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jamiehalap

New ER PA, stressing out

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Hi everyone,

I graduated about 5 months ago and just started my job on January first in the ED (credentialing=longest process ever!). I was an A+ student during PA school, did well on rotations, etc. but I just feel like I am drowning and burdening my docs. This is the first time the ED I'm working in has PAs, and I am just trying to do my best because I want it to work out as I love my coworkers and I love the job. I know everyone has this sentiment as a new PA, I just feel so stressed during some shifts. Some docs are very easy going, don't mind me running things by them constantly since  I am new, etc. but others seem to be bothered by my questions and I feel like such a nuisance. I'm also stressed because some of the hospitalists I admit to are so incredibly rude when I call them, partially I think because they aren't used to having PAs admitting to them. They are more critical of my diagnosis/treatment, etc. than if the docs were calling them, but not in a constructive way. Overall, I love love love my job and the ED but I just needed to vent about the stress of being a new grad! Patients don't follow the textbook like they told us they would in school!

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what did you do as HCE before PA school? Many hospitalists and surgeons are assclowns, so don't let that ruffle you. it's easier to be a jerk on the phone to someone they don't know, so they do it. I only work at small, rural hospitals and know all the hospitalists /surgeons on a first name basis, so they are not jerks to me now, but experienced what you are feeling when I worked at big trauma ctrs.

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When I did ER I use to feel bad by how horrible the specialists and FP guys were to me when I called them.  Then I started listening to the ER docs speak to them.  They got treated as bad or worse then me!  I then realized that being in the ER and having to call a specialist or primary just sucks.  There is no fix unless you are in an ER that has a crapton of respect.  I read about one in Colorado where there is some residency program considered top notch.  Back in the day the primary and specialist guys treated those ER guys well, but in the real world it's a shit show.

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Uh, I used to call the section chief and tell them that Dr Genius wasn’t responding to our request for help (helps if you know them). We’d hear back fairly quickly in most cases. Everyone has a boss.

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1 hour ago, GetMeOuttaThisMess said:

Uh, I used to call the section chief and tell them that Dr Genius wasn’t responding to our request for help (helps if you know them). We’d hear back fairly quickly in most cases. Everyone has a boss.

I complained loudly and often about 1 particular hand surgeon who refused to speak to PAs at all. he was on the hospital board so it went nowhere. I soon discovered the best payback was NEVER to refer patients to him ever. If he was on call for our hospital I would arrange f/u with other surgeons who I knew were looking for business and treated me well. If it was an emergent case those folks got transferred because he refused to come to the phone if a PA called. that meets the definition of need for transfer. I think he might have gotten hit once or twice with emtala violations because of this. I surely hope so. 10 years ago and I am still mad about it. his name rhymed with prick too, which gave him lots of great nicknames around the dept....

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7 minutes ago, EMEDPA said:

I complained loudly and often about 1 particular hand surgeon who refused to speak to PAs at all. he was on the hospital board so it went nowhere. I soon discovered the best payback was NEVER to refer patients to him ever. If he was on call for our hospital I would call arrange f/u with other surgeons who I knew were looking for business and treated me well. If it was an emergent case those folks got transferred because he refused to come to the phone if a PA called. that meets the definition of need for transfer. I think he might have gotten hit once or twice with emtala violations because of this. I surely hope so. 10 years ago and I am still mad about it. his name rhymed with prick too, which gave him lots of great nicknames around the dept....

Incredible. That sounds like reckless endagerment to me.

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I think it is always easier to assume the hospitalist doesn't treat you well because you are a "PA." If I were you, I would run all admitted cases to your attending, so you can practice presenting before you speak to the hospitalist. 

I always recommend to my students who I precept about post-graduate residency/fellowship. Most of them would like to do it.  One of them don't want to do it and her excuse was she has too much loan to pay back. She called me a month ago complaining to me her ER job is basically just super easy fast-track and triaging. However, she does get paid a lot for doing only that. I told her If she had done a residency, she could get a real ER job and do her easy fast track/triage job on the side. 

I think in general, jobs that hire new grads are usually not a job you would stay for long term.  

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I know some of the docs at who will refuse to speak with NPs or PAs for consults or signouts.  None of them are nice people and they treat residents like crap too.  Thankfully, as time goes on, this type of attitude will become less and less acceptable.

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20 minutes ago, EMEDPA said:

I complained loudly and often about 1 particular hand surgeon who refused to speak to PAs at all. he was on the hospital board so it went nowhere. I soon discovered the best payback was NEVER to refer patients to him ever. If he was on call for our hospital I would call arrange f/u with other surgeons who I knew were looking for business and treated me well. If it was an emergent case those folks got transferred because he refused to come to the phone if a PA called. that meets the definition of need for transfer. I think he might have gotten hit once or twice with emtala violations because of this. I surely hope so. 10 years ago and I am still mad about it. his name rhymed with prick too, which gave him lots of great nicknames around the dept....

I used to have an issue with one of those types until I made a rather crass statement to my SP one night with an open line about him only talking to a real person...he at least pretends to be polite with me now.  Thing I learned about dealing with fecal cephalics in the Army - anyone can be a knob on the phone; when you're nose to nose/in neck wringing distance with them, they usually think before speaking.  Being a bit physically imposing helps too, lol (I'm 6'2" and a bit and about 225lbs) - our staff guys have to look up their noses at me.

I like "Are you done yet?"...especially after I've put the phone down while waiting for a lull in the verbal diarrhea to chart or just plain ignore them.  If they go off the deep end again (it is a little inflammatory after all), put the phone down until there is another pause.   Follow that up with "I'm sorry, I had someone more important than you to deal with - now can you please admit that important someone?".  If you have them on speaker, everyone else can be entertained by how developmentally delayed they are and you can record it for posterity...and for later when you're in the office with the invertebrates in management.  You could also send a psych referral on their behalf if things really go sideways :-D.

What I'm trying to say, I guess, is you might as well try to have fun with it, because, unless it becomes suddenly legal for us to take folks like this out back for a good old fashioned fist to face consult, it's not going away anytime soon.

 

SK

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In my first 1-2 years as an ED PA I was almost always intimidated speaking to consultants: hospitalists, surgeons, etc.  There were a number of issues which did get better over time:

  1. I really didn't know what I was doing.  My workups weren't always complete.  The 1-2 things I hadn't done were important to they're medical decision making.
  2. I really didn't know how to give a concise presentation, including the key pertinent positives/negatives.
  3. I didn't know each ones preferences - because 2 different specialists in the same area can want different things.
  4. I just wasn't confident (and shouldn't have been).  This included confidence that having an EM level (broad but shallow) level of knowledge was sufficient and that it's OK to say "what else would you like done".
  5. I didn't have personal creditability - because I hadn't earned it.

It did get better - slowly - because I learned from doing, from asking my PA & NP colleagues and attending docs, from making mistakes and getting yelled at.

Now it's a very small number of consultants that are difficult - usually the same ones that are difficult to the docs.  When I can, I refer patients elsewhere, because usually the same consultants that are rude to us are also rude to their patients.

 

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I'll throw in my .02 on this.  I'm just a pre-pa person but I worked in the ED with PA's for about five years so I observed a lot and this is one of those scenarios that I was actually surprised to observe.

I once overheard a plastic surgeon tell an ED PA "Put your attending on the phone, I don't talk to PA's."  This guy has a real reputation for being a douchebag so I wasn't surprised it was him on the other end.  The PA was younger and she was visibly upset about the situation and was crying and trying to laugh it off at the same time.  That's one PA's experience.  There are three other PA's that worked in the same Fast Track area who were not working that day and if they had taken that call, they would have ripped that plastic surgeon a new one.  And I promise you, that plastic surgeon would actually respect those PA's who stood up to him a lot more after an encounter like that. The plastic surgeon was pushing the envelope so to speak and this one PA let him do that.  Some people are tougher than others and there's nothing wrong with that but you must adapt to deal with people like this. It's hard to do it in a snap like that but you have to learn how to do it.

The point I'm trying to say is that once you let someone walk over you, they will continue to walk over you and walk over you some more.  You have to be firm and be in command of your role at all times.  You're the PA, you have been hired for that position, and you have a job to perform; you're not volunteering your services there.  It does not matter if some attending or another staff member feels otherwise just because your title is that of a PA and they may or may not understand that title or your role as you feel they should.  Who cares what they think, what pull do they have regarding your job and the profession itself?  This particular PA, did not stand up to that plastic surgeon and I think she will forever be walked over by that plastic surgeon because of that one encounter.  I want to add that when I left the department I heard that particular PA got another job at a Derm group.  Good opportunity for her but part of me says she went Derm because she really didn't like the ED environment.

Another quick story that ties into this one...

I was shadowing a bunch of third year MD students once upon a time when I was a pre-med trying to test out the waters of med school.  We were in a conference room with a few surgery attendings and everybody was talking about this one particular "person" who was assisting the surgeon we were observing that day.  I actually didn't know this "person's" role and I thought they were just another MD but apparently they are an MD back in their home country and they couldn't get licensed or whatever in this country so they were working in the capacity of a surgical PA while not actually being a trained PA. I personally thought this person was actually very mean.  He always looked unhappy and he was rude to the students and I didn't think he had the greatest bedside manner but that's besides the point. I also observed him botch a catheter placement into the groin because he didn't do it under US guidance, which I later found out he wasn't trained to do because he didn't learn it that way in his country, but again that is besides the point here.

I remember during that meeting, the student's were asking if he was a PA and one of the surgeon's said he was not a PA.  There was another female attending in the discussion and she said "He's DEFINITELY not a PA, his knowledge base is so much more advanced."  Those are the discussions that go on behind the scenes when the attendings and even medical students are alone and you're not there.  I guarantee you that female attending probably left that conference room and at some point during the rest of the day she smiled at another PA and said "Hi, how are you today?" while secretly judging their "knowledge base."

The point of that story is that this female physician had her mind made up about PA's already for whatever reason.  This fake PA guy or whatever you want to call him clearly exceeded her expectations in some capacity and that is why she apparently thought of him or maybe his knowledge base more "highly" I presume.  So knowing that's how some attendings might see you for no reason other than your job title, why give them that opinion?  Work to the best of your abilities so that they see you as a person and not under the umbrella of a profession that they may or may not understand completely.

I have witnessed the medical hierarchy even in my observational capacity.  I don't think that will change because I have seen a lot more doctors with ego issues than I have with doctors who are down to earth and will have a beer with you.  When you sign up for this path, I really hope people realize that the hierarchy is a real thing and you have to develop thick skin the lower down you are.  I still say reputation wins in the end.  So focus more on that.

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on a bright note, during my 31 yr career in medicine so far from ER tech to paramedic to PA I have seen this kind of stuff getting better. this used to be an almost every day occurrence, but now happens to me once/yr or less.

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I'll play here.

A lot of good responses;  a lot of good experience on this board.

 

The ER is a battlefield.  You will be put in situations that test you mentally and physically; situations that are exciting, and ones that make you cringe.  It comes from all angles.  You have to have courage to do this job and do it well.  This is what got me through the first few years:

 

1. What I didnt know today, I'll know tomorrow

2. Confidence, confidence, confidence.

3. I am human; humans make mistakes.  My mistakes will teach me more than my successes...

...

...

except for killing someone.

 

4. Oh God, please dont let me kill someone today.

5. My Attendings do not hate me.  They hate ignorance, indecision and weakness.

I will do my job without being any of these things.

 

EM has a 3-5 year tryout.  You can do it.

?

 

 

 

 

 

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13 hours ago, jwells78 said:

5. My Attendings do not hate me. 

no, it's the hospitalists and surgeons who hate you. you remember how it was where we used to work trying to get even straight forward admits to come in....they wanted more crap to delay the admit just long enough that they could get off shift....no more of that now as my new job has family med hospitalists(who everyone knows are better human beings than internists) who take 24 hr call. also, there are only a handful of them and I have bailed all of them out at least once for floor emergencies.

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On 2/6/2018 at 10:37 AM, EMEDPA said:

Many hospitalists and surgeons are assclowns, 

This was way funnier than originally intended.  

I've no fear whatsoever of verbally saying and then thoroughly documenting that a consult was refused.  Let them explain the reason when a follow up is made. 

"Great.  I'll document your refusal to accept.  Is there someone else on your service who is accepting consults this evening?  I can just use the call schedule if you like. "

Call to Dr. Prick made at 20:14, consult refused.

I can be passive aggressive and I will be gunning for you from that day forward.

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Yea... I'm in UC now but have been in a few smaller ERs over the years. I will never forget having to call a neurosurgeon in a big medical center from my 22 bed critical access hospital for a guy with an intercranial bleed.

"Why are you calling me?

He is bleeding in his head...is there someone who would be a better choice?

"Where is your attending? I want to speak to him!"

He is at home in bed and hasn't seen the patient. I can have him call you but he knows less about this patient than I do.

"AT HOME IN BED!!!! THAT IS OUTRAGEOUS!"

Um... we are a 22 bed critical access hospital. I am the only one here and if I wake my FP doc up and make him come in it is going to delay the transfer that is going to happen anyway.

"Critical access hospital? Why didn't you say so?"

(Thinking to myself) WTF does that have to do with this patients need?

Thank you sir I'll send him to your ER and let them know you have been consulted. (asshat)

 

I have many similar stories but the best advice is if they bite...bite back. A bully loves an easy target. We have an ortho dick who pimps the crap out of any PA who calls him. He has already been run out of a regional hospital for being an asshat. So my guidance to the youngsters is just what someone else has already said... 'thanks for your time Dr Asshat. I'll document your refusal to consult and after I get the patient taken care of will refer the matter to medical staff for review." Than hang up before he can back peddle. It's fun when he has to call back with his hat in his hands....

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Not to say you're doing any of this, so FWIW from the perspective of a surgical subspecialty PA who is on the receiving end of ER consults, it's frustrating to get called about a patient as a "heads up." No. Don't call me about a "possible" fracture or "possible" abscess. Please gather all your info before calling me. So that means get your CT scans, x-rays, aspiration results, or whatever prior to calling. And for goodness sake, review the images with your own two eyes. We've received consults on fracture patients that had nonexistent fractures or "abscess" patients with a negative MRI/CT who actually just had cellulitis. This doesn't happen often, thanks to most ER guys/gals taking care of business and knowing what we want, but every now and then we'll get a new guy who isn't prepared. Although there's no reason to be an a**hat like some specialists can be. What goes around comes around, though.

When we had some unpleasant docs on call, there were issues and we'd get consulted instead because of that. We routinely get outpatient referrals for that same reason. The on-call guy is still supposed to have the first right of refusal since they're the dedicated on-call guy, so don't burn bridges by not calling them first. Just document their refusal and call someone who will talk to you.

I've heard of ER PAs/docs calling hospitalists to admit a patient to them, and they tell the hospitalist they've already consulted us and we've agreed with the admit. But we were never called. And boy does that rile up the hospitalists. Not to defend their behavior, but maybe that's why some are pricks... Try not to do that. Lol

Do a good work up. Trust in your knowledge and don't be afraid to stand up to consultants and protect your patients. Look to your senior PAs and docs for guidance. Understand that there are things you don't know and continue to work on improving your practice and gaining more knowledge and experience.

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20 hours ago, Sed said:

This doesn't happen often, thanks to most ER guys/gals taking care of business and knowing what we want, but every now and then we'll get a new guy who isn't prepared.

 

I think this hits the nail on the head.  Nobody is going to intentionally frustrate consultants... but when we are new we just don't know any better.  Being nice will go a long way to improving things for you... without being patronizing and talking down to the newer person, just explain what it is that you'd appreciate done in the future.

 Of course, there will always be new people cycling through... so if you're sick of repeatedly explaining your preferences, you could do what several of our consult services have done: make a "playbook" for ED reference.  Our orthopedists literally wrote out a guide with specific reasons mandating ED consult, and specific situations that are fine for outpatient follow up without ED consult.  This playbook was approved by the orthopedic team and with our ED quality committee.  It has been working quite well for us, and the orthopedists have seen a big decrease in volume of calls.  Win-win situation.

 

Now if only every specialty organization could sit down and create a formalized thing like this for reference... would be very helpful!

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3 hours ago, SERENITY NOW said:

 

I think this hits the nail on the head.  Nobody is going to intentionally frustrate consultants... but when we are new we just don't know any better.  Being nice will go a long way to improving things for you... without being patronizing and talking down to the newer person, just explain what it is that you'd appreciate done in the future.

 Of course, there will always be new people cycling through... so if you're sick of repeatedly explaining your preferences, you could do what several of our consult services have done: make a "playbook" for ED reference.  Our orthopedists literally wrote out a guide with specific reasons mandating ED consult, and specific situations that are fine for outpatient follow up without ED consult.  This playbook was approved by the orthopedic team and with our ED quality committee.  It has been working quite well for us, and the orthopedists have seen a big decrease in volume of calls.  Win-win situation.

 

Now if only every specialty organization could sit down and create a formalized thing like this for reference... would be very helpful!

This is a great idea, and I'm glad to hear it's working for you guys. 

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Check out my other post...

Sounds just like my ER experience.  Mine was so bad that I am still bitter about it to this day, although I guess I am thankful because it gave me the tools necessary to get the HECK out and transition to urgent care.

I was in a city ER much like yours. Attendings generally ranged between garden-variety abusive to full on narcissist/egomaniac and near psychotic; lots of surgical PGY3 consultants with their heads up their rectums, and so on...I think it just goes with the territory, unfortunately.   To be drawn to ER work, a doc has to be generally high-strung, have great memory (which they often wrongly self-diagnose as great intelligence), and not care too much about their patients...just enough to do their jobs and feign personal interest without slowing them down, but not more than that.   Ability or desire to teach, or even to work well with coworkers, is not a job requirement, and if it was, most ER docs would be out of a job.  There are exceptions, but this is the general type.  Doesn't make for very compassionate people or great teachers, in general.  I very likely will NEVER return to EM due to having dealt with these people and not wanting that kind of abuse and misery in my daily work life.

That being said, there are some things you can do, which I learned the hard way thanks to my transition to Urgent Care: 

(1) Trust yourself and your gut.  Often you will be right. Don't use the attendings or staff as an OCD-type "just make sure i'm right" tool, because they don't have the patience for that, and will come to hate you for it. Use other PAs as sounding boards, if you can, in place of attendings, but learn to trust yourself.  You know far more than you think you do, it may just be hard to call it up under pressure.

(2) Be confident in your dx and plan, even if it's wrong.  The ER vulture docs are just waiting for a hint of insecurity or hesitance to tear you a new asshole.  Don't give them that chance...even if you are BSing, it is better to BS confidently and be wrong than to be unsure. Trust me.

(3) Realize that feeling drowning and overwhelmed is 100% normal early in your career, early in an ER career, and exponentially hard with both happening at once.  It's not you. There is a shitton (metric) to learn in EM, and most PA schools suck at EM didactic, and suck even more at teaching the EM mindset.  At the same time, you have to play ego games with attendings who each are showcases for various extreme DSM  personality disorders and conduct disorders.  Not an easy task in any circumstance.   It may take six months to a year before you BEGIN to feel comfortable, but it all depends. 

(4) If you are more sensitive like me, and get tired of going home crying after ER shifts, give Urgent Care a shot...it's great.  No attendings to abuse you, no upstairs residents to sneer at you. It's much nicer.  EM is fun, but i'd rather keep my soul and my mental health.

 

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As a specialist PA who has to take overnight ED calls, I am not a jerk to you because you are a new PA, I am a jerk to you because you work in the ED and are calling me in the middle of the night.

 

JK, I am nice to everyone.

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Mindasone,

Perhaps I'm fortunate in not working in as toxic as environment as you, but I strongly disagree with your point #2.  You need to be confident in why you did what you did: how you structured your workup based on your differential.  You also need to be confident that it's MUCH better to ask for what else needs to be done or thought of than to stick to an incorrect diagnosis or treatment plan.  The more experienced a provider is, whether doc or APC, the more they'll likely know.  Still, they'll be calling consultants frequently for advice - not just for admissions but for what else needs to be done in the ED eval or confirmation that a patient is safe to d/c home.

BS'ing will always be found out: someone will get more information from the patient or from the physical exam; the patient won't get better & will bounce back or go to a different ED.  You will have missed a chance to learn.  You're reputation will be that you're too sure of yourself and miss things you shouldn't.

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3 hours ago, ohiovolffemtp said:

Mindasone,

Perhaps I'm fortunate in not working in as toxic as environment as you, but I strongly disagree with your point #2.  You need to be confident in why you did what you did: how you structured your workup based on your differential.  You also need to be confident that it's MUCH better to ask for what else needs to be done or thought of than to stick to an incorrect diagnosis or treatment plan.  The more experienced a provider is, whether doc or APC, the more they'll likely know.  Still, they'll be calling consultants frequently for advice - not just for admissions but for what else needs to be done in the ED eval or confirmation that a patient is safe to d/c home.

BS'ing will always be found out: someone will get more information from the patient or from the physical exam; the patient won't get better & will bounce back or go to a different ED.  You will have missed a chance to learn.  You're reputation will be that you're too sure of yourself and miss things you shouldn't.

Objectively, I agree with you...in a normal situation, perhaps in a far better place with better practitioners. And perhaps I am overstating it based on what I went through...but the salient point is to be clear and sure, and list only a few ddx possibilities and why you doubt them.

Where I was, there was a lot of "Are you sure...? Anything else?"-ing from the attendings...as if they were trying to call your bluff, find your weakness.  A lot of stone-face, cold-eyed, emotionless stares to see if you would flinch or doubt yourself.  It was, literally, a game...but must have been the way they were trained.  But that was the environment I was in. 

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Regarding OP:

Hello,

**Disclaimer** I am an EMPA with almost 2 years experience under my belt. I am EM postgrad fellowship trained, now working at a different level 1 inner city teaching hospital)... Still feel like I don't know shit... Still ask too many questions. But I thoroughly enjoy it!

 

After touching the hot stove too many times; here are a few basic rules of communication while working in the ED:

#1 When in doubt ask the PA/NP first.

- We have all been in your shoes. Our feet have only grown. 

- There is no such thing as a stupid question... Just stupid people (just kidding).

 #2 Keep it Simple. Stupid. Your a Salesman!

- The "One liner" is absolutely critical anytime you talk peer to peer. 

- Sell that shit!

- Applicable to everything regarding medicine. (Acronyms, mnemonics, explanations, etc..) 

#3 The 5 C's of Consultation.

- Google search it. Great for consults AND admissions AND presentation.

- Evidence-based, Effective and Efficient. Very useful method.

#4 Horrible phone conversation? Know how to end it.

- Is the consult/admit team asking for every little detail after your pitch? Are they asking for more test to rule out other diagnoses that would significantly increase time in ED (CT scan, MRI)?

- A good out is to simply say, "I do not have time to give more details over the phone. I'd gladly discuss this further with you in person after you see the patient here in the ED. In the meantime, who is the admitting attending, and are there any other tests (Blood work) you'd like me to check?"

- Be cognizant of objections that are likely to arise prior to speaking with consult/admit.

- Google search "Horror story consultations while in the ED" and you can read about other good ways to end phone calls. I did this after yelling at a cardiologist on the phone at 3am in the morning, and it stuck like glue.

 

 

Now I'd like to share some other words of wisdom; the amount equivalent to a pea-sized pituitary gland: 

#5 When in doubt... whip it out!

- EMRA antibiotic guide that is.

- Other sources of knowledge. (LIFTL, Radiologymasterclass, UpToDate, Your hospital's EM Manual), etc.

-Read, read more, then read some more! (Before, during, and after shifts). The best is when you read about an unstable condition right before your shift, and then sure as shit it's your first patient!

#6 Emergency medicine: Jack of all trades; master of resuscitation.

-And primary care.

#7 Tincture of time eventually tells all.

- Assume all patients are dying.

- See patient's sooner than later, especially Airway related complaints regardless of triage vital signs.

-Call that consult back if an absurd amount of time goes by. For example: Renal forgot to see ESRD pt needing urgent dialysis. 8hrs later... Pt goes into flash pulm edema. Leads me to my next point.

-That simple cough might not be that simple in the patient with ESRD and HFrEF 15%.

-Don't be afraid to change pt disposition.

#8 "We're all just swimming around with sharks in a fishbowl full of landmines."

- One for all and all for one in the ED, but before you trust you must first VERIFY...At first and whenever possible.

- Diseases, patients, consults, and hospital are all against you.

- Working in the ED is like playing Minesweeper. Eventually you win, right?

 

My 2 cents.

 

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