Any words of wisdom for new grad anxiety (going into ER)?

[Guest ERCat]

Finally... The licensing and credentialing process is now complete. It has been a four month process and I've been dying to start working the whole time. I officially have three weeks till I start my job in the ER, as I just learned I am being added to the December schedule. I've been excited for months, doing many things to prepare myself, but last night I woke up at 2 AM with a knot in my stomach and have felt anxious all day.

 

I have been extremely motivated to be a rock star PA in the ED -- a good provider for patients and a good member of the ED team that people want to work with. I want to follow the most cutting edge, evidence based practices, I want to be compassionate, I want to be thorough. I want to show that I am smart. I have actually studied quite a bit since I graduated four months ago. Have been doing an online ER Bootcamp, brushing up on x-rays, flipping through my Minor Emergencies text book and I even started looking through Bates. Even an ER conference in another city. As a result I feel like I have a leg up on book knowledge as compared to many new grads who aren't as motivated to hit the books. If someone asked me about the latest guidelines on a topic or certain medical legal pitfalls I could confidently answer... but in reality I have problems applying that knowledge. My terror limits me. For example...When shadowing and working with a PA a few weeks ago for a potential per diem job, we had a back pain patient and I led the encounter and I found myself freezing up -- when asking the patient questions, feeling nervous and then not knowing what else to ask next so just nervously doing extra steps on the physical exam to make it look like I knew what I was doing to buy myself time to think. When the patient asked questions I felt inside I had an answer and it sounded right but I found myself not saying anything and instead looking at the PA to formulate a response. I have a certain shyness and uncertainty and nervousness that makes my smart mind go dumb. At this point I feel I am so unsure of myself I would need to ask my SP questions about everything. I think a lot of it is the fact that I read SO MUCH on the details that it hampers me. When many people see the big picture they simply apply their knowledge to individual scenarios... But I am so detail focused I am afraid to miss an important thing (I.e. A med interaction, a contraindication to a procedure, the super uncommon differential diagnosis) that it almost keeps me from acting. I want to KICK BUTT in the ER but I am not sure how to overcome this fear.

 

I am also afraid of realizing I don't know something when I am in front of a patient. What if I am right in front of them and they ask me a basic question I should know but don't? What if I am in the middle of a procedure and realize I forgot the next step or forgot how to do something? I am also afraid of the fact that I will have to look up information for every single case for a while -- even for something as simple as a URI -- to make sure I am not missing relevant parts of the history and to ensure I am offering the right treatment. I don't understand that after all my studying I still froze up with that back pain patient and didn't know what the next step should be.

 

I realize I sound like an anxious mess. Anyone have any words of wisdom?

[delco714]

This won't be elaborate: you're doing what you can. You'll gain confidence and wit with time, support, good outcome, and experience. Have fun and be safe. You've set yourself up for success. Give yourself the chance

[HJK]

Time and time.. and more time.. give yourself plenty of time to learn.

 

you will have to ask questions for every cases even if it is URI symptoms. As time passes and you become more experienced, things will start coming easier and faster. Until then take time to learn and ask questions.

 

Good luck.

[Reality Check 2]

My answer to most questions about medicine these days

 

Quantity does not equal quality or a good production or good medicine

 

Good medical outcome for the patient is the single most important measure

 

I worked with a new grad PA in an ER when I had 10 years experience. She thought she was all that because she could see 50 patients in 12 hours. Her notes sucked and her bounce back rate was around 30-40% sometimes - missed strep or failure to adequately dx and treat a lot of things.

 

I might have seen 30 to her 50 in that Urban Hospital in Texas but my confidence level in doing the right thing was a lot higher. Did I miss stuff? Yes, we all have. Did I learn for the next encounter? You bet.

 

Treat 'em and street 'em is a load of BS.

 

With an ER patient, you get one chance to see them and do the right thing. 

 

ASK when you do not know - research, watch, soak up everything like a sponge. Make friends with the nurses and the radiology staff and LEARN all the time.

 

Be compassionate, be thorough, educate, treat appropriately - send a patient home with the best you can offer.

 

Do not become a production drone.

 

My very old 2 cents

25 years in - been there, done that

[DogLovingPA]

A few tid bits to help ease your anxiety.....  (btw, you are not alone, my first year I was an anxious mess.  2.5 years out and there are days I'm still terrified I've missed something.  I worry more about my patients than I expected - they don't teach you this in school).  I'm in UC, not ER but some similar things apply. 

 

It's okay to tell a patient "I don't know".  If they ask something I don't know the answer to or can't remember - I simply tell them - "that's a great question and I actually don't know/remember the answer but I will find out and let you know before you leave".    If you don't know what is wrong with them, that is okay too.  You are in the ER, you can't solve every case with one visit.  Rule out the bad stuff.  In UC - if I am still worried about someone, they go to the ER for admit/obs.  If I think they are safe to go home, I reassure them and give them a plan.  Ie:  "I don' t know exactly what is causing your chest pain but we've ruled out a heart attack, a blood clot, a collasped lung, etc and I don't think it's anything dangerous.  Here is what some of the other possibilities are and what I'm going to do to try to make you feel better."  Then they get outpatient follow up (and of course instructions to go to the ER if they get worse). 

 

It's also okay to pause and think in front of a patient.  I've never had any of them say a thing if I just kind of stand there for a minute and ponder - I just tell them I'm thinking things through for a second.  I've gone back in after my initial exam and checked something else that popped into my head, etc.   99.9% of patients appreciate that you are putting thought into them - they aren't thinking poorly of you or your skills. 

 

If you browse through the posts on this forum - you'll see a 100+ like yours and those of us who didn't write a post like yours still felt the same way.  What you are feeling is normal. 

 

And agree with reality check 2 - do not feel pressure to move faster!  I have a hard time with this in UC when I know the waiting room is full with 15+ people who have been waiting an hour.  Take a breath, treat every patient like you would if there was no one waiting. 

[Boatswain2PA]

1)  As Mel Herbert said in one of his EMRAP podcasts....if you are working in the ED and you are not a little scared, then you are having the wrong response.  Your fear is normal, and will help you perform better.  Be scared.  Let the fear be your friend.  If you don't know, look it up, or ask someone.  

 

2) Carry a cheat sheet in your pocket where you write out the common things you find yourself looking up over and over, it'll save you money.  (Edit - It'll save you TIME)

 

3) The single most important thing for an ED provider to have is the ability to determine "sick" from "not sick".   If they are "not sick", and you miss something...oh well, they aren't sick anyway.  If they are "sick", and you can't figure out why....then get help.

 

If you don't have the ability to look at a person from across the room and determine "sick" vs "not sick", then you shouldn't be working ED yet.  

 

Good luck!

[Simplify]

1)  As Mel Herbert said in one of his EMRAP podcasts....if you are working in the ED and you are not a little scared, then you are having the wrong response.  Your fear is normal, and will help you perform better.  Be scared.  Let the fear be your friend.  If you don't know, look it up, or ask someone.  

 

2) Carry a cheat sheet in your pocket where you write out the common things you find yourself looking up over and over, it'll save you money.

 

3) The single most important thing for an ED provider to have is the ability to determine "sick" from "not sick".   If they are "not sick", and you miss something...oh well, they aren't sick anyway.  If they are "sick", and you can't figure out why....then get help.

 

If you don't have the ability to look at a person from across the room and determine "sick" vs "not sick", then you shouldn't be working ED yet.  

 

Good luck!

 

 

This.  It takes time. 

[EMEDPA]

work on the basic procedural skills; suturing, I+Ds, ingrown toenail, slit lamp use, etc get good with this stuff so you can do most of what presents to fast track. look at lots of xrays. talk to other folks about their cases. I still do that all the time. when I walk into a shift after the usual bs I ask " so anything cool today?' and often they pull up a film or tell me about a cool case. read case studies. start with the easy ones and work your way into harder ones. sounds like you are doing all the right stuff as prep. at some point if not already done take PALS, ATLS, the difficult airway course, and FCCS. ( I assume you have acls already). anytime you can take a cme class for free do it. over the years I have racked up quite a few because we get free cme at my home facility and through my DMAT(disaster team). to date I have taken the following, many for free:

Advanced Cardiac Life Support (A.C.L.S.)

 Advanced Trauma Life Support (A.T.L.S.)

Advanced Pediatric Life Support (A.P.L.S.)

Pediatric Advanced Life Support (P.A.L.S.)

Advanced Burn Life Support (A.B.L.S.)

Fundamental Critical Care Support (F.C.C.S.)

Advanced Life Support in Obstetrics (A.L.S.O.)

Basic Disaster Life Support (B.D.L.S.)

 The Difficult Airway Course

 Remote Medicine for the Advanced provider (RMAP) 

 FAST Plus Emergency Ultrasound Course

 Basic Trauma Life Support (B.T.L.S.) and Prehospital Trauma Life Support (PHTLS)

 Cardiopulmonary Resuscitation for Health Providers (C.P.R.)

 Neonatal Resuscitation (N.R.P.)

[cinntsp]

I am also afraid of realizing I don't know something when I am in front of a patient. What if I am right in front of them and they ask me a basic question I should know but don't? 

 

You will be surprised how much you actually know and what will pop in your head at the right time.  There will be times that you don't know the answer to something.  I've told patients "That's a good question and I don't know the answer off the top of my head but I will definitely look into it and get back to you."  I've watched my attendings do the same. The patients just appreciate that you are taking the time to answer their questions and will not think less of you for it.

[kittryn]

you'll be fine. just take a big breath, relax, and jump in. you're going to come home shaking for awhile, but you'll hit your stride.

 

a friend of mine gave me great description of the progression of a learning curve:

 

1) unconscious incompetence (you were already there)

2) conscious incompetence (where you are now)

3) unconscious competence (not there yet)

4) conscious competence (ditto)

 

it's TRUE!!

 

learning curves are bloody uncomfortable but they don't last forever; it just feels like they do.

 

your excitment and enthusiasm for your specialty will take you far. never be afraid to ask for help. and never let it throw you if someone reacts in a crummy/nasty fashion. medicine is full of nice people like you and me :-) but also crummy/nasty a$$holes.