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From what I've seen in EM, PTO is very rare. For most employers, 10-14 shifts/month are considered full time, so there is an expectation that you'll schedule yourself off when you want to take a vacation. In general, I've found schedulers try to work with you to give you your requested days off. Vacations usually aren't the issue - holiday coverage tends to be. Even in my current job, where I'm the lead PA and scheduler, it takes planning and cooperation among folks.

EM, not in-patient, but I'm seeing that hospitals are dividing beds into COVID (+) and COVID (-). I have to do a rapid COVID test on all patients I admit or transfer. It is very hard to find a bed for any reason, much harder to find one for a COVID (+) patient, whether their admission is due to a COVID related issue or whether their COVID positive status is incidental. For example. last week I had to transfer an intubated COVID (-) patient on propofol and levophed from western Indiana to western Ohio to get an ICU bed. We called about 25 facilities before finding a bed. Indiana had no ICU beds, eastern Illinois had no ICU beds (including Chicago), and most hospitals in southwest Ohio had none. It was a 3+ hour ambulance ride because it was outside the flight range of medical helicopters. I have heard that ~ 15% of ICU beds are unavailable due to staffing shortages. That will only get worse when nurses who refuse vaccination lose their jobs and hospitals' staffing shortages worsen.

And they are ignoring the pope, who has very publicly stated that people should get the vaccine.

For our students I think there are several teaching points, many of which aren't really taught in PA school: Stabilization/resuscitation of patients not only can, but must, occur before diagnosis, and often before even full assessment. It does not matter whether this patient's lungs are full of fluid because of flash pulmonary edema, acute exacerbation of chronic congestive heart failure, or other reasons. They need pressure support to push the fluid out of their alveoli. This extends to other interventions for breathing, blood pressure support, altered mental status, etc. During this phase of patient care good enough quick is way more important than best slower. Nitroprusside is great, but requires an IV, which this patient may or may not have. SL nitro or transdermal nitro paste may not be as fast, until you consider the time to get the IV, get the drip ready, etc. You may need to start with the quick and transfer to the better later. More broadly, PO and IM may be 1st step, if IV access is going to be slow. Symptomatic management doesn't require definitive or necessarily even probable diagnosis as a pre req. Fever gets antipyretics, nausea gets antiemetics, pain (if likely to be real) gets analgesics. It doesn't matter if the fever is from cellulitis, pneumonia, UTI, etc; if the nausea is from gastroenteritis, head injury, etc; same for pain. This thought process for resuscitation/stabilization/symptom management goes for all types and locations of practice, whether primary care, urgent care, emergency medicine, in-patient medicine, etc. The tools available to you will change and you will need to know them. Your only option may be to punt, even if it's calling 911. Even with the same type of practice, say EM, approaches will vary based on local capabilities. For example, the Lt. reaches for ultrasound because he's calling his rad tech in from home. My rad tech is at worst 30 yards away and will get me a stat portable chest before my ultrasound machine even boots up. We're both in critical access hospitals. We don't have exactly the same meds, in house labs, etc. available to us. Some of the tools: meds, labs, imaging that Mike the hospitalist/ICU guy has I'll never have at my sites. Biggest point: PA school teaches this flow: Patient shows up and gives symptoms/chief complaint => history & physical => differential diagnosis => work-up: imaging, test, etc. => diagnosis => treatment plan. Actual medicine: Patient shows up and gives symptoms/chief complaint => Initial assessment => resuscitation/stabilization/symptom management => history & physical => differential diagnosis => work-up: imaging, test, etc. => diagnosis(es) => treatment plan => patient response => loop back to differential diagnosis; repeat until patient better, transferred to other care, or deceased.

If the patient won't tolerate the BiPAP, 1st try a small dose of ativan, e.g. 0.5 mg iv. If that doesn't work, try sub-dissasociative doses of ketamine.

I came to medicine after 29 years in corporate america, with partially overlapping time in the fire service and teaching at the university level. Each organization had its own politics, with many of the same issues. Any organization thinks first of self-preservation, and most leaders within the organization buy in to the organization's world view as the only correct one and then try to advance themselves by playing by the local version of the rules. I've found medicine to be no different. Large medical staffing companies are no different than other corporations in how they act. Large non-profit hospital systems that call their sub-organizations "ministries" are no different than other corporations. Smaller organizations seem to have less issues, but the effect of individuals is larger. We're all people, so this is hardly surprising. The best path I've found is to find a place whose culture, values, and lifestyle match yours. That answer will be different for different folks.

THIS!!! The key point in EM is to start stabilization of the patient with the limited information you can get quickly while you're gathering information for yourself and downstream providers to move towards a more definitive diagnosis and treatment. This patient is having significantly increased work of breathing. Whether she has some sort of restriction of air movement or impairment of gas exchange, e.g. fluid filled alveoli - or more likely both, she needs pressure support. This will both keep the small airways open and push the fluid in her alveoli back into the tissue. She needs STAT BiPAP to (hopefully) avoid intubation. Nitrites are a good choice. You can give her a SL nitro while you're putting her on BiPAP, then go with IV or nitro paste if you're having trouble getting IV access. Try to avoid tubing the patient if you can, she could be very hard to tube and very hard to wean. Don't send her out of the dept until her breathing is stable. You can get a portable chest in the dept. Ask the rad tech what their limits on GFR for use of contrast before you do the CTA chest. In terms of flow: Back to room, with provider following patient in to room Vitals, eyeball patient, lung sounds, touch legs O2, call for BiPAP STAT, nitro BiPap - should be on patient ASAP, ideally within 5 min (I'm spoiled, small ED, can make things happen fast) Then EKG, IV, labs, STAT bedside CXR. Hopefully the portable has a screen so you can view the image at bedside. Someone stays at bedside until pt's breathing stabilizes. Other thoughts: Foley may not be necessary. Some institutions policies limit their use. You can get a good sample for a UA without it and close enough info on UOP from bedside commode. Pro-calcitonin: won't help you any, can be helpful for the inpatient folks. But, can you even do it in-house or is it a send-out (think 2 days later)? D-dimer: can be one of the slower labs to result. You can make a clinical decision on need for CTA without it.

Are there any off shift rotations like ICU, anesthesia, U/S, ortho? What is actually done in the 5 hours/wk didactic periods? It may be a great place to learn, but it really sounds like what they're calling a fellowship is in fact an 18 month relatively low paying training job in a high cost of living area. For comparison, I started out at a Level III trauma center 8 years ago with about the same volume for $50/hour. We rotated through all areas, saw pretty much everything except level 1 pt's and grew at our own pace. We didn't have dedicated didactic periods.

I sort-of have call. My company staffs rural critical access hospitals emergency departments. We all travel to the site and stay there. The doc works a 12 hour day shift and the PA's/NP's work the 12 hour night shift. We call the docs for a few kinds of situations, they call us occasionally during the day when the department gets slammed.

Another thing: have you shadowed any PA's? Does their life look like a life you'd want? You should shadow PA's i n many different parts of medicine. UGoLong's life in cardiology and teaching is very different from mine in EM. Consider becoming a physician as well. In many parts of medicine, the life of a PA and the life of a doc is the same. The differences often boil down to: 1) the doc spent 4-8 more years in training between medical school and residency, 2) the PA makes 40% (+/-) of what the doc makes.

Mike - you're doing a great job of teaching the analytical diagnostic process. There is a key difference in how emergency medicine thinks that I don't think has come through yet: is there stabilization/resuscitation needed while we're working up the patient. Based on what I'm interpreting from the scenario, the answer is YES!!! This patient appears to have LLS - Looks Like S@#$. She's tachypneic, tachycardic, hypoxic - with insufficient improvement after high flow O2. She's wheezing (or could it be rales?). She was tripoding. She's had lots of birthdays. So, she's in respiratory distress, impending respiratory failure, and old enough to have minimal reserves. You know all this the minute you walk in the room with the patient. Then. add in vitals and some of the physical exam findings. The stat CXR is very helpful but isn't necessary to start the stabilization. So: consider that ventilation has 3 components: air movement gas exchange circulation Rhetorical question: which portions of this need support in this patient? So, what interventions will help with these problems? Supplemental O2 isn't enough. Once those interventions are in place, all of the other diagnostic workup can continue. There are some excellent ideas that have already been put forward. Get this patient stable (or at least closer to it), then you all can U/S, CT, wait for lab results, etc with less worry that you'll be coding and tubing this patient. Let's let the students chime in and after awhile I'll make suggestions on the flow of the visit.

Every night the nurses and techs are talking about the bonuses they are getting at other facilities or how much they could make doing travel assignments - making 2-3x what they make here. Can't blame them if they take travel assigments.

The nurses in my ED tonight pulled up various web sites listing the huge numbers of positions available. Almost all of them pay > $100/hour when the travel stipend (not taxable) is included. This includes a position available at my facility. There are nurses at hospitals near where I live who with disaster pay/bonus/overtime are making ~$115+/hour. They're earning it, but they're also making more than me. Wonder if (only sort-of) if a PA/medic could fill these roles.

I don't remember if it was ACEP or ABEM or AAEM, but some of their statements also took aim at the "for profit" residencies run by EM staffing companies.

That's alright, just call the Zpack for their URI.