Getting into Emergency Medicine

[queenofhearts]

For those who work in EM, what was your background when you started? Did you need/have prior experience as an EMT, Scribe, Paramedic, RN, Tech etc in order to get into a job or a residency program? I am currently looking into EM jobs but most of them want experience, which is justified, but even residency programs are having that expectation too even if it is in a different role (ie the ones mentioned above). What about those who decided once we got to PA school we really liked emergency medicine? Insight appreciated!

[RuralER/Ortho]

EMT and worked as an ER Tech. Did essentially all inpatient/acute care type rotations in school.

What is your background?

[EMEDPA]

EMT/ER tech in college then paramedic x 5 years.

I recommend a residency to EVERYONE coming out of school now that wants to do EM. there are 30 of them. apply to 5 and you should get a slot if your grades and em rotation LORs are good.

also do as much EM, critical care, trauma surgery, etc as you can as a student. I did 1/2 of my clinical hrs(>1500) as a student in em(2 rotations) , peds em, and trauma surgery.

[surgblumm]

I came from the background of a Special Forces Medic, in combat in Vietnam. I was well trained but when going to the ER I saw that I needed additional reading and training. Eric is correct; as he is the resident expert in Emergency Medicine on this forum. Today, you may be in an ER but you will see the absolute need to attend SEMPA conferences and then to reconsider your status and get a residency so that you are prepared for every scenario. I have been a surgical PA for 46 years and have spent 16 years as an ER PA and I loved the excitement and the mystery of what I would be seeing as I picked up the next chart.

[queenofhearts]

Thanks for the replies thus far! Definitely want to do a residency, but they also seem super competitive. I had a great EM rotation and hopefully good letters too, but my concern is that I had no ED experience prior to PA school (tech, scribe, or otherwise) and it seems like a lot of people do :(. I thought the whole point of a residency was to get people who have no experience up to speed. Ahh, well just gotta see what happens. 

[Boatswain2PA]

If you are willing to move you can certainly find good EM jobs that hire new grads.  One (very busy, VERY well run) shop I work part time at just hired two new grads and I'm sure are looking for more.

Like E has said, you can have location, pay, or specialty.  If you're lucky you can have two of them.  It may take years to get all 3.

[EMEDPA]

MOST em residencies are more interested in your PA school performance> prior experience.

[LT_Oneal_PAC]

17 hours ago, EMEDPA said:

MOST em residencies are more interested in your PA school performance> prior experience.

Agreed. You have to articulate a sincere desire about practicing EM, but grades and LORs are more important.

[quietmedic]

Residencies are absurdly selective, and few and far between...they also want fresh, young, energetic meat right out of school, not anyone with experience or baggage (family, age, etc).

For hiring, it's tough. In my experience, having EMT or Paramedic background is fairly useless...very different medical mentality from ER practitioner.  The best I can say is BE READY....listen to EM boot camp 100 times, memorize it, read Tintinalli ten times, memorize it, then send out resumes weekly, make phone calls, apply your butt off...Took me half a decade to get an ER job. 

Also, realize that half the battle in many ERs is dealing with the generally criminally-psychotic and pathologically-abusive attendings and PGY3s...and only the other half is medical.  If you are someone who cries easily or is easily hurt....gotta work on a thicker skin.  You will NOT be treated like you were as a student. It will be far, far more vicious.  (just speaking from experience).  In the wrong ERs, you will be lucky to keep your soul and sanity. And not because of the patients.

Then again, the further you are from a city, the more pleasant the experience, and the easier the hiring.

[EMEDPA]

5 minutes ago, quietmedic said:

In my experience, having EMT or Paramedic background is fairly useless...very different medical mentality from ER practitioner.

 In the wrong ERs, you will be lucky to keep your soul and sanity. And not because of the patients.

Then again, the further you are from a city, the more pleasant the experience, and the easier the hiring.

disagree with point 1 and agree with 2 and 3.

1. I feel that my paramedic training and work experience was critical to my job today as an em pa. As a paramedic you are used to working with very few people, having serious responsibility, knowing who is sick and who isn't, and developing great trauma and medical resuscitation skills. 

2. I have worked in places that hated PAs and made no effort to hide it. the administrators, the docs, the nurses, the whole place. Left several of those places early in my career.

3. small community ERs or rural is where it's at. everyone is happy you are there and your work is recognized and appreciated. I know some folks like Medic25 and Trueanomaly have had good experiences at major trauma centers. I have worked at several and have not had that experience. always felt like an interchangeable cog in the machine. may be a west coast vs east coast thing. I have worked at 3 rural departments(still work at 2) and felt appreciated at all of them. 

 

[LT_Oneal_PAC]

25 minutes ago, quietmedic said:

Residencies are absurdly selective, and few and far between...they also want fresh, young, energetic meat right out of school, not anyone with experience or baggage (family, age, etc).

For hiring, it's tough. In my experience, having EMT or Paramedic background is fairly useless...very different medical mentality from ER practitioner.  The best I can say is BE READY....listen to EM boot camp 100 times, memorize it, read Tintinalli ten times, memorize it, then send out resumes weekly, make phone calls, apply your butt off...Took me half a decade to get an ER job. 

Also, realize that half the battle in many ERs is dealing with the generally criminally-psychotic and pathologically-abusive attendings and PGY3s...and only the other half is medical.  If you are someone who cries easily or is easily hurt....gotta work on a thicker skin.  You will NOT be treated like you were as a student. It will be far, far more vicious.  (just speaking from experience).  In the wrong ERs, you will be lucky to keep your soul and sanity. And not because of the patients.

Then again, the further you are from a city, the more pleasant the experience, and the easier the hiring.

I was highly desired by my EM residency and I have a family, I’m older, I have years experience as a PA. So I think that’s pretty bunk. Have you tried for a residency?

EMT and paramedic experience goes a long way in the ED. Just my opinion.

my attendings are super nice, except one or two, and all the PGY3s are nice. They often go out of their way to give procedures to me and other interns. I work in a major city, granted in a less populated section of the country. Certainly not NYC. I would refuse to work in such malignant practice settings. 

 

[quietmedic]

25 minutes ago, LT_Oneal_PAC said:

I was highly desired by my EM residency and I have a family, I’m older, I have years experience as a PA. So I think that’s pretty bunk. Have you tried for a residency?

EMT and paramedic experience goes a long way in the ED. Just my opinion.

my attendings are super nice, except one or two, and all the PGY3s are nice. They often go out of their way to give procedures to me and other interns. I work in a major city, granted in a less populated section of the country. Certainly not NYC. I would refuse to work in such malignant practice settings. 

 

Yup, Applied to quite a few.  Got rejected from all.  The rest of the nominees (we all interviewed together) were barely out of teens, barely out of school, and as green as the grass. I was the only one not young and not inexperienced, with plenty of PAing and EMTing under my belt. Needless to say, I was not called back, and one of the residency admins all but told me it was because they want fresh meat. Go figure...

As well, did my decade as an intermediate EMT.  Trauma, code resuscitation, mass-casualty-incident and solo-responsibility experience is great, but only goes so far.  ER resuscitation are far different than field, the roles are very different, and as a PA in trauma or codes you are rarely anything more than an extra hand for a long time.  And ER medicine is very different.  As an EMT, your job is to follow the algorithm, follow the algorithm, and follow the algorithm, and if you can, don't kill the patient. And get him to the ER without killing anyone else.  As an ER PA, your job to consider every DDX, figure out what might be going on, prove to the attending what ISN'T going on, get yelled at and torn a new butthole for a few minutes, formulate treatment plans, follow through, and do that on multiple patients at once...and then, get yelled at anyway for being so dumb. And do it all over again tomorrow, and not dare to be so dumb as to get it wrong the second time.  Oh, and today's attending B expects a completely different treatment plan, thinks attending A is an idiot, and therefore thinks you're an idiot.  Completely different skill set, setting, expectations and medico-legal realities than an EMT. About the only commonality is that both involve blood and it's always a hurry. 

(Sorry if I sound bitter....but my ER experience was horrible. And you two hit it on the head...correct, NYC).

But anyway, enough venting...that was my experience with NYC ER residencies and NYC ERs. YMMV.

[LT_Oneal_PAC]

11 minutes ago, quietmedic said:

Yup, Applied to quite a few.  Got rejected from all.  The rest of the nominees (we all interviewed together) were barely out of teens, barely out of school, and as green as the grass. I was the only one not young and not inexperienced, with plenty of PAing and EMTing under my belt. Needless to say, I was not called back, and one of the residency admins all but told me it was because they want fresh meat. Go figure...

As well, did my decade as an intermediate EMT.  Trauma, code resuscitation, mass-casualty-incident and solo-responsibility experience is great, but only goes so far.  ER resuscitation are far different than field, the roles are very different, and as a PA in trauma or codes you are rarely anything more than an extra hand for a long time.  And ER medicine is very different.  As an EMT, your job is to follow the algorithm, follow the algorithm, and follow the algorithm, and if you can, don't kill the patient. And get him to the ER without killing anyone else.  As an ER PA, your job to consider every DDX, figure out what might be going on, prove to the attending what ISN'T going on, get yelled at and torn a new butthole for a few minutes, formulate treatment plans, follow through, and do that on multiple patients at once...and then, get yelled at anyway for being so dumb. And do it all over again tomorrow, and not dare to be so dumb as to get it wrong the second time.  Oh, and today's attending B expects a completely different treatment plan, thinks attending A is an idiot, and therefore thinks you're an idiot.  Completely different skill set, setting, expectations and medico-legal realities than an EMT. About the only commonality is that both involve blood and it's always a hurry. 

(Sorry if I sound bitter....but my ER experience was horrible. And you two hit it on the head...correct, NYC).

But anyway, enough venting...that was my experience with NYC ER residencies and NYC ERs. YMMV.

I’m sorry for both of your experiences. Truly crap.

[EMEDPA]

1 hour ago, quietmedic said:

a PA in trauma or codes you are rarely anything more than an extra hand for a long time. 

And ER medicine is very different.  As an ER PA, your job to consider every DDX, figure out what might be going on, prove to the attending what ISN'T going on, get yelled at and torn a new butthole for a few minutes, formulate treatment plans, follow through, and do that on multiple patients at once...and then, get yelled at anyway for being so dumb. And do it all over again tomorrow, and not dare to be so dumb as to get it wrong the second time.  Oh, and today's attending B expects a completely different treatment plan

this is why rural med is the bomb. at a trauma/code/airway disaster I am the only clinician in the room with a bunch of nurses and a tech or 2. I don't have to have anyone approve my treatment plans because there is no one else here. 

I worked for years at  a place (actually several places) like you describe. there is a reason I don't do that any more...

[quietmedic]

31 minutes ago, EMEDPA said:

this is why rural med is the bomb. at a trauma/code/airway disaster I am the only clinician in the room with a bunch of nurses and a tech or 2. I don't have to have anyone approve my treatment plans because there is no one else here. 

I worked for years at  a place (actually several places) like you describe. there is a reason I don't do that any more...

Perhaps one day....

[ohiovolffemtp]

My 35+ years in prehospital medicine was a huge help in the ED, even when I started.  As EMED said, there's no substitute for all that experience in recognizing sick/not sick.  As the medic on a call, I was responsible for coordinating the other responders - similar mindset to coordinating all the folks in the room on a sick patient.  There's no substitute for experience - whether you have to get it in the ED or if you come in with a fair bit of it.

Being a medic really teaches you how to manage trauma.  ATLS is really about teaching docs, esp. non-EM docs like surgeons, to think like medics and then adds some procedures & imaging.

I share EMED's perspective on a residency.  It would have been very beneficial, but for life reasons I chose not to do one.  So, now I'm piecing together the learning: procedures, ultrasound, skills from off-shift rotations, on my own.

I'm sorry quietmedic's experience was bad.  I work in a level III trauma center in a city of ~60K, right now about 55K ED visits/year and have found the docs very willing to answer questions - though there's really not much time for them to truly teach.  PA's & NP's are valued here.

[CAdamsPAC]

EM/EDs can be snake pits for the unenlightened PA, nurses, admin, physicians and yes other PAs can and do make the places so. I surmise that ED Residencies grant not just education but exposure to the snake pit . Should a PA be fortunate enough to gain employment in an EM practice that is all about educating and developing a competent clinically skilled  PA, no residency is required. I worked as a staff PA in an ED where the director told me a PA with 10 months of experience " there's nothing closed to you, do what you know and when you need to be taught let me know". With that license I was doing LPs,abdominal taps, central lines, chest tubes, even running a code when the Resident was in the middle of another! All of this was before PA Licensing and even hospital credentialing were required in Connecticut and the respect given to the ED PAs by the housestaff was unquestioned. This was the facility that now offers an EM Residency to PA's. Yes my 14 years of experience as a advanced level Medic in the US Army gave me some insights to a different type of EM, it didn't prepare me to practice EM in a inner city University  Teaching/Trauma hospital ED. I can believe there are EM programs that prefer younger candidates or that are biased towards applicants with many years of clinical experience, a bias based on a belief that it easier to teach new skills rather than unlearn bad habits or preconceived knowledge. That said, a good strongly supportive practice where teaching and development of the PA's skills over turning numbers and billing excellence is the best option for most PA's seeking a career in EM. Just my $.02 after years of EM in multiple practices.

 

[Will352ns]

I got lucky and fell into an ER position that I had a rotation in during school. They hired me because of my previous experience and how I was able to demonstrate how it was useful. 

I was a 20 year military medic. 9 years as a basic hospital medic (mostly ER) and 11 years as an Independent Duty Medic. During my time in, I saw my share of trauma and such, which was helpful.  Most people would assume that is what would give me the advantage in ER; it wasn't.  It was my ability to safely see low/mid acuity patients at a good pace. It was essentially what I had been doing for years, just easier now that I had a better foundation of knowledge (not to say I knew everything...definitely did not). 

 

Experience dose matter.  I landed a >90% pay range job in a good location with a good group right out of school. I encourage everyone with my similar background to apply, there are hundreds out there.