EMERGENCY PA'S - Question

[Salesian]

To PA's who currently/used to work in emergency medicine, does anyone have a recommendation for a book or online course to help prepare new graduates for a job in emergency medicine? I recently became board certified, and have about 4-6 weeks until starting my job in the ED. I would like to be as prepared as possible...

Thanks

[jeepgirl]

1. Book: EM Case Files provides a good overview

2. Online/live course: EM Boot Camp (before you spend the money, you should check with your employer to see if there are plans to make this option available to you)

 

[quietmedic]

EM boot camp is great, but it can be expensive.  Some ERs have a copy to lend out to prospective employees. But if you can get your hands on a copy of it, listen to it as many times as you can bear.  Take notes on it too.

If you will be starting out in "fast track" or low-acuity, (or even if not) get the "Minor Emergencies" Book, and start watching videos to refresh you for basic procedures...suturing, I&D, pelvic exams, etc.  Watch a video on the basics of the slit-lamp (it's simpler than it seems).

Either way, get the EMRA antibiotic guide, and EMRA emergency medicine guide. And get a subscription to UpToDate if they don't have one on-site.

The most important advice I can give you in the ER is:  (1) carry a little notepad, or index card spiral, or whatever, and keep, keep writing...best treatments for X, each attendings pet peeves, frequently used phone numbers and departments, etc.  The worst thing is to be told something by an attending and not have that info handy the second time.  It will be noticed. (2) ER docs can be among the most brutal, ruthless, heartless, soul-crushing humanoid creatures known to mankind. Be ready for it.  Don't let it get you down.   Just make sure you are doing your part and what you are supposed to be doing.  And document any serious negative encounters with any ER staff so that you have the ammunition, should you need it. (3) ER attending are not there to be your friend or suggestion source.  Come to them with a tentative DDX including what might kill this patient and why it isn't that, and come with a tentative plan. Believe me, even if you are wrong as hell, better to appear to have thought each patient through.  Do not look to ER attendings for suggestions for your DDX or plan, ever, unless they offer it.  (4) Don't be lazy about doing tests.  If there is an eye complaint, whatever it is, you darn well better have done visual acuity with Snellen before you even think of talking to an attending. Same with anything else...full cerebellar exam, full cranial nerve exam, etc.  (5) Now is the time to brush up on your physical diagnosis book.  And learn clinical decision rules...Ottawa knee, Canada Head CT,  CENTOR, PECARN, Ottawa foot and ankle, Well's, PERC, etc etc.

 

[SEMPA]

Join the Society of Emergency Medicine Physician Assistants (sempa.org).

SEMPA just rolled out a new member benefit that gives you free video access to all 71 30-minute lectures that were given at the ACEP/SEMPA EM Academy. The lectures were designed to be emergency medicine core content for new graduates or PAs new to the specialty.

Discounts on SEMPA educational activities such as SEMPA 360 and our ultrasound course. 

Discounts on EMRAP, EMSono, Rosh Review, ECGWeekly, Emergency Medicine Practice, and more. 

Free electronic access to Annals of Emergency Medicine.

SEMPA has also published a toolkit for practicing PAs. This toolkit provides an extensive list of emergency medicine education resources and tools as well as the history of the profession, pertinent medical laws, career planning and contract negotiation information.

Check out these benefits and more!

[ohiovolffemtp]

My experience has been different that quietmedic's.  I've worked with attendings that will answer questions.  He's correct that they don't have the time to teach.  Your fellow PA's and NP's are a much better source for tricks of the trade.  The clinical decision rules he cites are good for documentation purposes - justifying what you already want to do.  However, on a practical basis, many of them aren't that valuable.  For example the Ottawa rules miss enough in a field where you're not supposed to miss that it's usually better to follow the "it hurts - plain films" rule.  Especially in those folks who actually have pain tolerances, usually older adults, the rules miss too much.

[Will352ns]

EM Boot Camp, EM: RAP are great suggestions.  Seriously, take notes on the Boot Camp. 

I always found that the best reference is myself.  I carry a leather (sturdy) note book in my backpack that I sectioned off by system (cards, pulm, renal....). When I started, I went back through my notes from school and further broke it down to big ticket items in each system. Over the last few years I have added further notes for things that I have encountered with best treatments and tricks. I still add to it and reference it.

[quietmedic]

7 hours ago, ohiovolffemtp said:

My experience has been different that quietmedic's.  I've worked with attendings that will answer questions.  He's correct that they don't have the time to teach.  Your fellow PA's and NP's are a much better source for tricks of the trade.  The clinical decision rules he cites are good for documentation purposes - justifying what you already want to do.  However, on a practical basis, many of them aren't that valuable.  For example the Ottawa rules miss enough in a field where you're not supposed to miss that it's usually better to follow the "it hurts - plain films" rule.  Especially in those folks who actually have pain tolerances, usually older adults, the rules miss too much.

Admittedly my ER experience was awful, and I'm (apparently!) still bitter 'bout it.   Anyhow, I digress...excellent point about the "it hurts" rule...treat the patient, not the film/ECG/etc.

[quietmedic]

6 hours ago, Will352ns said:

EM Boot Camp, EM: RAP are great suggestions.....

Oh yeah, EM Rap is cool too (www.emrap.org).   I also very much liked the EM Basic (embasic.org) podcast.   But I definitely also upvote EM Boot Camp, first and foremost,  above all.

[EMEDPA]

Any lecture by Mel Herbert and Stuart Swadron is worth viewing.

also, check out the free and very short videos on a variety of em topics on the youtube EMRAP TV section

 

[GetMeOuttaThisMess]

Mel is good. He used to lecture at the EM Abstracts conferences.

[EMEDPA]

10 minutes ago, GetMeOuttaThisMess said:

Mel is good. He used to lecture at the EM Abstracts conferences.

Since I first heard him lecture in 96 I have thought no one gives a better em lecture than he does. the man can make diarrhea sit on the edge of your seat interesting. 

[SERENITY NOW]

When I first started out in EM, I found that I had to learn with a much different perspective than in school.  Its not about learning the details from a disease-centric perspective (ie heart failure causes these symptoms and is treated this way)  its all about the approach to the chief complaint (ie how do I work up a patient with shortness of breath).  Very different perspective to go about your learning... it replicates what you are doing on the job.  You are given a chief complaint from triage, and have to know the relevant emergency ddx, and based on that, know the relevant HnP, and the tests to order to rule out those emergencies.  That is 90% of what we do in EM. Once you establish a dx, just uptodate it on the spot for the treatment details... no need to memorize treatments at first since they will just be drilled into you over time anyways.   

Best resources to study the approach to chief complaint...

-#1, bar none --> emrap C3 (continuous core content) -- Many resources are academic and not what we actually do, but emrap C3 is spot on....  its simply the best I've seen.  They start with a real patient case and have a discussion about each step in the process of working up and managing the most common patient scenarios.  

-Beginning chapters of Rosens (one of the EM textbook bibles) focus on approach to chief complaint.

-Minor emergencies is excellent for on the job reference of practical "what do I need to do", but perhaps not really geared towards studying and understanding the principles of what you're doing.  

-to practice your learning with a practical EM simulation app, check out EM Gladiator's app called "resuscitation" -- it is interactive, very good content and provides feedback on what you missed.  It is free as well.

One of my colleagues had a great idea that I adopted and am very glad I did when first starting out...  As you are learning from the above resources, especially if you have access to your EMR, start to make your note templates with the learning points written into them.  Ie if you are learning about chief complaint "back pain" and studying the resources, you can have your HPI already prepopulated with things like "patient denies saddle anesthesia, bilateral radiation down legs, incontinence, retention, immunosuppression, IVDU, etc" which are targeted to the ddx and can spark your memory if you are taking care of a patient down the road and forget what is important to ask (I chart in the room so its right in front of me while examining).  So with this method, studying is helping you learn the essentials, making your evaluations more thorough on shift, and making your charting more efficient... killing 3 birds with one stone. 

 

[EMEDPA]

Serenity said it above, but I have also heard it as "the job of emergency medicine is ROWS" (Rule Out the Worst case Scearios).

If you ask an FP provider why a pt has chest pain their list will look like this: muscle strain, shingles, contusion, bronchitis, etc

Ask an EM person and they will say : MI, PE, Aortic dissection, tension pneumothorax,  ruptured esophagus, hemorrhagic pancreatitis, cardiac tamponade.....20 more things....the fp list above

[SERENITY NOW]

And of course, during your learning process, if you stumble upon any particular lectures or resources that really stand out as being superb, you could share it with the rest of us... on a website like FOAMest.com 

And while you are there, you can check out the resources that others have found to be the most helpful too.  

This is one of the educational projects I've been working on, since I remember how frustrated I was as a new grad wading through all of the countless resources out there.  I hope it helps~

[EMEDPA]

6 minutes ago, SERENITY NOW said:

And of course, during your learning process, if you stumble upon any particular lectures or resources that really stand out as being superb, you could share it with the rest of us... on a website like FOAMest.com 

And while you are there, you can check out the resources that others have found to be the most helpful too.  

This is one of the educational projects I've been working on, since I remember how frustrated I was as a new grad wading through all of the countless resources out there.  I hope it helps~

I just signed up for this and am looking forward to watching some of the lectures. Thanks!

[ohiovolffemtp]

7 hours ago, EMEDPA said:

Serenity said it above, but I have also heard it as "the job of emergency medicine is ROWS" (Rule Out the Worst case Scearios).

If you ask an FP provider why a pt has chest pain their list will look like this: muscle strain, shingles, contusion, bronchitis, etc

Ask an EM person and they will say : MI, PE, Aortic dissection, tension pneumothorax,  ruptured esophagus, hemorrhagic pancreatitis, cardiac tamponade.....20 more things....the fp list above

I heard that the EM mantra is "ROBS" - rule out bad s@#$.  

[EMEDPA]

1 minute ago, ohiovolffemtp said:

I heard that the EM mantra is "ROBS" - rule out bad s@#$.  

indeed. 

[GetMeOuttaThisMess]

7 hours ago, ohiovolffemtp said:

I heard that the EM mantra is "ROBS" - rule out bad s@#$.  

It does one well in PC as well (or maybe it's just the EM background).

[Salesian]

Awesome, thanks guys! I'm certainly looking into each suggestion.

EM Boot camp seems to get recommended over and over, so I will certainly look into that (especially if employer can give me access).

I plan on buying and reading the "Minor Emergencies" so as to at least reinforce the commonly seen "low acuity" complaints. I'm also gonna check out SEMPA and EM:RAP.

Despite only having clinical rotations to go off of, I definitely get what you guys are saying about ruling out the worst case stuff before even considering the horses, which obviously affects the most effective learning style as well.

I'll let you know if I find any other outstanding resources, etc. These suggestions seem like a good foundation, and I'll let you know how it goes!

[EMEDPA]

5 hours ago, GetMeOuttaThisMess said:

It does one well in PC as well (or maybe it's just the EM background).

I thought the PC rule was "when in doubt, after 4 pm, on any weekend or any holiday, just send the Pt to the ER. they can sort it out".

[CAdamsPAC]

Find out if they are suffering from anything that will, kill , cripple or blind them, treat & stabilize them for the inpatient teams.  If not the case them refer out!!

[GetMeOuttaThisMess]

I thought the PC rule was "when in doubt, after 4 pm, on any weekend or any holiday, just send the Pt to the ER. they can sort it out".

 Nah. We’re only here till 4p on most Fridays and last appt. is 3:30p so this couldn’t apply to us, especially during the summer when we’re not even in the office! We would just refer to the SP’s walk-in clinic with a smile! We all know folks don’t go to the ED over the holidays. Man, I hated those ED shifts New Year’s night when NO ONE wanted to go to work on the 2nd. [emoji14]