pa12ew Posted August 6, 2012 Share Posted August 6, 2012 Hi everyone, I am a recent new grad who got offered a job in the ED. Currently, I'm waiting for hospital credentialing to be completed before I can officially start in September. I have volunteered to shadow with the ED medical director (who is also my supervising physician) for this month so I can get a good jump start. I feel like I know NOTHING compared to what I've been seeing. It's so scary and intimidating and I'm not sure what should be the best way for me to prepare for this intense job!? I did 2 ER rotations and an urgent care rotation during PA school, but I haven't touched a patient since April and I feel like I lost some of the things I learned. Any tips on how to bring myself up to speed as quick as possible? I worry about making myself look like a fool (which I already anticipate)...or worse, having the doc raise doubts about my ability to do ER! :sweat: I love emergency medicine which is why I went into this field straight out of school...I just need some great advice and helpful tips from you great EM PAs out there! Any input GREATLY appreciated :smile:...Thank you! Link to comment Share on other sites More sharing options...
bgdog Posted August 6, 2012 Share Posted August 6, 2012 I worry about making myself look like a fool In my humble opinion, being afraid to look foolish when learning a new skill, especially a critical skill-set such as Emergency Medicine is the worst mind-set you can have. Instead of admitting that you’re a complete novice and will not have much of a knowledge base but is willing to do everything it takes to learn, you are worried how you look. As such, you will tend not to be open to asking, checking and re-checking. Instead, you will have an internal dialog that your ego is in control of, “of course I know that, Im a PA.” When you learn to ski, there is no way you will look cool. The only way to look cool on the mountain is to learn how to ski. Same with ER or any medicine for that matter. There is just no way you’re going to be anything other than a rookie, instead of being hung up on it, embrace it. Own it. Freely admit, “I’m new, and I’m here to learn.” Now grasshopper, snatch the pebble from my hand. Link to comment Share on other sites More sharing options...
shnor77 Posted August 7, 2012 Share Posted August 7, 2012 Well said. I will keep this in mind as I go into my fall semester of didactic year and beyond. Link to comment Share on other sites More sharing options...
sunny2spot Posted August 7, 2012 Share Posted August 7, 2012 I just started this May in the ER as my first job out of school and it's been great. I think shadowing is a really good idea and that will be an invaluable help since, as you probably know, starting any job in medicine requires you not only to learn the medicine but also the flow and the EMR and the staff and how things work. ASK QUESTIONS! The docs will respect you most if you openly and readily communicate to them when you're out of your depth. THAT's how you earn their trust, because their worst nightmare will be you going cowboy-up, faking it and hurting someone. So don't be ashamed to ask questions and say so when you feel like you have no clue what to do next with a patient. I would also highly recommend looking into an EMed-based conference to hit up and refresh all that book knowledge that's a little dusty after a few months off. I just went to the Emergency Medicine Bootcamp last month, and I know the AAPA is putting on their CRASH course in September. It's definitely worth while in my opinion. And you need those CME from somewhere ;) Link to comment Share on other sites More sharing options...
pa12ew Posted August 7, 2012 Author Share Posted August 7, 2012 Thanks for the reply! I know that I'm a rookie with limited experience and trust me, because of that, I intend to ask A LOT of questions. I was once told by a PA that the most dangerous kind of mid-level provider is one who doesn't know when to ask for help! So I know it will be very detrimental to both the patient and my credibility if Im afraid to ask a question...I am willing to do everything it takes to learn, as I mentioned previously I am shadowing before starting the job. Im also reading up on ER literature at home. What new grad isn't "worried" to some extent on how their going to look for any job? I didn't write that post to imply that Im afraid of my image more than learning how to be a great EM PA...after all at the end of the day it doesnt matter if I look "cool." What matters is whether I'm able to provide excellent patient centered care to those who need it. I will try my best to embrace it, afterall I know it will take some time before I feel comfortable. I am going to humble myself and take it in day by day. :smile: In my humble opinion, being afraid to look foolish when learning a new skill, especially a critical skill-set such as Emergency Medicine is the worst mind-set you can have. Instead of admitting that you’re a complete novice and will not have much of a knowledge base but is willing to do everything it takes to learn, you are worried how you look. As such, you will tend not to be open to asking, checking and re-checking. Instead, you will have an internal dialog that your ego is in control of, “of course I know that, Im a PA.” When you learn to ski, there is no way you will look cool. The only way to look cool on the mountain is to learn how to ski. Same with ER or any medicine for that matter. There is just no way you’re going to be anything other than a rookie, instead of being hung up on it, embrace it. Own it. Freely admit, “I’m new, and I’m here to learn.” Now grasshopper, snatch the pebble from my hand. Link to comment Share on other sites More sharing options...
Moderator True Anomaly Posted August 7, 2012 Moderator Share Posted August 7, 2012 If your ER doesn't already have it, invest in a couple of texts- either good ol' fashioned hardcover for sitting at home and reading, or available as a file on a tablet. Get both Roberts and Hedges (the ER procedure bible, plus some good general ER stuff), and either Rosens or Tintinalli as your ER bible. Rosens is a bit more descriptive and readable, and Tintinalli is more of a quick reference. For what it's worth, we give our physician and PA emergency residents copies of Rosen's. I also highly recommend listening to an ER podcast or two. The most popular and probably the most comprehensive is EMRAP, done by the guys at LA County hospital/residency program. Theyve been doing it over ten years now, so as you can imagine lots of good info. They are also now in year 2 of a 3-year cycle of reviewing basic ER topics every month, so by the end of 3 years they will have covered just about every ER text subject. Each podcast is about 4 hours. The catch is that you do have to pay for it yearly, but your CME budget should be able to handle that. I also recommend getting a PDF reader for your phone/tablet because they also give written summaries on the podcasts and you can make notes and highlight on the PDF for you to use as quick reference at work, which is what I do Best of luck. It's a difficult field, but I can't see myself doing anything else in medicine Link to comment Share on other sites More sharing options...
fuma102 Posted August 9, 2012 Share Posted August 9, 2012 Tinntinali as a "quick" reference? Its about the size of Harrisons! reading: Buy "The basics of Emergency Medicine, A Chief Complaint Guide" ... You should be very comfortable with these complaints within your first month or two if youre seeing "Main ED" patients. So you dont scan every headache or seizure, but then you know when to CT/LP. (PS- Ive had 2 meningitis cases in the last 3 months from afebrile seizure patients! one with a known history of seizures. scary.) prep at home / at starbucks: after you see a patient, read on differentials via Tinntinali or on uptodate ... ie- indications for abx in hand lacs, workup management of seizures, sepsis management / appropriate abx coverage, management of Rapid Afib... covering your arse: ALWAYS rule out the worst, and ALWAYS give appropriate follow up. nasty lacs come back for a wound check. avulsion lacs get hand f/u. for procedures, clearly explain risk / benefit and document they had competency. even having a patient AMA doesnt completely cover you - give the most possible care you can give and have the follow up office call them. explain AMA in front of family and document they ALL knew risk / benefit and WHY you wanted them to stay and possible bad outcomes (written on signed discharge papers: "youre 87 and we were concerned your nausea & sweating were signs of a heart attack. we wanted to keep you in the hospital for further monitoring and work up, but you refused. you may return at any time for further evaluation and please promptly return for any worsening or new symptoms. you understood that these symptoms are concerning to us and that its possible these symptoms may be life threatening. Please call your doctor TOMORROW or follow up in our clinic if you choose to not return to the ED.") Start thinking ahead: when you see a patient, figure out a backup plan - patient failed PO keflex for cellulitis- what now? your rapid Afib patient didnt break with cardizem, now what? Stay open minded and dont stay focused on 1 or 2 things. Not all Chest pain is ACS. PE? dissection? pancreatitis? differentials and back up plans are key! GI cocktail didnt work for your nauseated 42 year old obese bengali patient with early family cardiac hx... time for an ekg (if you didnt think of it before!) Along those lines... DONT GET JADED: once you've been in the ED for about 6months to a year, you'll likely become some form of jaded with the chronic offenders. they are sometimes REALLY sick. Nurses will laugh when you work up the drunk with a questionably tender abdomen until you discover a GI bleed or raging pancreatitis. same approach to every patient, antennae up, every time. If you roll your eyes before you enter the room, deep breath & start over. Good nurses are worth their weight in platinum. pay attention when they think someone is sick. be the person the nurses come to when they think someone is sick / in pain. you help them, they help you, my friend. Otherwise, it may be difficult to get a urine sample at times. Lastly, scalpels really are sharp. Pneumonia, HIV, TB and Hepatitis really are communicable. BE CAREFUL & PAY ATTENTION. Link to comment Share on other sites More sharing options...
bradyg007 Posted August 9, 2012 Share Posted August 9, 2012 ^nice statements!! Why I wanna be a PA :) Link to comment Share on other sites More sharing options...
katief262 Posted October 5, 2012 Share Posted October 5, 2012 I'm a new grad starting in the ED this month, thanks for these tips!!! :) Link to comment Share on other sites More sharing options...
RetNavyPAC Posted October 10, 2012 Share Posted October 10, 2012 PA12ew, Welcome to the specialty. All good advice & comments here. I don't know you, but you sound just like many of the eager, bright-eyed new grads we've hired over the past couple of years. Let me share with you some of the wisdom I offer them, and understand this is my take and reflects my current practice setting & milieu. . . . One of the great things about medicine – especially emergency medicine – is that you will never know everything. Take every opportunity to learn. Challenge the attendings & staff PA/NPs to teach and mentor you! Know what you don’t know – and then fix it. Never be afraid to ask questions. Demand constructive criticism. You need to constantly work to expand your comfort zone. This provokes much anxiety. It should, but it'll keep you on your toes. It's nice and warm and safe in your little cocoon with all the sore throats and sprained ankles. When you are first starting out it is very understandable not really wanting to pick up that 68 year old woman complaining of shortness of breath, fever, nausea and chest pain, a history of COPD, MI, CHF, and with a pulse of 134 in Triage. Patients like that often have scary things going on. The ONLY way to make them less scary (or even eventually UN-scary) is by taking them on, demystifying them; learning the pathology, the treatment options, potential complications and the disposition. No one should ever let you jump in to the deep end of the pool. Wade in. Up to your knees at first, then your waist and chest once you get more comfortable. Tell your attending that you would like to pick up that moderately complex patient and that you’ll be asking them for help and advice. Emergency medicine is the ultimate team sport. I promise you that initiative will be rewarded in both tangible and intangible ways. It should be self-evident that only by continually expanding your fund of knowledge, clinical skills, and medical decision-making that you become a better clinician and a contributor not only to your own personal and professional success, but to the ultimate success of your Emergency Department. A few words about ‘speed’: You’re new and you’re slow. That’s okay. No one expects anything else right now. No one is going to ask you why you aren’t juggling/managing 5-6 patients at a time. But . . . becoming fast and efficient is part & parcel of being a successful emergency medicine provider. It is something you need to work on and develop as quickly as you can (along with everything else). Everyone understands that this takes time. But by the end of the next several months you should be pretty comfortable with having 2, perhaps 3, and maybe more (everyone develops differently) lower acuity patients ‘cooking’ at any one time. There are many different ways to skin a cat and everyone develops the strategy & tactics that work best for them. In the meantime, badger your preceptors for tips & tricks that work. Eventually you will get to the point where you can safely and competently manage 4 or more patients at a time, with varying levels of acuity. You have to be literate, in the sense of being well-versed in the ever-growing and changing body of emergency medicine literature and knowledge. There is no other specialty that strives to be as evidence-based and evidence-driven as emergency medicine. In order to thrive and be the best EM PA you can be you MUST read and stay up to date. It is not enough to just listen to a podcast once a week and read JAAPA and Advance for PAs/NPs once a month. Ugh. But don’t go to the other extreme: you shouldn’t feel compelled to start reading & memorizing Tintinalli’s or Rosen’s cover to cover. I trust you have CME money – put it to use wisely. The CME funding in most places for EMPAs won’t completely cover the cost of a conference (that means registration, flights & hotel), but it can go a very long way to continuing your education. Much is available online. Here is a list of excellent resources I have found that have helped me immensely – and continue to improve my fund of knowledge: BOOKS: Emergency Medicine: Avoiding the Pitfalls and Improving the Outcomes; $50.00 Avoiding Common Errors in the Emergency Department; $58.00 Emergency Medicine Secrets & Pediatric Emergency Medicine Secrets; $34.00 & $38.00 Emergency Medicine’s Top Clinical Problems & Emergency Medicine’s Top Pediatric Clinical Problems; handbook-sized, $26.00 each; you can order get these from the ACEP website ECG in Emergency Medicine and Acute Care; $58.00 JOURNALS & MONOGRAPHS: Emergency Medicine Practice & Pediatric Emergency Medicine Practice; www.ebmedicine.net Monthly, up to date, evidence-based issues about things you see every day; no esoterica here. They are $279 & $199 a year respectively which might seem a bit steep at first glance, BUT you get full online access to searchable evidence-based archives, CME testing and tracking for the 48 Category 1 CME hours (each title) plus an additional 144 CME credits available from online archives. That’s $480 for a total of 96 hours of Category 1 CME – or $5 per CME hour. You’ll NEVER find a conference that’ll come close to that value. Emergency Medicine magazine; http://www.emedmag.com/ Free online subscription and you may get a free print subscription Journal Watch – Emergency Medicine; http://emergency-medicine.jwatch.org/ From the Massachusetts Medical Society (publishers of NEJM); $99.00 BUT – if you’re a PA or NP, it’s only $49! WEBSITES & BLOGS: Almost too many good ones to count. . . EMBasic; START with this collection of podcasts: http://embasic.org/ This is designed for off-service residents and others who are new to EM. This is the basic meat-and-potatoes of emergency medicine. They are relatively short (~ 20 minutes) about how to do the workup of common things: chest pain, shortness of breath, back pain, 1st trimester vag bleeding, headache, etc. It is awesome! I wish it had been in existence when I started in EM EMedHome; Probably the best. www.emedhome.com Podcasts and video lectures available for CME and, like Emergency Medicine Practice, they will track your CMEs. If I only went to one EM website, I’d go to this one Academic Life in Emergency Medicine; http://academiclifeinem.blogspot.com/ Michelle Lin, MD from the ED at UCSF runs this one. Her 4x6 Paucis Verbis cards are great. SMART EM; http://smartem.org/ ERCast; http://blog.ercast.org/ Emergency Medicine Literature of Note; http://www.emlitofnote.com/ Life In The Fast Lane; http://lifeinthefastlane.com/ Free Emergency Medicine Talks; http://freeemergencytalks.net/ Hope even a little tidbit from this lengthy ramblng helps you. Good luck. See you around. :smile: Link to comment Share on other sites More sharing options...
rcdavis Posted October 10, 2012 Share Posted October 10, 2012 ^^^^most excellent post. Link to comment Share on other sites More sharing options...
Cody89 Posted October 11, 2012 Share Posted October 11, 2012 Nice rambling. Thanks for all of the great advice and resources. Link to comment Share on other sites More sharing options...
Corpsman2PA Posted January 30, 2013 Share Posted January 30, 2013 I'm curious as to a follow up with the OP, now a 5 month seasoned EM PA :) How are things? Link to comment Share on other sites More sharing options...
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