had 3 EM rotations (required, elective, peds em) and a trauma surgery rotation. I started out doing urgent care and fast track, moved to a community hospital seeing all comers, then a level 2, then a level 1, now entirely rural and mostly solo.

 

 

When PA's first came to EM in N. Texas this is how it was for us (me).  Start with lesser acuity cases (snot noses, cough, rashes, etc.) and over time build trust with others and confidence in self.  In neither of my two DFW area ED groups was I expected to be primary for cardiac arrests, ACS, CVA etc. (this was pre-FT at the time).  Very rare trauma case rolls in (stab wound to chest for example) then there is no other option other than yourself and the ED physician.  Soft tissue injuries and lacs were all yours.  Fast forward to implementation of FT then the only time you were in the main ED was when you were slow and the main ED was busy.  Funny how it never seemed to work the other way.  Present day?  Who knows.  I know I turned down a Parkland ED position earlier this decade where they stated that it would have been myself, a resident (2-3 year) and an attending where cases were rotated amongst pods and you got whatever came in next.  If I hadn't already given my word to another facility I would've gone that route for the trauma experience just to show that I had what it took and then call it a career (which is what I told them in the interview).  You have to remember that I go back far enough to where it was a big deal for myself and a fellow classmate, both us of with EMS experience, to be the first PA students at UTMB-Galveston to take ACLS for heaven's sake!

 

Now?  I'm just a mercenary for a paycheck seeing easy, no brainer stuff and keeping an eye out for sub-clinical ACS in what you think is a head/chest cold, and a diaphoretic lady like no one's business who can't get her hands on enough paper towels to stay dry who also has tightness across her upper chest and neck radiation but refuses transport with EMS and goes to her PCP and is dx'd with strep (HUH?).

Link to comment
Share on other sites

  • Moderator

I was the first student at my pa program to take ATLS. my first rotation was trauma surgery and I was the only student on the service. I made a good case that I should have ATLS before day 1 of the rotation. I got it for free at our affiliated hospital and I dragged 2 other students with me (the next 2 guys who would be at that rotation site). that was 1995.

Link to comment
Share on other sites

Fortunately, I started in a busy ED ~ 60K visits/year, level 3 trauma center.  I found that the best teachers were the other PA's & NP's.  ED docs were good, but only had time to answer brief questions, not give explanations.  The other PA's & NP's had a bit of time to give those explanations or to show you tips for more complicated procedures.  It still took me 1.5 years to get efficient at moving the level 4-5's, and another 1-1.5 to get efficient at moving the level 2-3's.  Still working on that - I still get bogged down sometimes.  That's coming in with ~ 30 years pre-hospital, ACLS & PALS (not just the cards - having done it in the field), and lots of trauma experience as well as ATLS.  I spent a lot of time looking pretty dumb to hospitalists, surgeons, etc.

Link to comment
Share on other sites

Archived

This topic is now archived and is closed to further replies.

×
×
  • Create New...

Important Information

Welcome to the Physician Assistant Forum! This website uses cookies to ensure you get the best experience on our website. Learn More