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U of Iowa EM PA resident - Ask Me Anything

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9 hours ago, DLane said:

I suppose an update is in order. I've completed about 2.5 blocks. Started in Peds and now in the main ED, which sees kids but primarily adults. The experience has been amazing. There was growing pains learning the system, the attendings, working odd hours with a family, adjusting from FM to EM, but overall great.

For those considering transitioning from prior practice and returning to a residency I'll offer this experience. I'm perpetually fatigued, partly of my own doing trying to make time with family. I feel my prior experience in FM is both good and bad. The staff seem to overall like it. No one has complained of needing to get rid of prior "bad habits". They feel very comfortable with me taking the vast majority of non-critical patients. The main criticism I've received is I'm sometimes too long in my presentations and I need to learn to be more "sensitive" and less "specific" in my work ups. Not that my differentials are incomplete, but my risk stratification leans sometimes more towards less testing.

 

Do you mind expanding on the residency/life balance? what kind of hours are you working and on-call, what shifts do you work etc?

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On 6/16/2018 at 3:57 AM, boli said:

Do you mind expanding on the residency/life balance? what kind of hours are you working and on-call, what shifts do you work etc?

I find the work/life balance kinda tough with a family. I think it would be much easier as a single man or just a spouse. Trying to make time for my kid who has her own school schedule is difficult, but doable. It’s certainly more than PA school where I felt I had a decent amount of free time. This is not to say I don’t have any. I take my kid to the park or something outside at least once per week and we play video games together plenty. My wife doesn’t work, so I don’t need day care which would be a must if she did. 

the number of hours aren’t bad. We do the same as physician residents and averages to 60 hours. Plus conference every Thursday morning and journal club once per month. That’s the average from Sunday to Sunday. Sometimes you can end up 5-6 in a row. Once I had 4 days off in a row and it was awesome, but then I paid for it on the ends. What gets me though is the frequent flipping. Your following shift is always equal or later than your previous, so you always have time for adequate time for sleep, but sometimes I can’t. Then my kid is up and I’ll sacrifice sleep to spend time together. I go through melatonin like candy.

There are many different shifts. Day, slightly later day, eve, slightly later eve, night.There is no call in the ED really, but you have to cover minimum 10 call shifts in 18 months. Not hard. Just do your thing and don’t drink in case they need you to come in.

another procedure I forgot to add that I’ve done is US. Tons of it. Eyes, heart, lung, fast, gallbladder, appendix, kidneys, soft tissue, dvt. It’s basically my stethoscope now.

 

 

 

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Just to follow up DLane- I completed the Iowa residency with a wife working full time and three school age kids. I'll say it's tough. I had episodes of decent time off, but looking back I simply remember it being rough. My wife would definitely agree! His description of the hours/wk is spot on. The didactic, Thursday morning conference, is the kicker. That's one of the big reasons to do residency, but it's also the bane of your existence while your going through it. 

As far as procedures- I had a similar experience and procedures as that point in the program. My first ED shift was a call in shift because someone was sick. Came in for overnight shift around 2245 and first pt is a head bleed, not intubated and decompensating. First pt = intubation, critical care and a change of pants! 

I also agree with US being the new stethoscope. Lots of US can be done if you are willing to put in the time to learn. The average Iowa body habitus can make US tough sometimes though! 

 

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Since my last post I did ALS month, which was a good review, but more for the MD interns since we did an abridged version when we started and already working for a couple months. The EMS ride along with RAGBRAI was fun. Hit or miss depending on what rig your on. Some people saw some nasty traumas and MIs.

Ortho was honestly an unpleasant experience. The interns I was with on night float were too green which prompted them to do a lot of the reductions. Would have been more of a learning experience if I hadn’t done a ton of reductions on an awesome rotation in school. I probably could have done more if I had pushed, but we do our own reductions in the department, so I let it go. The time in hand clinic was invaluable though. It was with an ortho hand PA and went through lots of XR findings and clinical scenarios.

Anesthesia was a good rotation. Lots of intubations. Not much else to say about it. Got what I needed out of it.

I did a peds block and a main ED block as well. Getting much more comfortable stabilizing our sickest patients. Some ones that stand out were a new onset heart failure I diagnosed immediately with lung and cardiac US. Tons of B-lines in the lung and severely depressed EF. That was a happy day that I took someone so sick and turned them around in 30 minutes. Managed a hypertensive crisis with a AAA complaint of abdominal pain. Immediately got his BP down with a esmolol drip and did well. 

Up next is trauma surgery and MICU. I’ll report back after those.

 

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Thanks David- We just hired an NP straight out of the Iowa program at the top of our pay scale at my per diem rural coastal job. I worked with another grad (a PA) at my last urban trauma ctr job a few years ago. She was(and is) a rock star. I am jealous of the great training you guys are getting. Keep up the good work!!

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Just finished trauma surgery and MICU. I’ve never been so chronically exhausted in my life. 

Trauma surgery isn’t hard work. You’re pretty independent, but very restricted by policy algorithms. Not just the interns, but everyone. Still learned a lot about managing spine fractures, head bleeds, and a lot about inpatient medicine since half the patients seemed to be elderly who fell on Coumadin with multiple comorbid conditions.

I normally hate any surgery rotations because I loathe working with surgeons, but these were great. Friendly, teaching, made sure I got procedures, really helped shape it to make it educational and minimize scut, but I did plenty of scut too. Of course there are plenty of opportunities to do trauma surveys. It becomes muscle memory. I didn’t get any really cool cases because the luck of the draw, but 2 cric’s were done while I was there. I only did one chest tube and couple pigtails for procedures though.

MICU has by far been the most beneficial experience in residency (haven’t done SNICU yet). First, procedurally it was amazing. I put a line in at least every other day for either someone on vasopressors or put in a HD cath for dialysis. I did several thoracentesis and so many paracentesis that I honestly don’t even want to do them anymore. I did lumbar punctures on 2 ventilated patients, which was excellent to fine tune my side lying technique, as I usually do them easily sitting up. No intubation since that is only for the Pulm fellow.

I was given a huge amount of autonomy. They treated me like a 2nd year since all EM folks who go there are 2nd years. 7-5 daily, though often late, with 30 hour shifts every 5 days and one day off per week. The IM interns rotate there as well and they have to share patients with the second year IM resident and only work nights with no 30 hour shifts. I’m the first APP resident to go there and they were very unsure of what to do with me. Fortunately I had plenty of experience to fall back on. The fellow is constantly swamped and they were just so grateful that I would do procedures independently and didn’t ask them to be there for everything, which frequently the case with the IM residents who rarely do procedures. Lots of work managing vents, weaning, extubating, antibiotic management. CVICU sent several overflow patients. One was actively dying when they arrived. Did POC echo and diagnosed a RV failure and got a right sided EKG. I ended up hanging levo, dobutamine, and a mixing my own epi drip and doing push dose epi to keep her alive until CVICU finally came to take her to cath lab and placed an RVAD. Another patient I had to float a swan and start milrinone for severe acute on chronic heart failure. Just a great time and learned lots, but it was exhausting. Also learned a lot about palliative care. 

Now I rotate back to the ED for 3 months, the longest I’ve been in one place, and then I do wilderness medicine for a month.

Edited by DLane
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Awesome! A swan?! Didn't even think about getting to do that while I was there. Of course I didn't want to do a MICU elective rotation either... You'll likely need that if you do the ICU coverage. 

Don't worry, wilderness medicine won't be nearly the hours and is much more fun. I'll prolly be helping out with that one. 

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