SERENITY NOW

High impact mvc with abdominal pain and tenderness --> CT scan with IV contrast is negative.... patient is obnoxious and bothering nurses, so they keep asking you, "can you just discharge him already?!". What can still be missed, and how do you proceed? (saw this case in residency)

Bingo! I had always been taught that while CT w IV contrast wouldn't pick up the specific clot location, it should still show you secondary signs of ischemia and thus if its negative you can stop there (wrong - it would only pick up late stage ischemic changes but by that point it is too late). I had also been told that negative lactate helped to rule it out (wrong - again only a late stage marker). I also had been taught that the CT angio requires a huge contrast load and despite that it has a different focus so you might miss things you'd otherwise see if you got a normal CT w IV contrast.... all that being said I only very rarely see it ordered. The emrap episode turned that one on its head! They explained that CT w IV contrast is NOT sensitive to rule out signs of ischemia, so even if it is negative you can't rule it out. They also said that ordering CT angio has only minimally increased contrast bolus, not significantly increased risk for AKI, and it has two scans so the rads will still get the normal CT with IV contrast images to assess for everything else. Lesson learned! I'll be ordering more CT angio abd pelvis on my elderly abdominal patients now!

Learned another good one on emrap today! 68 year old F with PMH of a fib presenting with abdominal pain and benign exam --> lactate and CT abdomen pelvis w IV contrast negative --> ??

Nice case! Top ddx: trauma/ptx, PE, boerhaves, effusion/tamponade -- CT will find all of them! What did the tunnel of truth find?!

You do make a good point - those aren't things that could really be put on a resume, but they certainly are things that would have a strong impact on me in the interviewing stage so I think it would still be practically helpful in the job application process. To know that someone's heart is set so much on the specialty that they are immersing themselves in FOAMed, reading tintinelli, learning from lectures given by the legends in the field... that really tells me that they are truly motivated to learn, they are resourceful, they know how to learn without needing their hands held, and will probably take off quickly at the job. I'd be impressed if I heard this from a graduating student or someone in urgent care trying to break into EM. If more resume boosters are needed to get into the interview stage, I agree with emedpa that the EM certs may provide some benefit, but at the end of the day many may have to relocate to the areas where they are short on EM providers or start with something like urgent care or trauma and bridge their way in to EM over time. Just my 2cents at least.

I can not for the life of me understand why someone would drop that much money when there is so much incredible free (or nearly free) options openly available around the web, and this free content is often from the best lecturers in the country (....and could be found on a website like foamest.com ). There is no replacement for the clinical experiences of a residency, but you could to a certain extent learn some of the didactic components of a residency online by using these free resources. There are residency programs that have great websites that list out the content and lectures from their educational conference, tintinelli reading club questions, etc. You could also read through the residency blogs out there and pretend you are with them month by month as they rotate on different services, immersing yourself in that specialty's free online content. In my opinion that would be much more valuable than this course.

Hey gang,I wanted to finally share this (free) website that I've been working on for some time now... As PAs, we often don't have the benefit of a residency to curate the best lectures and content to learn from outside of the clinic/hospital. We have to learn a lot of the medicine on our own with whatever resources are available, but lets be honest, there are a TON of resources available. Lets say I want to learn from the best lecture out there on electrolyte abnormalities since I had a challenging hyponatremia case the other day... if I search online I'd get hundreds of hits and I wouldn't know where to start, which is unfortunate because there are a select few incredible electrolyte lectures (Corey Slovis's) freely available online but hidden amongst the masses. Even if I knew that a specific content producer like EMRAP was great, they have over 15 years of content which is too much for any individual to sort through. Like in other fields, we in medicine could really use a tool that can upvote the best specific content so that the 'best of the best' resources will rise to the top over time. The content / resources could be anything... lectures, articles, podcasts, youtube videos, textbook chapters, or any specific content that is available online. The website provides the tools to do all of that; anybody can link in specific content from any source (louisville lectures, emrap, etc) into the site and it is plugged into a rank'able list which anyone can upvote or comment on. The lists are organized by body system and are searchable to make it easy when you want to find a specific topic to learn about. Essentially we would be forming a centralized, crowdsourced list of everyone's favorite medical lectures and resources from all around the web. Anyways, I'd appreciate it if you checked out the site and let me know what you think. I'd like to modify and improve things to fit the goals of the community, so let me know your feedback. Also, please keep the site in mind when you are looking for a great lecture to review a given topic, or if you hear a great lecture out in every day life, please share it to the site so the community can benefit from it too! Thanks! -SN link --->>> https://foamest.com

Lots of good advice here. I would add one more consideration that shouldn't be at the top of the priority list but is still part of our reality as modern health care providers.... asset protection... If we get sued on the job (or if neighbor kid breaks his neck in your pool) and you lose for over limits of insurance coverage, they CAN and will take your personal assets. All of that money you worked so hard for over the years down the drain in an instant. You can't plan to just hide it away once you are served the notice since they will have discovered your assets and frozen them... so you need to protect yourself ahead of time. First, know the details about your malpractice insurance! What are the limits? Is it occurrence or claims made? Know that there are things you won't be covered for (prescribing for friends / family, "illegal or unacceptable behavior" like hippa violations or workplace harassment). Also, consider getting high limits on your personal insurance (auto/home etc) and get umbrella insurance on top of it - its generally quite cheap but can at least double your insurance limits. Next, instead of having a ton of money sitting in vehicles that creditors have access to, its worthwhile to store it away in protected vehicles from the start. Doesn't have to be offshore accounts or LLCs or other expensive measures, but in general put a good portion of your money into any of the simple things that offer protection from creditors: 1) your home equity / "homestead exemption" - states range from protecting all of your home equity to nothing! Look into whether titling your home as joint "tenancy by the entirety" would provide more protection. 2) retirement accounts (401k, roth, etc) 3) cash value life insurance policies / annuities 4) things "off the radar" -- collectibles, gold / silver / etc buried in your backyard that nobody knows about is also safe haha These are all state specific, so take time to learn your local laws -- check out link below: http://www.assetprotectionsociety.org/wp-content/uploads/2013/07/50-State-Creditor-Exempt-Asset-Chart-2013.pdf So, to address OP's initial question.... keep this in mind if you are hesitant about putting money into investments like 401k / roth. There are so many benefits already mentioned, and I would add asset protection as another big benefit to consider. Add me to the list of people above who max out both 401K / roth as my top investing priorities!

Hello everyone! I realized that it has been over a year since I finished the residency, so I wanted to give a bit of an update on what things are like post residency life. As I think I had mentioned, we moved across the country and the wife and I are loving life out here! The job actually hired me before I even moved, so I really didn't have time to shop around hospitals to see which might be the best fit, but in the end I have come to really love my job. The people that I work with are great, the leadership team is wonderful, and the patients are still challenging. Since we cover a few different EDs, I get a nice variety from low acuity to high acuity depending on where I go and what I want out of the shift. We work in the main ED, and always have docs available for consult when we need them - the support is really quite good. I have still been able to do advanced procedures, and the docs love that they don't have to walk me through them, whereas the majority of the other APPs do not feel comfortable performing advanced procedures on their own. Here's my favorite part: NO NIGHT SHIFTS! The hours are of course much less than residency, so I have finally been able to get back in shape, cook, travel, and just all around enjoy life more. Life is good! I've been getting PMs / questions asking me about the residency and if I think it was worth it now that I can look back after the fact. I can definitely say YES without a doubt for me it was worth it. Everyone is different and has different circumstances so it might not be right for everyone but for me it definitely was. All of the benefits I have listed throughout the blog have held up to be true... it provided me a great base of knowledge in a safe structured atmosphere, gave me with a great network of contacts/friends in medicine, will always be a big resume buffer that helps me stand out from the majority of EM PAs, etc etc. I have noticed that the doctors I work with really respect the fact that I went through a lot of the same path that they went through, and visa versa, I have a ton of respect for them since I know how long and hard their path has been. Overall, it has been incredibly valuable to me. The downsides of residency, namely the long hours and low pay, have already been more than recuperated considering I was able to land an amazing job with great pay and a great work life balance, and I'll be able to enjoy these benefits for the rest of my career. Since I still have had the energy to learn new things, I've been trying to get involved with our group in a few nonclinical ways as well. First, for whatever reason, I've really enjoyed being a part of the morbidity and mortality committee - the group that reviews bad outcomes, referred providers, pitfalls, lawsuits, etc. It has been a really excellent learning experience and I'd recommend everyone go to these if their group has them. It really helps open your eyes to the many ways that things can go wrong with cases, have an eye out for the pitfalls waiting out there for us, and how to chart effectively / defensibly. Medical malpractice is a very interesting field indeed. I've also been lucky enough to get a position as APP lead and will be helping in the medical direction / process improvement for one of our sites. This is a relatively recent development for me, but I'm looking forward to learning more about the business, the metrics, how to improve efficiency, etc. I know I know all of the negative sides of the "bean counter" approach to medicine and I have felt the pressure of that, but I still think it will help me to be a more well rounded EMPA if I am able to really understand all of these different perspectives in the practice of medicine. Since these are new waters for me, any tips would be appreciated from those of you out there who have done this type of thing before! Feel free to PM me. Anyways, thats the update for now. Feel free to ask me anything (AMA) like the other bloggers have done - post away with any questions that you might have. I do miss writing these types of educational posts on the site. If there is interest for a thread on a given topic (like certain EM topics, medical malpractice, or admin/medical direction, or anything really) let me know and maybe we could start up a new educational thread. -SN

I've been considering an admin/leadership position in my EM group and as usual I try to ask around and scour the internet to see what I am getting myself into. I happened to stumble upon this gem of a thread on SDN... its a diamond in the rough for sure. It walks step by step through the happenings of a private EM group from a business perspective to help give a sense of what the doctors and the business is worth, and the dynamics as a result of the ever-enchroaching "national staffing corporations". I would highly recommend everyone take the time to read this if you want to have an understanding of modern medicine and the clinician's place within this business. It is written largely from the perspective of physician practice owners / partners, but I think it also opens up great discussion topics for us as PAs. The read gives us a sense of how much we actually earn for groups vs how much we actually cost... in a nutshell, we are so profitable for them that we are a part of why modern physicians (and hospital administrators, and CMGs, etc) are able to maintain their salaries. Despite being so profitable, as PAs we are pretty much always going to be limited to the status of employee and not reap the equitable returns that we bring in. What do you all think about this? Is that okay? At the very least, I think that being educated and aware of our true worth should help give everyone perspective when we go to negotiate our pay collectively. Groups may try to tell you that you are costing the practice money, but you will know the truth! It will also arm you with some of the things you should ask about when applying for jobs from a business perspective... what is the patient volume per year, patients per hour expected to see, average RVUs, payor mix, etc... these can all give you a sense of how much your employer will be making off of you, and in return, what your worth will be. Check it out! (be aware, this is a LONG read that might take a few days, but its worth it!) https://forums.studentdoctor.net/threads/how-much-are-you-actually-worth.1236817/ The common acronyms explained: -SDG - small democratic group - a small independent physician-owned group that contracts with the hospital to fill given specialty like the emergency department. EMGA is the example SDG in this story. -CMG - corporate medical group - the "national staffing corporations / agencies" like TeamHealth, EMcare, Schumacher, AppoloMD, Hospital Physician Partners, Sheritan, CEP, EMP, etc - these are the huge agencies that staff hundreds - thousands of hospitals and are very much so metric and profit driven. ...Thoughts? -SN

Nice thoughts @fishbum. The answer to the "trick question" of #8 is that the ddx doesn't really change and the real error is the ordering of the head CT in the first place. Head CT really rules out very little in a non traumatic headache patient. The test is still for some reason part of the "standard workup" for so many docs/PAs/NPs. I think it actually hurts our case when a well appearing patient who you think will be fine has a "just to be safe" head CT come back negative and you go on to discharge the patient... would have been better off not ordering it at all. We have these discussions on our M&M / quality committee all the time... the plaintiff attorneys say things like "the PA clearly knew something was wrong so they ordered a head CT, but they didn't know how to finish the workup to confirm the diagnosis". The test begets a follow up test if it is negative, like an LP, CT angio, MRI, etc etc. So, I am always careful about first thinking what it is on the ddx that I am able to clinically rule out, what specific disease I am still considering, and what rule out tests that needs. CT is almost never the sole answer... so be careful with it!

If I were back in the shoes of residency applications I would strongly favor joining a residency program that puts you in with physician residency classes, which all start in July. I know its competitive so I'd probably apply everywhere I'd be willing to live, but I'd definitely prefer the traditional ones. Its possible to fast track licensing and hospital onboarding in many states and you could graduate, finish pance, and be working within a period of a month or two. I think having even 4-5 months of experience before going into a residency would be valuable - read the first few posts from my blog to get a sense of how overwhelming it was going from student with no responsibilities to managing main ED patients within the period of a month. Not to mention the fact that truly sick patients are challenging for everyone, it was the million little things that you don't do as a student that all heap on you at once... hospital policies and procedures, EMR maneuvering, charting, interacting with consultants, etc... it was very overwhelming and even having a few months of normal job experience under your belt will help you sort out a lot of those things before jumping into the deep end of sick residency patients. Of course I agree it would be crappy for the place hiring you to only stay for 4-5 months, so because of that I would definitely be up front with them about your plan. It would likely be tough to get a job in the first place making it a moot point, but it can't hurt to apply and if you do luck out with a job, I think it would help. Might also be more realistic to reach out to the residency program you get accepted to and see if they have staff PAs/NPs working in their ED - you'd probably have a better chance having their group hiring you since they'll think you have a much higher chance of staying after residency. Can't hurt to try!

I'd try to get a job in your field before hand if you are able. Not only will it give you a nice headstart on loans, it will give you a good base of experience so that you can jump into the deep end in residency and really make the most of it. That being said, what field are you going into? A march start seems odd for a standard residency which typically will have a summer start.

Thanks for replying ERCat! Good answers too. The more perspectives, the better. I'll share a few more cases that have come up.... keep on guessing folks, and feel free to share away your own! 7) 42 year old M comes in with hand and finger pain after falling last night while drinking, she doesn't remember the details, hand and pointer finger are swollen and painful --> triage hand/finger X-rays negative --> ? ddx / plan / why? 8 ) 32 year old F comes in with a new / unique headache compared to her prior migraines --> head CT negative --> ? (this is almost a trick question but bear with me) 9) 32 year old F comes in 3 days postpartum with a severe headache --> head CT negative --> ? 10) 87 year old F comes in immediately after a mechanical fall with head injury, on warfarin, is asymptomatic --> CT head / neck negative --> ?

I wrote a blog post on this topic a while back in my EM residency blog (link below). Will copy / paste here: FOR STUDENTS: INCREASING YOUR CHANCES OF GETTING INTO AN EM RESIDENCY... The following are the main application components and what you can do to strengthen them: 1. Past experience. If you're a pre-PA, it would be great if you could get experience as an EMT/paramedic/ER nurse/ER tech before school. This looks great on your application and will seriously help your transition to an EM provider. If you aren't able to do this, you will still have a chance so don't worry. Shadowing experience is a good start for getting a sense for the way things are done in EM. 2. GPA - study hard! Higher GPAs are favored in admission committees, so don't shrug this off as unimportant in PA school if you really want to be competitive for a residency. I don't think that your PANCE score matters at all. 3. Letters of recommendation - The best way to get the best LOR is to really shine on your EM rotation, which requires you to really know your EM stuff... During didactic year, focus on EM topics, really prepare for and do well in your procedure labs, and consider starting to listen to EM podcasts on free time/commutes. Start with a podcast like 'EM Basic'. Also, develop a relationship with your PA program director, and make sure they can see your passion for EM. Many residencies require one LOR to be from your program director, and it will look a lot better if it isn't a generic cookie cutter LOR! During clinical year, work really hard on your EM rotation, come in early and stay late, show initiative and be active about learning from your preceptor. Definitely dive into the EM podcast scene; its a lot more fun way to learn and its more clinically relevant than the textbooks IMO - Check out EM basic, emrap, foam cast, emcrit, etc. Also very important: Get as many EM-related electives as possible (trauma, ortho, peds EM, ICU). If you stick with all of these things, you'll be an EM stud on your rotation and will get a shining LOR. Please see the post below from a prior post I made about more tips for making the most of your rotations. 4. "Buffing the resume" - show a specific interest in EM and do activities that reflect that. Does your PA program have a unique track dedicated to acute care? Perhaps a student "EM interest group"? Opportunities to learn about bedside ultrasound, advanced procedures, ACLS/ATLS/PALS? Opportunities to go to EM conferences around the area? 5. Personal essay and Interview skills - be prepared, practice, and articulate yourself well. See my earlier post about interview questions to reflect on. Hope this helps! -SN