SERENITY NOW

It isn't a cert one time that lasts for life, its a lifetime access to the website where you can recert every two years for free for the rest of your life. I'd agree that the first time around its helpful doing these in person. I've already done them twice in person and the second time was essentially an easy refresher, especially considering in residency we were running codes and getting plenty of lectures on resuscitation that went way beyond the scope of ACLS. This is why you'll hear many EM docs ridicule these types of certifications, saying that it is protocol cookbooks for nurses or FP doctors who don't do this for a living. But, if its really the case that many hospitals require the in person sessions, that is good for me to know since it might not be worth it to get one of these life time subscriptions.

So my certs from residency are due to expire in a few months. From what I understand, ATLS is the only one of those that needs to be done in person. BLS, ACLS, and PALS can all be done online it looks like. Is this how you all go about re-certing as well? Any particular source that you'd all recommend online? I have some $$ left on my CME for the year and noted this website that is a pay once and be able to recert for free for the rest of your life for all 3 BLS ACLS PALS which seems like a good deal considering I've got many years left in the field. Does anyone have experience with this program? https://nhcps.com/bundles/ Thanks! -SN

Are the PAs the ones putting on splints at your place? IMO, that is below our pay grade and not an efficient use of provider time. Should be techs or nurses to do it... make them go through the training. Sure, reductions that need to be immobilized perfectly should be splinted by us, but for everything else its not necessary as long as you properly train the techs/nurses.

Numbers to know in EM - 35$ collected per RVU for medicaid, up to 100+$ collected per RVU for private insurances. 150$ collected on average per ER patient. You work 150 hours per month X 12 months per year X 2 patients per hour X 150$ collected per patient = 540,000$ per year collected in your name. Now it doesn't seem so outrageous that we have PAs making over 200k per year...... Know what you are worth.

-you will likely find that the way you can impact this number the most is by putting the focus on low acuity patients. get these patients in and out in no time. when it gets busy, i don't give most 4s and 5s any meds in the dept - i just e prescribe and they can take it once they get to pharmacy like they would in an urgent care environment. putting in a med order, waiting for pharmacy to verify, nurse to find time to get it, etc, all adds up big time. -e prescribing is key - one of my coworkers said admin did a comparison and those who use e rx have shorter dLOS, and those who convert to erx improve as well -- no more nurses running around trying to find you to sign the paper rx. -avoiding unnecessary testing is also huge for decreasing dLOS... I clinically clear the majority of my simple MVC patients and have them in and out whereas many people are CT scanning constantly. -for patients who only need a positive/negative test (X-rays, hcg, etc), I use epic's "discharge pending" option right from the get go and tell patients the contingency plan up front... "I suspect this is an ankle sprain and so long as X-ray is negative, my team will come back with aircast and DC paperwork, but if there is a fracture I'll come back to talk to you" - that way the majority of the time I don't have to go back in there and nurses can discharge as soon as they see the X-ray is negative. -similar to the avoiding unnecessary testing, i have found that directly asking every patient something along the lines of, "what are you really here for?" many patients will come out and admit "I just want a med refill", "work note", "referral", etc. You can avoid an entire unnecessary workup and save tons of time by figuring out their goal. -with regards to you mentioning frequent reassessments on things like migraines, I hit it hard right up front. migraines get 3L IVF, toradol, compazine, benadryl, tylenol all up front... they always feel better quickly and I always have them out by around 1.5 hours max. (back painers - I don't give them any meds in the dept) I've been doing a new role with the admin team and focusing a lot more on improving these things myself as well, so I'd love to hear what others have to say too. -SN

Lots and lots of gel is key. I often squirt a whole cup of gel on the anterior abdomen before starting the exam, then I scoop up plenty onto the probe for each individual scan. You wouldn't have to press on the abdomen at all if you have enough gel contiguous with the transducer. The exception as noted above is the subxiphoid view (agree with switching to PSL if they're too tender).

So I'm at the advanced EM bootcamp conference in Vegas and we had a great lecture on "serious illnesses that can present in a benign fashion"... A wolf in sheep's clothing". Great lecture by Dr Diane Birnbaumer, who is a wonderful teacher that presents things in a unique way compared to many other lecturers. If you ever have a chance to hear her speak, take it! Her cases definitely fell into the umbrella of test negative or occult EM, so I figured I'd periodically share some of them here for you all to learn from too. 13. 22 year old F had a severe headache while she was sitting down at work yesterday, with the severe intensity lasting around the first 15 min, she took tylenol and went home. No hx of headaches / migraines in past. It has since resolved and she feels fine now, and is asking for a work note. Do you give her note and discharge her? 14. 28 year old M presents with R knee pain and swelling since yesterday "while playing basketball" (though no injury and he didn't feel like he tweaked it while playing). He now can't move his knee. XR neg for fx. DDX? HnP that would help? Workup from here? 15. 36 year old F presents with fever, sore throat, hoarse voice. On exam her oropharynx is clear. Strep test is negative. DDX? HnP that would help? Workup from here?

Sounds like an awesome opportunity. Agreed that it would be very difficult to find the same setup as a PA outside of new age academic EDs, but I would totally do it if I were in your shoes! A year will pass in no time and you'll take that experience with you for your whole life. I would see if you could get some shifts in the ED throughout the year though, since you'd be surprised at how quickly things atrophy after you leave the ED and put all of your attention to a new specialty.

Great idea. I'd be happy to help. I had already been accruing the basic "things to do after graduating" list over the past couple years, which was made into a sticky in the hidden sticky section. I think it would be a great idea to add more topics (like below) that would cover the spectrum of things to learn and challenges for new grads. Would be good to keep this sticky actually on the front page here because we do see so many questions on these topics. Just off the top of my head, I can think of several topics that I wish I had a brief primer on when first starting out.... -practical first steps (process of getting state license, DEA, keeping logs, etc) -choosing a specialty (general forum pearls like trying to stay general first) and considering residencies -process of applying for jobs. Where to go, qualities to look out for, questions to be ready for, and questions to ask them, etc. -business of medicine, know what you are worth! Basics of metrics and what we are now judged on. -malpractice risk and insurance - different types of insurance, ensuring you have occurrence or tail coverage, etc. basics of identifying highest risk situations, risk avoidance, charting. -starting your first job - biggest challenges when starting practice: interacting with consultants, transitioning from didactic resources to practical clinical resources, etc.

And of course, during your learning process, if you stumble upon any particular lectures or resources that really stand out as being superb, you could share it with the rest of us... on a website like FOAMest.com ? And while you are there, you can check out the resources that others have found to be the most helpful too. This is one of the educational projects I've been working on, since I remember how frustrated I was as a new grad wading through all of the countless resources out there. I hope it helps~

When I first started out in EM, I found that I had to learn with a much different perspective than in school. Its not about learning the details from a disease-centric perspective (ie heart failure causes these symptoms and is treated this way) its all about the approach to the chief complaint (ie how do I work up a patient with shortness of breath). Very different perspective to go about your learning... it replicates what you are doing on the job. You are given a chief complaint from triage, and have to know the relevant emergency ddx, and based on that, know the relevant HnP, and the tests to order to rule out those emergencies. That is 90% of what we do in EM. Once you establish a dx, just uptodate it on the spot for the treatment details... no need to memorize treatments at first since they will just be drilled into you over time anyways. Best resources to study the approach to chief complaint... -#1, bar none --> emrap C3 (continuous core content) -- Many resources are academic and not what we actually do, but emrap C3 is spot on.... its simply the best I've seen. They start with a real patient case and have a discussion about each step in the process of working up and managing the most common patient scenarios. -Beginning chapters of Rosens (one of the EM textbook bibles) focus on approach to chief complaint. -Minor emergencies is excellent for on the job reference of practical "what do I need to do", but perhaps not really geared towards studying and understanding the principles of what you're doing. -to practice your learning with a practical EM simulation app, check out EM Gladiator's app called "resuscitation" -- it is interactive, very good content and provides feedback on what you missed. It is free as well. One of my colleagues had a great idea that I adopted and am very glad I did when first starting out... As you are learning from the above resources, especially if you have access to your EMR, start to make your note templates with the learning points written into them. Ie if you are learning about chief complaint "back pain" and studying the resources, you can have your HPI already prepopulated with things like "patient denies saddle anesthesia, bilateral radiation down legs, incontinence, retention, immunosuppression, IVDU, etc" which are targeted to the ddx and can spark your memory if you are taking care of a patient down the road and forget what is important to ask (I chart in the room so its right in front of me while examining). So with this method, studying is helping you learn the essentials, making your evaluations more thorough on shift, and making your charting more efficient... killing 3 birds with one stone.

Nice work, team. Sorry I haven't been able to post recently but have been busy with work, but the questions were discussed just fine. This patient ended up having ED stabilization of BP, blood sugar, head of bed, coags and we called a neurosurgery consult. They took him to OR for a crani, was in the ICU for some time, and I believe in the end had a poor outcome. It is very unfortunate that this was a bad outcome, but it is a case that certainly has a lot of teaching points at each step of the way, so I hope you all found it valuable as well. If you enjoyed these cases and this format, let me know since I am happy to do more. If you have a particular chief complaint or condition that you struggle with, let me know and I can gear future cases to those needs. Thanks for following along! -SN

I have been recommended to keep a log of all of my advanced procedures that I do in EM. I track it all under the "patient list" feature in epic, with a category of procedures. It saves mrn, procedure, date performed, etc. My credentialing team with the hospital wanted us to provide proof that we have performed every procedure at least 2-3 times in the past 2 years, and that is all of the info they would need.

Really enjoy your posts - thanks for sharing. If it makes you feel any better, I felt like I didn't know anything throughout the entirely of my residency program and honestly I still feel that way today a year and a half out. Imposter syndrome is very real, especially for us as PAs trying to kick it in EM and critical care with the docs. But then again, I see physicians who have been doing it for years find themselves in situations where they feel like they don't know anything either. I think that is probably a healthy feeling that fuels us to never stop learning. Put one foot in front of the other and don't sweat it...