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CSCH

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CSCH last won the day on December 29 2018

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  1. CSCH

    New Grad CCM Job resources

    The Ventilator Book by William Owens. It's the best. I read it twice before starting residency and I felt like it gave me an edge. Just make sure you find out what brand of vent your unit uses and what names they have for the standard/special vent modes so you can apply what you learn in the book to your machines. Marino is great; I think the mini is sufficient, but the full shebang is certainly good. I also really liked the Washington Manual of Critical Care. If you like things put into flow charts of if/then, it's perfect. Less theoretical, more about action items. The EMCrit podcast has lots of topics super relevant to the ICU, and the PulmCrit blog is great.
  2. CSCH

    New Grad in the Cardiothoracic ICU

    I always recommend The Ventilator Book by William Owens. Short, easy to read, packed with the real info you need about vents. Ideally, in CTICU-land patients are quickly extubated, but you'll certainly have your share of people who need more active ongoing vent management. (When you get to your ICU, make sure you find out what brand of vent they use and what each of the standard modes is called on their machine so you can apply your knowledge.)
  3. If critical care is your passion, and you know you get two electives, I would consider either getting into two different ICUs (MICU/SICU/CCU/neuro) or picking your second elective to be in a field relevant to the ICU, like ID, pulmonology, cards (esp heart failure), EM at a busy hospital, hospital IM. Really anything that keeps you in the hospital rather than clinic setting. I 100% flipped what I wanted to do in PA school, so make sure you keep an open mind!
  4. CSCH

    Residency for CCM??

    I'm in a CCM residency right now, and it's the best decision I've ever made. If you're thinking about it, at the very least apply and allow yourself the opportunity. But if you're asking me, you should do it. It has shaped me into a totally different provider than I would have been otherwise. The experience of rotating through every critical care specialty as well as spending designated time with consultants has been invaluable. There's no way to replace the experience.
  5. Thanks, Lt Oneil -- That's exactly what I was trying to say. My amygdala is starting to retain medical knowledge haha
  6. CSCH

    Residency VS Doctorates

    I agree this ProSpectre's point. I looked at and thought about both, but I felt that I wanted my clinical skills to grow first, so I did residency right out of school. Someday I may pursue a doctorate, but I want to feel like I have a real clinical practice established before I choose a doctoral focus.
  7. Also, you need to read House of God. But start it when you're at least 4-5 months in. It's a great book, but it'll really hit you right in the feels if you read it while you're in the midst of residency and you can really relate to the characters. It took me months to finish because of so little free time, but literally everything he goes through I went through (emotionally--and no, not *literally everything*). Another thing I've been musing on today is the way I move around the unit these days. Everything used to be scary. Everything. Now I know what I know, and I know what I don't know. I can recognize most real emergencies, and I know when I can walk down the hall to the patient's room and when I need to run. The machines aren't scary, and neither are their beeps. Questions from nurses don't feel like I'm being pimped (even being pimped doesn't feel like I'm being pimped anymore). But on the flip side, the real emergencies get my blood pumping much more than they used to. As I've taken on more and more responsibility, my spidey senses have become more acute, and there are certain vitals/labs/imaging/etc that (I think I stole this phrasing from someone) make my butt pucker. I always imagined myself going through this process and becoming increasingly more objective, thinking through things in a clear and efficient way. And I'm not saying I haven't grown that skill. But the funny thing is that I've also become much more instinctual, and I've stored all this factual knowledge in a casing of emotional knowledge, and the emotional side is the first thing to appear in my mind. Am I explaining this at all well? Maybe someone else has experienced this and can explain it better.
  8. The most important advice I can give you is to read The Ventilator Book by William Owens. Maybe twice. Maybe three times. It's short, easy to read, and has all the info you need to get started on day 1 with vents. (That man owes me money for the number of times I have recommended his book to some intern.) If you want more reading, Marino is the classic. I like how opinionated he is. When you first start out, you don't have experience upon which to build your own opinions, so I think it's good to borrow opinions and try them on for size. The full-size is good, but frankly the "mini" Marino is probably all you need. However (similarly to before PA school), I think it's really important to just enjoy your time off. Residency is exhausting, and there's no reason to go into it tired because the exhaustion is cumulative. Go travel or visit friends and family, or enjoy the hobbies you won't have time for. Or just sleep. I dream about sleep
  9. @Notfall Hours vary a lot between rotations. My off-service rotations were 9-5 M-F. My ICU rotations have averaged 4-5(+) 12-hour shifts per week. My last two rotations have included 30-hour call, so that changes the math a little bit. It's a one-year residency, and basically I live at the hospital. So, back to report on two high-intensity rotations. I already completed echo, which was kind of boring but has already been paying dividends in terms of my ability to do a good quick bedside echo, check IVC, etc. November was my month in the trauma surgical ICU. Things were *very* different there from what I'd been used to. This was the first surgical ICU I've been in that's actually run by surgeons, rather than having intensivists as attendings. (And I can tell you now that I VASTLY prefer intensivists.) Trauma is a different world, with a very different patient population and very different set of problems. I learned a lot about resuscitation-focused medicine, and I also really enjoyed working with PM&R. My team was amazing, and that was the only thing that made that month bearable. Our patient load was absolutely insane, and so the stress level was very high. I definitely hit a low point during the month where the hours and the workload caught up with me. My very first call night I had a patient actively hemorrhaging from an open pelvic fracture while the NP was dealing with a patient actively hemorrhaging from a stab wound to the heart. This month has been MICU. Because of the hospital I'm at (the community/county hospital), the patient population is predominantly lower income with a lot of barriers to care, so we see a lot of complicated people with advanced disease, stuff that I don't usually see at the other hospitals. I have a really great team, and I've liked the attendings a lot. In this hospital, once you're admitted to an ICU, you belong to that team, no matter where your physical location is. Because of this, we wind up with a lot of patients "boarding" in the ED. This can be really challenging, and these patients are really hard to keep up with. Big things change, and you don't find out for a while. I spend a lot of my time taking the elevator back and forth between our unit and the ED. Doing call shifts has been really good for my skill of admitting patients. That has been one of my weaknesses/fears. I find getting a new patient that another ICU provider hasn't seen yet very intimidating. Any new ICU admit is full of crash potential, and it's my job to work them up fresh. What you're told by the person transferring the patient to you isn't always the full story. Sometimes they don't even have any labs or imaging yet. Coming up with an extended differential, placing all the right orders, and decided what the priority problem is can be very challenging. Somehow, up to this point in residency, I've done very little admitting of fresh patients, probably at least in part because my shifts have been majority days, and many new admits come at night. So I'm glad I'm getting this chance. One of the really fun developments in these rotations has been seeing my progression from pure learner to part-learner, part-teacher. My team is comprised of one PGY-3 and two interns, neither of whom have been in the ICU before. It's been pretty cool getting to teach the interns ICU things and help them with procedures. I've even gotten to share some knowledge with my senior, although he's great and has a good amount of ICU experience himself--I learn a ton from him about medicine-y things. This year has been amazing but quite exhausting. I think it finally caught up with me, because I'm typing this from home where I'm stuck sick with the flu (yes, of course I got my flu shot, but they're not perfect). I feel very guilty not being there with my team for their call shift tonight, but I do think I needed to slow down a bit. As this year has progressed, the way I've learned has changed a lot, and these days I spend literally no time actually "studying." It's been all experiential learning, and while I wouldn't give up a single minute I spent in the hospital to go read a book, I am looking forward to dropping the pace and having dedicated study time again. Now that I'm this deep in, a whole new world of potential knowledge has opened up for me! Oh, and I might want to develop a few hobbies, too.
  10. Well, I survived a month of "off-service rotations" (aka nephrology and ID--good for learning but I'm glad I picked the field I did) and got back into the CVICU. I was surprised by how much I really loved it. Some of it had to do with the great team, and some of it had to do with the interesting patient population. I had several ECMO patients, lots of post-CABG, some vascular cases, some esophageal resections. The interesting part about this unit is that on weekdays they have an additional APP who's just there to take new admissions, usually fresh from the OR. I enjoyed working that shift because taking postoperative patients is all about the art of resuscitation, finding that right balance of fluids, pressors, inotropes, and pacing that gets them back online. For the uncomplicated cases, it's very satisfying when you get them to a good stable point, extubate them, and by the next morning they're sitting up in the chair looking great. On the other end of the spectrum, this unit had some *really* sick patients, some of whom had been transfers in from outside hospitals that just didn't have the resources to take care of them. We actually had one patient who died less than an hour after they were admitted, simply because they were so very sick. Working nights in this unit was great, and the NP I was working with really let me run the show, which was fantastic. I'm reaching a point where I really want to spread my wings. At the start of residency, if you'd asked me if I'd accept a permanent nights position, I'd have said only if I had no other choices. But now, and after talking to a lot of other providers who did nights early in their career, I'm thinking I'd prefer a night position. During the day, there is great teaching, it is true. There are attendings and fellows and residents who each have their own opinions, and hearing all those opinions is really beneficial to shaping your own viewpoint. But it can also be frustrating at times. I haven't gotten to actually run any of my own codes. When a patient crashes, other people arrive in the room quickly, and they outrank me and often don't know me very well, so I'm hardly directing things. But at nights, it's totally different. When the nurse notices a change, they come to be directly and I get to make and enact my plan right away, no "waiting to discuss it during rounds." I think I've grown exponentially more on the nights that I've had than the days, even with the safety cushion of having another provider there. I really want to keep that growth going, and I want to rack up experiences with unstable patients, managing them on my own. Upcoming is two weeks of echo, which I'm looking forward to because I really do want to practice my skills so I can become a better bedside echocardiographer, but I'm also dreading it because when I'm out of the ICU I really miss it.
  11. I'm guaranteed a job within their system. Other residencies I looked at offered a signing bonus for residency grads if they stayed. Most systems that have residencies know how valuable you are to them afterwards and try to recruit you.
  12. I had about 2 months, which was just the right amount of time to get all my licensing stuff taken care of and also kick back a little. No, I didn't have loans. I'm very lucky.
  13. CSCH

    CCM fellowship after EM residency

    Really interesting idea. Being EM/CCM trained seems like you would be exceptionally well-rounded. Even if you can't keep the dual-job thing going at other institutions, a lot of critical care happens in the ED, and you'd be a huge asset at your next institution if you knew how to manage those patients in a way that doesn't make the CCM people roll their eyes. (I always stick up for my EM colleagues when a patient rolls into the unit in a less-than-ideal state--you guys have my eternal admiration for the number of patients you juggle at once, and the difficult decisions you have to make with very little information!) Not to get off into a side discussion, but EMEDPA, what/where is that US fellowship?
  14. PS -- Dlenoci -- Go for it! Ignore everyone else and just do it. I'm so glad I did. (And no one else from my PA program went to residency.)
  15. And I thought I was tired last month... I just completed my CCU month, with the longest hours I've had so far in residency. It was a rough month, and not my favorite, but totally worth it in the end. Having a cardiologist for an attending, rather than an intensivist (or anesthesiologist or surgeon--but they're different, too) means everything revolves around one concept: hemodynamics. I had never given the subject the thought it probably deserves, and I can honestly say that after a straight month of it, I see patients in a totally different light. I've dealt with heart failure patients before, but this unit was chock full of them, and it made me realize how many mistakes I'd made in the past with them. The other big learning point of the month was PA catheters (aka Swan-Ganz). Nobody else in critical care likes them right now (well, maybe sometimes CTICU/CVICU), but I'm glad to have spent a month with them to learn their strengths and weaknesses (it's all about the trends, baby--otherwise they're pieces of shit and random number generators at best). I also got to finish out my month with a week of nights, which was fantastic. The providers I was with at night were residency grads themselves, and they wanted me to get the full experience, so I got to keep the unit phone and any time a decision needed to be made they would direct the nurse to me for my plan. Even without any crazy events the first three nights, having to take care of all the little things for an entire ICU worth of patients was a great learning experience. The last night, we had a patient roll in hot (right at shift change, of course, and of course much hotter than advertised by the transferring unit) and I got to make a lot of management decisions on a pretty tenuous patient. I'm realizing now that this patient would have terrified me even just two months ago, but the thing about residency is you grow in such leaps and bounds, that suddenly you're in a totally different place than you'd started and you're not entirely sure how you got there. All I know is, these days I run a lot fewer decisions by the people around me, because I know what I know, and I can mostly handle most patients. I also know what I don't know (btw, I think this is one of our greatest strenghts as PAs), and I've gotten better at knowing who to ask and how to hold things together until I can get an answer. I was also encouraged by a PA on the unit to start looking for ways to grow as a mentor, and I got a few opportunities to do some teaching with a PA student and medical student who were rotating with us. Now for most of the next two months, I get to live that cush consult service life. 9 to 5! What will I do with all this free time? Might be a good time to reset some healthy habits (I'm looking at you, midnight hospital grilled cheese).
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