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New ER PA, stressing out

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2 hours ago, CJMO said:

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.

 

This is great advice, especially for newbies.

And also a good laugh. Thanks for that. "When in doubt... Whip it out." Haha

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On 2/7/2018 at 1:24 PM, EMEDPA said:

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....

This is one of the greatest things about my hospital; we don't call medicine for admissions (except ICU), period.  It's our call whether they stay or not.  If we decide that we want to admit a patient, I just put the order into Epic and bed management starts working on their bed.  The admitting team can read the note and come do their own H&P, but there is no such thing as stalling or blocking an admission.  Makes life so much less stressful....

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Yeah but ED does that too, to reduce their length of time in the ED.  So you get admissions for a kids in "status asthmaticus" in room air and needing 2 puffs every four hours....

Or bronchiolitics on oxygen but the prongs are out of their nose and they're starting 100% when they hit the floor  

Or my favorite, a kid walks up under his own power holding his mom's hand, with an IO hanging from his leg. 

I get it. I've been in the ED.  It's hard and you have to start from scratch and gauge sickness without having the benefit of time to observe.  But maybe we should be able to block SOME admissions. 

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On 2/6/2018 at 3:28 PM, ohiovolffemtp said:

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.

 

7 months in as a new grad and every point rings true for me as wrll

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On 3/8/2018 at 9:48 AM, medic25 said:

This is one of the greatest things about my hospital; we don't call medicine for admissions (except ICU), period.  It's our call whether they stay or not.  If we decide that we want to admit a patient, I just put the order into Epic and bed management starts working on their bed.  The admitting team can read the note and come do their own H&P, but there is no such thing as stalling or blocking an admission.  Makes life so much less stressful....

This was a beautiful thing when I worked at the University Hospital in central MA as well... it made life much easier.

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First, welcome to EM.  Congrats on choosing the field (or did it choose you...).  You have received some excellent advice already, but I'll throw my 0.02 in as well.  We have all been there.  Here's how I dealt with it.

1. Know your shit.  Plain and simple.  That means reading, reading, and more reading, asking questions, listening to podcasts, follow literature both in and out of EM, and build that wealth of knowledge you need to be able to recall at a moments notice, without looking it up, such that as you progress, when the BS reasons come to give you crap, it's easy to counter.

2. Learn the Golden Rule of EM:  Sick or Not Sick.

When you peel back all the layers, look through it all, and just look at someone, you just need to know, sick or not sick.  I have seen far too many new people struggle with this simple concept, and in the world of EM, it is THE defining aspect of our job.  If sick, know why and hold to your guns.  If not, move the meat. 

3. You MUST KNOW the next step for every patient, period. For example, if a patient presents with a STEMI, you have to know they are going to the cath lab.  If they can't, you have to know if lytics are in play.  You have to know what is coming from the next person to take care of them so when you do talk to them, you are telling them EXACTLY what it is you need from them.  If you can't talk a cat off the back of a fish truck - keep at it.

4. Find a mentor.  This is critical.  You are new, green, inexperienced, and the learning curve is anywhere from 1-3 years to get "good" at what you do.  Having someone guide you while going through this is critical to your long term success.

5. Final rule - don't take it personally. People are lazy, entitled, and think they know what is best.  And I am being generous.  This DEFINITELY applies to people in medicine, as its more a business now than "the calling" it once was, and people just don't want to work in an overworked system.  They will look for ANY reason not to help you, all while smiling to your face.  You are the patient advocate in the EM setting, which is why rule no. 3 is so important.  When you can quote there own literature to them and what they are expected to do, by both medical standards and due to EMTALA requirements, it tends to snap people into line.

The above approach will make you into "an a-hole" to most because you are forcing people to do what they don't want to do - and that is help someone out.  But it doesn't matter. Its not the reason you do the job in the first place - you aren't here to make their job easier -  you are here to take care of those who have seeked out your help.  With being the above, comes the respect you earn over time, and slowly that all changes, when it is you to whom they turn when they need help.  That's when you know you have arrived.  And usually not a moment before.  

Good luck - and keep the chin up,

G

 

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When I worked in EM (the first 10 years of my career, started as a new grad), I’d come home after a shift and my husband would ask, “So, who did you have to fight with today?”

 

Your main concern is the patient’s best interest. You have to brush up on your skills and develop confidence.

 

Look stuff up, practice according to evidence based guidelines, then you can support your workup if challenged.

 

And when you encounter some asshat consultant or hospitality who only cares about not adding to their workload, stand up for your patient.

 

Someone won’t speak to a PA? “I am the provider in charge of this patient, so I am the person calling for this consult/admission.”

 

They refuse to take your call, won’t see the patient, try to dodge the admission? “Just to be clear, are you refusing the consult/admission? I want to clarify so I can document in my chart that your refusal is why the patient required transfer to an outside facility.”

 

Chart then says: “Attempted to consult/admit, spoke with Dr. Dickhead who refused the consult/admission. Patient was transferred to OSH to receive services required by his/her condition.”

 

Hospitals don’t like gratuitous transfers. They lose business. It will be addressed, and you will have advocated for your patient.

 

The first time I stood up to a hospitalist I was shaking inside. But ultimately, it served my patient, my department, and our profession well.

 

Be brave, be strong, be confident, and READ all the time about conditions you encounter so you can develop unshakable skills. YOU HAVE TO KNOW YOUR SHIT. Nobody will take you seriously if you don’t, and most people won’t brush you off if you do.

 

It gets much easier, I promise.

 

And to clarify, I highly recommend using the “more bees with honey than with vinegar” first, whenever possible. You’ll have many fights to fight, no sense looking for one when you don’t need one. If a slightly cranky consultant asks why you didn’t do XYZ, you can calmly say, “It was not part of the workup we deemed appropriate for the ED/we felt a specialist should spearhead that/I didn’t think of it/whatever. If you’d like for me to get that started (as long as it’s within your scope of practice), I’d be happy to.”

 

 

 

Sent from my iPhone using Tapatalk

 

 

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On 2/6/2018 at 2:50 PM, sk732 said:

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

I just fell in love a little 

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On 3/8/2018 at 1:35 PM, lkth487 said:

Yeah but ED does that too, to reduce their length of time in the ED.  So you get admissions for a kids in "status asthmaticus" in room air and needing 2 puffs every four hours....

Or bronchiolitics on oxygen but the prongs are out of their nose and they're starting 100% when they hit the floor  

Or my favorite, a kid walks up under his own power holding his mom's hand, with an IO hanging from his leg. 

I get it. I've been in the ED.  It's hard and you have to start from scratch and gauge sickness without having the benefit of time to observe.  But maybe we should be able to block SOME admissions. 

I snorted margarita at the IO comment.  How true though.

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1 hour ago, GetMeOuttaThisMess said:

I snorted margarita at the IO comment.  How true though.

yup. from the other side...the "emergent patient" sent from clinic who looks good from door and you KNOW your 2 hr workup will find nothing. Thankfully decision rules sometimes help. I recently got someone "coughing up blood who needs to be ruled out for PE". looks great. heart rate 70. good sat. not tachypneic. clearly bronchitis in a young smoker. Wells score 1(for single episode of "hemoptyisis"-blood tinged spit- THE PREVIOUS DAY). documented: nad, wells score 1. cxr neg. chance of PE <1.3%. discharged. no labs. no cta. discharged.

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On 6/22/2018 at 5:35 PM, EMEDPA said:

yup. from the other side...the "emergent patient" sent from clinic who looks good from door and you KNOW your 2 hr workup will find nothing. Thankfully decision rules sometimes help. I recently got someone "coughing up blood who needs to be ruled out for PE". looks great. heart rate 70. good sat. not tachypneic. clearly bronchitis in a young smoker. Wells score 1(for single episode of "hemoptyisis"-blood tinged spit- THE PREVIOUS DAY). documented: nad, wells score 1. cxr neg. chance of PE <1.3%. discharged. no labs. no cta. discharged.

I appreciate your input. I work as a new grad in rural Primary Care in a small mountain town. I try to avoid sending pts to the ER unnecessarily unless warranted, such as my pt w/empyema 2/2 pneumonia on Thursday. I follow-up on those that I do send so I can get feedback either directly from the ER provider (of which there are 3 total; 1 on duty at any given time) or from the discharge summary etc. so I can a. Determine what workup the ER did, and get an idea for how those providers operate, b. If my referral was appropriate/not, c. Was there anything I could do differently or learn. I appreciate my fellow ER providers as much as I hope ya'll appreciate us out in primary care trying to take care of the masses and keep em out of your ER. ?

Edited by Colorado
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On 2/6/2018 at 12:44 PM, 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 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 did this exact same thing in a residential, upscale hospital system ED with primarily insured folks.  The then new kids on the block loved the referrals and would even stop by the ED on their way out to ask how things were going and if there was anything that we needed help with.  Offending specialty?  Overwhelmingly Plastics.  Occasionally ortho or GI (food bolus refractory to glucagon).  Ophthalmology quit taking call since the hospital wouldn't buy them the play toys that they wanted so we'd have to transfer out eye patients to the mothership ED.

Edited by GetMeOuttaThisMess

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Congratulations because you feel just as you should. I always suggest that a PA does "House" or Primary Care for two years before going into the ER as the ER requires experience. I used to tell my students that you are not a PA when you graduate and pass PANCE but two years later when you have gathered the experience. If it does not work out, follow my first suggestion and then return to the practice that you love and you will be able to fulfill your responsibilities.

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9 minutes ago, surgblumm said:

Congratulations because you feel just as you should. I always suggest that a PA does "House" or Primary Care for two years before going into the ER as the ER requires experience. I used to tell my students that you are not a PA when you graduate and pass PANCE but two years later when you have gathered the experience. If it does not work out, follow my first suggestion and then return to the practice that you love and you will be able to fulfill your responsibilities.

I'm going to disagree with my esteemed colleague on this part. If you want to do something before an entry level EM job, work in urgent care. The vast majority of places looking for folks with prior experience want it to be in EM or UC. There are still EM jobs out there for new grads, but many are fast track only type positions. I know none of the places I have ever worked in EM would look at someone who listed PA school + 2 years of FP on their CV. One of my former students just applied for an em position. she was a hospitalist for 15 years. even with my stellar recommendation she did not get an interview.

Primary care is a different field and a different mindset than EM. UC is basically EM-light. you still think "what is the worst thing this could be". The FP mindset is any problem is probably the most likely dx, not the one that will kill you. Probably a muscle strain and not an MI. probably a cold and not sepsis, etc. My advice to new grads wanting to go into EM today is to do an em residency. Commit to the specialty and get the best training possible in that specialty. That applies to anything, not just EM. 

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22 minutes ago, EMEDPA said:

I'm going to disagree with my esteemed colleague on this part. If you want to do something before an entry level EM job, work in urgent care. The vast majority of places looking for folks with prior experience want it to be in EM or UC. There are still EM jobs out there for new grads, but many are fast track only type positions. I know none of the places I have ever worked in EM would look at someone who listed PA school + 2 years of FP on their CV. One of my former students just applied for an em position. she was a hospitalist for 15 years. even with my stellar recommendation she did not get an interview.

Primary care is a different field and a different mindset than EM. UC is basically EM-light. you still think "what is the worst thing this could be". The FP mindset is any problem is probably the most likely dx, not the one that will kill you. Probably a muscle strain and not an MI. probably a cold and not sepsis, etc. My advice to new grads wanting to go into EM today is to do an em residency. Commit to the specialty and get the best training possible in that specialty. That applies to anything, not just EM. 

Agreed. While I loathe UC personally, I can say there is a difference in mindset between FP and EM that has to be overcome. In FM, I was supposed to be specific and minimize testing based on the likelihood from history and physical exam. In EM residency now, I’m training to be sensitive and risk stratify patients to decide on testing. 

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I am going to agree with the two posts that followed mine. Urgent Care gives you the Fast Track model with coughs and colds and sprains and fractured and lacerations . You will learn radiology, Suturing, EKG’s, patient interactions as well as the general feel of a microcosm of a large ER. Mia Culpa

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