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Hi, 

So here's the story.  I am beginning my first rotation and it is in the ED (no previous ED or UC experience).  My preceptors are all very nice and willing to help, but I can't help but feeling like I am neither measuring up nor reflecting my program well.  I wanted to get some feedback to gauge if this is a normal experience, as there are no other PA students at my site to compare notes with.  I received an hour training on the EHR and beginning the second day was expected to see a few patients on my own and present them to my preceptor with assessment and plan.  This wouldn't be a problem except that I am very slow in addition to having forgotten a lot of the medicine (I have a 3.8+ GPA from didactic year, but once I took the test most of the info seemed to blur into general confusion).  I have no idea what to do with the mass of lab results from the current and previous ED encounters, nor sure that I've ruled out even 50% of the serious conditions.  I am also very slow at charting (for reference, my program allowed multiple days to finish one entire SOAP or H&P note).  I am also very poor at multi-tasking, which is an awful quality for the ED.  I know I am trying and that I am reasonably intelligent, but this makes me think I should have stuck with some desk job rather than managing healthcare. For all of these reasons I can tell that I am a drain on the preceptors who are already busy. I get that I am here to learn from the preceptors, but can't help but feel that this is not how things should be.  I do ask for feedback, but the preceptors are SO nice that I can't tell what they truly think. I'd appreciate any advice, what's normal, whats not, etc.

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What you're experiencing is perfectly normal. Even more so for the beast that is ED when you haven't ever been exposed to ED before. Tomorrow you should sit down with your supervising physician or lead PA. Let them know you feel a bit lost in the sauce. Then collectively identify some tasks that you wish to master prior to the end of the rotation. For the first of many, start with the basics: eliciting history of present illness. Emphasizing past medical history, previous ER visits for the same complaint. Utilize acronyms to help you get the clear picture (OPQRST is my go-to, others like OLDCARTS). Then doing a focused physical exam based on their complaint. Name of the game for ER presentations is chief complaint, past medical history, OPQRST for why they're there, physical exam findings (pertinent positives and negatives), what you think it is, what you think it isn't (arguably the most important aspect of ED presentations. Think of the 2-3 things that could kill the patient and rule them in/out), what you want to do for them.

 

Don't beat yourself up too much about how your rotation is going so far. You'll pick things up, and the skills will build upon themselves. Be better each day than you were before, and seek out opportunities to learn as much as possible. If a provider ordered a test for a patient and you don't understand why, ask them when there's some down time. If your assessment and plan get hacked to pieces (and it will), discuss with them what it was about the case that made them think it was X instead of Y. You can read on this forum tips for rotations, but the biggest thing I can emphasize is be teachable. Don't take offense to being corrected, but rather brush things off and go with the flow. 

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Yeah, sounds pretty normal to me. Here's the thing: you're supposed to be slow. You don't really know which questions are the important ones, so you have to ask them all. Don't worry too much about taking your time right now. Unless the patient is acutely ill and needing intervention right away, it should be ok for you to take a few extra minutes. 

One of the things I love about EM is that a lot of the time, you don't really have to come up with an answer to what is causing the problem. You just have to make sure it's not anything serious. So make a list of "can't miss" diagnoses for common complaints (headache, chest pain, dyspnea, abd. pain, back pain, and syncope is a good start). Then, come up with a couple of history questions you can ask to address each one, then add a PE test or two for each, then a lab/radiology test for each. Next time you're getting ready to see a patient, grab your list and remind yourself before you go in. Before you know it, the common complaints will become automatic. 

I think everyone feels a little out of their depth from time to time...or all of the time. Pretty sure that's normal and appropriate. Just keep going and you'll be fine.  

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Frankly if your preceptors are being nice and understanding - then they are nice and understanding!  I was thrown into day one of my ER rotation and sent to see pts in the first 5 minutes.  Each attending wants their presentations different, their notes different, etc.  One would make me restart my presentation multiple times until I got it they way he wanted.  It was a lot of trial and error but by the end of it I was better than when I started and that's what it's about.

You only get better by being pushed to get better.  Get the feedback.  Ask questions.  Ask them not to go too easy on you.  Clinical year is for learning and growing your skills; no one expects you to be perfect.  If we knew everything after didactic we wouldn't need clinical year.

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Sounds pretty normal to me if this is your first experience with the ED, which is a very unique beast from the other specialties... we are literally supposed to be able to handle anything that walks through those doors, from crashing anaphylactics to febrile children to MVCs and everything in between.  

So, instead of getting bogged down by having to memorize every little detail about every disease, EM is all about keeping things simple... what are the 3-5 emergencies that I need to rule in / out in this circumstance, and how do I do that?  That is the essential job of EM... and once life threats are ruled out, throw tylenol / ibuprofen at them and recommend PCP/specialist follow up.  

 

Set realistic expectations for yourself as a new student... you don't have to know it all, but you should develop a sense for this process... pick the most common chief complaints that they will be having you see (abdominal pain, fever / infectious syndromes, chest pain, etc), learn the ddx for the life threats, and learn what HnP / orders you need to do to rule them out.   

 

Some good places to start learning these things:

-EM basic podcast (free) - very nice walkthrough, geared towards newer learners

-Rosens textbook (find online) - has a nice intro section with the approach to the most common chief complaints.

-resuscitation app on iTunes (free) - good way to practice at home with interactive patient cases that let you put in the orders yourself and has good explanations at the end.  

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All sounds pretty normal. The ED can be a scary place even for people that have spent years doing it. So here's my advice:

1) If your not interested in EM don't worry to much. Focus on the bread and butter type stuff that you'll see anywhere you go clinic, urgent care, ect. Also get good at presenting patients and H&Ps because this will be everywhere too. Again don't worry too much but at least show your trying so your preceptor will know your taking it serious ... small world everybody knows everybody.  

2) If your interested in EM learn everything make it your cold to become the best PA-S this ER has EVER had. This will make you more comfortable when it comes time for electives and ultimately when you start to work. Also all the hard work will show and could land you a job! 

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As the day goes on, keep a list of questions you have and things you wish you would have known. You are likely to forget these if you don't keep track of them. Then, when you go home, research research research them until you can't get it wrong. 

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You're showing an effort to learn and improve. They understand and are nice and patient for a reason, because despite the fact you're feeling lost and slow....you are open learning and able to be taught. You'll improve :) For my Emed rotation, I used Tintinallis Emergency Medicine Handbook ( it's the smaller cheaper version of the main Tintinallis textook which runs in the hundreds of dollars) Its priceless and worth the $ imo. Try not to be too hard on yourself, take time to notice your progress/accomplishments, don' compare yourself to others, and have confidence....youve got this.

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