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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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So now I'm on Wilderness Medicine rotation and having a little more time. Just finished 3.5 months of nonstop ED rotations. It is a much needed breather from the endless patients, notes, procedural logs, speaking with consultants. I definitely have hit a stride. Doing some moonlighting at solo shops and finding that I handle everything easily, which has been a real confidence booster. At my solo locums gig, I've been brought coding patients, fractures, DKA with comorbid meth ingestion, overdose, volume overload s/p renal transplant refusing transfer, and more. Handling it all pretty well without flinching, which I definitely attribute to the residency and its excellent training.

I'll give more on wilderness med at the end, but I have figured up my procedures for the YTD. I figured I would post it since it is a more objective measure of "is it a good residency" than "we learn a lot of stuff". It's obviously incomplete because I haven't graduated, but I was actually surprised at my numbers. I'll just give the numbers on things people care about and it will be a bit generalized unless someone wants to specifically know how many infraorbital blocks, or whatever, I did. Some of these will look low comparatively, because honestly I stopped counting I was doing so many, like FAST. It was taking too much of my time to log them all. Also note this is even before my SNICU rotation and I have 4 more months in the ED.

CVL - 15

FAST -18

Total Point of care US - 181 scans (this is the main thing i've bad about logging because I probably have done twice this much)

Gallbladder US - 27

Renal US - 26

Cardiac US -41

Lung US -35

DVT US 15

Soft Tissue US - 6

US IV access - 10

US appendix (Appendix identified)- 2

Pylorus US - 2

Orbit US -6

IVC/Aorta US 11

Paracentesis - 10

Thoracentesis - 5

Peritonsillar abscess drainage - 3

Intubation 24

Procedural Sedation 8

Chest tube 3 (hoping to go up after SNICU)

Arthrocentesis 6

Regional blocks - 16

Lumbar puncture - 10

Penile aspiration and injection for detumesence - 1

Simulated

Tranvenous pacing 1

Blakemore tube 1

Umbilical cannulation 1

Thoracotomy 1

cricothyrotomy 1

Lateral canthotomy 1 (I plan on spending an afternoon in optho surgery where they do these all day for a particular surgery)

 

Edited by DLane
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Finished wilderness medicine, which was amazing. Not just because I didn't long into epic for an entire month either. Really great didatics from some people who had done amazing things. Practiced in Nepal and the Antarctic, climbed Everest (and several others), worked with SWAT, and much more. These people had seen and done it all. Lots of hands on training with snow rescue and mountain medicine in Colorado. Canoeing trips and water rescue. They should be adding some Dive training as well next year. I hope to be involved as an instructor next year. 

Come close to the end now. Graduation ceremony this June to lump us in with the graduating physician residents, but I still have a 1.5 months after that. Finishing up another 2 weeks of peds, one month of SNICU, and then 2 months in the ED and I am done. I've had lots of job offers and pretty easy negotiations with salary. I've never worked so hard, but it's all been worth it with what I've learned. I'll update after SNICU to describe that experience, then probably one more at the end. 

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Thanks for the updates! Been following this thread as the Iowa EM residency is definitely on my radar. As I enter my last semester of Didactic (thank goodness), I’m starting to prep for my future beyond PA school and how to be most competitive for EM residencies. 

Did anyone who was accepted do any additional EM rotations during clinical? My program, for better or worse, contains 15 rotations and thus I am trying to get at least 2, maybe 3 EM rotations set up. 

Also, for those accepted, what was your didactic GPA like? Is that weighed heavily in the selection process, or is it more experience/interest in EM that they look for? 

I was born and raised in Iowa, go to PA school in Iowa, and have an interest in practicing in rural Iowa, so I will certainly use that to my advantage when applying! 

Thanks again or all the updates, that Wilderness Medicine elective is right up my alley. 

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5 hours ago, Rudeboyirie said:

Thanks for the updates! Been following this thread as the Iowa EM residency is definitely on my radar. As I enter my last semester of Didactic (thank goodness), I’m starting to prep for my future beyond PA school and how to be most competitive for EM residencies. 

Did anyone who was accepted do any additional EM rotations during clinical? My program, for better or worse, contains 15 rotations and thus I am trying to get at least 2, maybe 3 EM rotations set up. 

Also, for those accepted, what was your didactic GPA like? Is that weighed heavily in the selection process, or is it more experience/interest in EM that they look for? 

I was born and raised in Iowa, go to PA school in Iowa, and have an interest in practicing in rural Iowa, so I will certainly use that to my advantage when applying! 

Thanks again or all the updates, that Wilderness Medicine elective is right up my alley. 

Glad to help!

I only had one elective in school and did ortho. Many people have prior EMS background. Not sure how many did extra EM rotations. 

My GPA was a 3.95. I'm not sure what other people had. Pretty sure the other resident with me graduated with honors. I don't know how much it counts. Once you make it to the interview, certainly less as they are looking for someone who is a good fit. Obviously having a good GPA doesn't hurt, so study hard!

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My GPA in PA school was like 3.5 or so. I did have 9-10 yrs of experience as a paramedic before school so that definitely helps. Getting the interview is the hard part. Once you get an interview, it's all about personality fit. Definitely use your Iowa connections if you apply there!

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Time for an update. After SNICU I got super busy moonlighting and my ED schedule was all over the place.

SNICU was a good experience. It’s a “open” unit and the SNICU team is separate from the primary team. So you essentially got to see how several different services manage different problems. Like doing multiple off service rotations in one. Learned so much about head bleeds, ventilators, multisystem trauma. Lots of lines to put in. It got to a point I moan and roll my eyes when I would have to do a arterial line. Personally I think these are incredibly easy, at least when using ultrasound. I trained before to do them without US and they could be difficult, but at this point we could have the nurses do it.

You are there to manage the ABCs and most everything else, but the primary team (neurology/neurosurgery/trauma/whatever surgical service) is their to manage their primary problem. It’s a very weird dynamic and I personally hated the fracture in care. Am I putting in this order? Are you? Often times the primary team would ask for something against evidence based medicine. The response usually was “you can do it, but we aren’t.” For this reason, I preferred the MICU who manages everything and everyone else consults.

I then spent 2 months in the ED, anxiously awaiting my official end. It was the longest 2 months ever, but I could definitely tell how easy everything had become. I rolled through complex problems like butter. Not that I never worried about making a mistake, but codes were a breeze, differentials rolled of the tongue like I was quoting my favorite movie, anticipating consults every question and move so people were dispo’d fast. It was nice when the attendings would just have me skip to the diagnosis and if I wanted a bed request, then wave to the patient from the door. Moonlighting feels good and comfortable. 

Took a job at a CAH in a solo provider ED. I asked for 20k over their original offer and it was accepted the next day. I turned down to other CAH job offers that I got without applying. They just knew me from moonlighting and knew my residency was coming to a close. I also had a basically guaranteed spot at UW Madison for a ED/CC fellowship position where you get to split time between the ED and CC. This was offered to the APP residents, not me in particular. I really wanted this, but I decided I had my family through enough and it was time to enjoy life.  I bring up the jobs and salary to demonstrate it was very much worth the time and effort.

one change from my time I hear is they will be making the MICU rotation mandatory and not come out of elective time, which will be nice.

not related to the residency: I’m taking a year off and then I plan on getting my DMS from LMU. I have hopes to create a somewhat part time administrative/clinical position at my hospital with that.im staying nearby and hope to continue my involvement with the residency. 

Hope this was helpful. Maybe one day someone from the residency a couple years down the line will pick it back up.

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On 8/16/2019 at 1:43 PM, DLane said:

Time for an update. After SNICU I got super busy moonlighting and my ED schedule was all over the place.

SNICU was a good experience. It’s a “open” unit and the SNICU team is separate from the primary team. So you essentially got to see how several different services manage different problems. Like doing multiple off service rotations in one. Learned so much about head bleeds, ventilators, multisystem trauma. Lots of lines to put in. It got to a point I moan and roll my eyes when I would have to do a arterial line. Personally I think these are incredibly easy, at least when using ultrasound. I trained before to do them without US and they could be difficult, but at this point we could have the nurses do it.

You are there to manage the ABCs and most everything else, but the primary team (neurology/neurosurgery/trauma/whatever surgical service) is their to manage their primary problem. It’s a very weird dynamic and I personally hated the fracture in care. Am I putting in this order? Are you? Often times the primary team would ask for something against evidence based medicine. The response usually was “you can do it, but we aren’t.” For this reason, I preferred the MICU who manages everything and everyone else consults.

I then spent 2 months in the ED, anxiously awaiting my official end. It was the longest 2 months ever, but I could definitely tell how easy everything had become. I rolled through complex problems like butter. Not that I never worried about making a mistake, but codes were a breeze, differentials rolled of the tongue like I was quoting my favorite movie, anticipating consults every question and move so people were dispo’d fast. It was nice when the attendings would just have me skip to the diagnosis and if I wanted a bed request, then wave to the patient from the door. Moonlighting feels good and comfortable. 

Took a job at a CAH in a solo provider ED. I asked for 20k over their original offer and it was accepted the next day. I turned down to other CAH job offers that I got without applying. They just knew me from moonlighting and knew my residency was coming to a close. I also had a basically guaranteed spot at UW Madison for a ED/CC fellowship position where you get to split time between the ED and CC. This was offered to the APP residents, not me in particular. I really wanted this, but I decided I had my family through enough and it was time to enjoy life.  I bring up the jobs and salary to demonstrate it was very much worth the time and effort.

one change from my time I hear is they will be making the MICU rotation mandatory and not come out of elective time, which will be nice.

not related to the residency: I’m taking a year off and then I plan on getting my DMS from LMU. I have hopes to create a somewhat part time administrative/clinical position at my hospital with that.im staying nearby and hope to continue my involvement with the residency. 

Hope this was helpful. Maybe one day someone from the residency a couple years down the line will pick it back up.

Now that you're at the end, how would you compare yourself today to the other PAs at areas you have moonlighted that did not do a residency? Are you quicker than they are? Pick up the more complex patients? 

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2 hours ago, Believe said:

Now that you're at the end, how would you compare yourself today to the other PAs at areas you have moonlighted that did not do a residency? Are you quicker than they are? Pick up the more complex patients? 

I was never speedy Gonzalez, as I prefer to be methodical. But yes, I’m faster than some people who have been around longer. Honestly I refuse to work places that want me to see more than 2 an hour. 

As far as complexity, I crush the competition. The limiting factor has been getting nursing staff comfortable with my level of training. They haven’t seen people doing push dose pressors, ketamine for pain, or regional blocks.

Edited by DLane
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20 hours ago, DLane said:

As far as complexity, I crush the competition. The limiting factor has been getting nursing staff comfortable with my level of training. They haven’t seen people doing push dose pressors, ketamine for pain, or regional blocks.

This is awesome!

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