Staying late... can’t... do it... anymore.

[Guest ERCat]

I just wrapped up a fourteen hour day today. I am frigging exhausted. My shifts are twelve hours, but I stayed late charting. I only saw about 26 patients, but a lot of them were nightmares and very labor and time intensive (huge dog bites on the legs, two distal radius and ulnar styloid fractures that required multiple attempts at reduction, a cervical laceration that would not stop, a hypotensive upper GI bleed... I could go on and on). 

I have been staying super late in the last year, and I am sick of it. Usually an hour, two in a blue moon. I think it all started when we started to get RVU pay. I make an additional 30 to 55 per HOUR just for the RVUs, so it’s tempting to try to pick up an extra patient here or there. We don’t get paid for the hours we stay late, but you’d assume the RVUs would more than make up for it. That’s what I have been telling myself but I am sooooo tired of staying late.

I have been blaming myself for “picking up too many patients for the RVU” but here’s the weird thing; I am not actually seeing significantly more patients than I did before we got RVUs. So I am staying substantially later because... God knows why... I don’t know.

Does anyone have any tricks for getting out on time? I don’t think what I am doing is sustainable.

[ohiovolffemtp]

I was never very good about getting out on time at my old FT job either.  I felt that averaging (pt + procedures + 30 min increments of critical care time) of 2/hour was plenty.  Don't know what your total hour compensation is, but I found that in my last 90 minutes of a shift I did best if I only picked up patients that wouldn't involve much of a workup or likely need admission.  In my last 45 minutes, I'd only do level 4's & 5's, and no procedure that wasn't simple.

[narcan]

Agree with ohio; I'm careful not to pick up complex patients near the end of my shift. Also, you should look into whether you can finish your charting from home via VPN. It's a lot nicer to finish those charts in your own environment with a cold beer than being stuck at the hospital under fluorescent lights.

[EMEDPA]

I try to do most of my documentation in real time. I don't chart from home ever. when I worked with an RVU bonus structure I pretended it didn't exist. you can't depend on it, so don't. Once I have 4 open charts(the most you can have on epic), I don't start a new patient unless they are dying or all the charts are up to date. That being said, I will stay late for disasters at shift change(codes, etc)  or if the night provider will be totally overwhelmed. I either work solo coverage or dual coverage, never more than 2 providers, so if I am leaving and it is just the night guy and there are 15 pts I generally won't leave. they generally make this up to me by kicking me out early another night. My primary job is solo coverage and a busy day is 15 pts in 24 hrs. my part time job is double coverage and I typically see 65 pts in the 3 days in a row I work once/month. I don't ever want to be busier than that again. I did 15 years of the 25-50 pts/12 hrs thing. never again. 

[LT_Oneal_PAC]

It depends on the day as I could be managing 8-10 rooms or things may be flowing and I’ve got everyone nice and packaged, but 2 hours prior to sign out I’m only picking up patients that I can get a good start on. Levels 3 typically that don’t say “history of renal transplant” or something else I know is going to require soul crushing specialist consult as these people are notoriously slow to implement their plan. One hour before I’m only picking up people that are young level 4. There is almost no such thing as level 5 here at my tertiary care center.

I try force my myself to get the HPI and physical done before I see my next patient. I often don’t because I’m working with an off service intern and have to pick up the slack of them seeing only 6 in a shift. When it works out though my charts are easy at the end of the day. I’m almost always staying late though to wrap up patients for the next team, as I feel too guilty to hand off work to another resident who is just as overworked as I am.

like Emed, I’m done with this rat race and can’t wait for my low volume high acuity rural job.

[EMEDPA]

almost done with a 24 right now. have seen 7 patients including a dissecting AAA, a recurrent syncope, and a septic patient with diverticulitis. high acuity, low volume. love it. at my last job I would manage an entire hallway(10 rooms) and be expected to help out in fast track if they got busy or be a procedure guy on traumas if that team got busy. I am done with that. 

[ohiovolffemtp]

I now work in a low volume variable acuity rural critical access hospital.  I feel so much better, even though I'm a nocturnist.  My wife feels like I'm back to being me, vs the constantly stressed out barely communicative person I was before.

That said, I'm the only provider in the ED from 20:00-08:00 and the only one in the hospital from 20:00-07:00, when the inpatient docs round.  So, if anything comes through the door, I'll start it unless it sounds very minor and it's the last 10 minutes of my shift.  However, signouts are expected unless the patient will be ready for discharge a few minutes after the normal end of your shift.

[Guest ERCat]

On 7/15/2019 at 4:07 PM, ohiovolffemtp said:

I now work in a low volume variable acuity rural critical access hospital.  I feel so much better, even though I'm a nocturnist.  My wife feels like I'm back to being me, vs the constantly stressed out barely communicative person I was before.

That said, I'm the only provider in the ED from 20:00-08:00 and the only one in the hospital from 20:00-07:00, when the inpatient docs round.  So, if anything comes through the door, I'll start it unless it sounds very minor and it's the last 10 minutes of my shift.  However, signouts are expected unless the patient will be ready for discharge a few minutes after the normal end of your shift.

HOLY CRAP. Are you joking me? You are the ONLY one for a good chunk of the day? In all honesty I can't even fathom that. So you're running codes, sticking in chest tubes, intubating, starting pressors...by yourself? One thing I lack as a PA less than four years out is critical care skills. Even though I work in the ER...I never have to do that stuff because the docs do it. I legit can't imagine. How long have you been a PA?

Thanks, everyone, for the responses. Never thought about working in a lower volume facility but it sounds tempting and maybe worth the drive...

[ohiovolffemtp]

I have the day doc on call.  They come back in for codes and thrombolytics.  It's about 50/50 whether they run the code or I do.  I do all of my own intubations, haven't had a chest tube or central line at this facility yet.  However, I have done both at other facilities.  I don't do LP's, but am in the process of learning and getting credentialed.  Yes, I do start pressors and/or IV antihypertensives when needed - which isn't often.  I've been a PA for 6 years - always doing EM.

I've also been in fire/EMS for ~35 years and a medic for 17.  So, coding and intubating is far from new to me.  It's actually easier at my age to intubate standing up vs. laying on the floor like most of my field intubations.

There are many PA's who do completely solo coverage, like Emedpa, Boatswain, etc. and from what it sounds like, in places with more higher acuity than I see.  Any EM PA can grow into this if they work at it.  Residency training is the best way, but experience and taking a few key classes can get you there too (that's been my path).  Ultrasound, ATLS, ACLS, and advanced procedure courses help get you started.  You also need to work with the docs where you work and have them give you the opportunities and coaching.  I was very blessed at my 1st FT job at a very busy level 3 trauma center to have lots of opportunities and supportive docs.  The nurses really appreciated having another person who could handle sick patients.  Actually, the only problems I had were from some of the nursing managers, who didn't like PA's who they couldn't direct to just move the low acuity patients.

As I told the CEO of my current (wonderful) company, the worst day I've had at this job was an average day at my old job.  He was thrilled.

[LT_Oneal_PAC]

14 hours ago, ERCat said:

HOLY CRAP. Are you joking me? You are the ONLY one for a good chunk of the day? In all honesty I can't even fathom that. So you're running codes, sticking in chest tubes, intubating, starting pressors...by yourself? One thing I lack as a PA less than four years out is critical care skills. Even though I work in the ER...I never have to do that stuff because the docs do it. I legit can't imagine. How long have you been a PA?

Thanks, everyone, for the responses. Never thought about working in a lower volume facility but it sounds tempting and maybe worth the drive...

It’s the best. I currently only moonlight there until my residency ends and I start full time, but I see much fewer people and some are truly sick. I have someone call the attending on when I’m coding someone, trauma activations, and if I’m going to give TPA. They don’t interfere with what I’m doing, but I appreciate them there because many times I need someone to help that can better anticipate what I want or need than the nurses.  I’m the only inpatient/ED provider in house at night or day. There are FM docs in clinic within the hospital during the day, but they don’t interfere with me, post residency, and another EM veteran PA, as they realize we do it all and do EM just as well or better. There is a newer grad on staff they work more closely with. I’ve been a PA for 4.5 years. 

[cdcd67]

I don't mean to hijack this thread, but for all of you PAs handling all these high acuity patients, I was looking for some words of advice. 

I've been working as a PA for 5 years. My experience is a mix of IM and EM, but mostly it's EM. The problem is that all of my EM experience has been low acuity population and most of the learning I had to do was on my own. I kind of wish I did a residency when I graduated, but anyhow...

I want to get more experience with higher acuity but I fear due to my lack of experience with high acuity patients, it would be difficult to land a job elsewhere. I work in NY, just for some reference, so in most places there are residents working and they usually take priority for any acute patients.

Anyhow, I was mainly asking because so far, working as a PA doesn't feel so fulfilling to me. I figured if I can work somewhere where I am actually making a difference in someone's life, it might make things better.

Any tips/advice? Consider rural EM though lack of experience with high acuity and likely need for more training?

[MediMike]

One thing to remember (*insert standard thread hijack apology*) is that higher acuity doesn't mean making a difference in someone's life.  It oftentimes is the complete opposite.  I went from 10yrs off/on in EMS to working critical care right out of school with that same thought process.  My wife (who works in the ED, sees mainly 3s-5s, some 2s) had similar thoughts as you the other day. 

To relay our conversation I had to let her know that the testicles she untorsed last week made a hell of a lot more difference in an individual's life than the VAST majority of high acuity super sick patients that I see on a daily basis.

Remember, everything you do makes a difference for someone, they're there to see you for a reason.  It may not be a good one to you, but to them it's important, and there's a lot to be said for that. 

[ohiovolffemtp]

@CDCD67

Consider getting at least a PT job in a community hospital that doesn't have residents.  Many but not all of them will give you a chance to handle higher acuity patients while having an attending there as a resource.  Network with EM PA's in the area - see what their experiences are.

[cdcd67]

On 8/3/2019 at 6:08 AM, MediMike said:

One thing to remember (*insert standard thread hijack apology*) is that higher acuity doesn't mean making a difference in someone's life.  It oftentimes is the complete opposite.  I went from 10yrs off/on in EMS to working critical care right out of school with that same thought process.  My wife (who works in the ED, sees mainly 3s-5s, some 2s) had similar thoughts as you the other day. 

To relay our conversation I had to let her know that the testicles she untorsed last week made a hell of a lot more difference in an individual's life than the VAST majority of high acuity super sick patients that I see on a daily basis.

Remember, everything you do makes a difference for someone, they're there to see you for a reason.  It may not be a good one to you, but to them it's important, and there's a lot to be said for that. 

I'm kind of shocked you don't feel like you make much of a difference helping high acuity patients. And I'll keep what you said in mind. Thank you. :)

 

On 8/3/2019 at 10:22 AM, ohiovolffemtp said:

@CDCD67

Consider getting at least a PT job in a community hospital that doesn't have residents.  Many but not all of them will give you a chance to handle higher acuity patients while having an attending there as a resource.  Network with EM PA's in the area - see what their experiences are.

Hey, yeah I actually just recently started a new job. But next job I look into, I will consider somewhere where there are no residents. Thank you. :)

[gatormaz]

Yes-

Simply stop picking up patients prior to your shift's end and leave yourself the last hour to clean up your documentation.  Are you making dispos without everything back near the end of your day (do you have a solid relationship with the hospitalist group that you can trust who will follow some ancillary things, etc?)  Have worked solely in EM for 9 years and this is literally the only thing that will help you.  Whatever you do, never chart from home unless you are literally a partner in the practice sharing profits.  Many RVU setups in my experience are a fixed pot of money whereby the only way you can make more is by your colleagues making less.   

Edited August 8, 2019 by gatormaz

[Boatswain2PA]

On 8/5/2019 at 9:36 AM, cdcd67 said:

I'm kind of shocked you don't feel like you make much of a difference helping high acuity patients. And I'll keep what you said in mind. Thank you.

Coded a lady today on/off for almost 2 hours today as she had brady arrest/rosc/brady arrest/rosc etc ad nauseam.  Finally after TPA and three pressers she stabilized and flew her out.

Sounds exciting, unfortunately almost guaranteed a poor outcome.

[MediMike]

1 minute ago, Boatswain2PA said:

Coded a lady today on/off for almost 2 hours today as she had brady arrest/rosc/brady arrest/rosc etc ad nauseam.  Finally after TPA and three pressers she stabilized and flew her out.

Sounds exciting, unfortunately almost guaranteed a poor outcome.

There are a select few where a big difference can be made. It's normally the young, otherwise healthy individuals who have a sudden precipitous event. Septic shock from PNA, arrest from a channelopathy, massive PE...these folks will often recover.  The remainder? There's a lot more prolonging death than there is extending life.

But it's still fun! Physiology is great. Procedures. Unending learning. And I suppose that what I consider "making a difference" could very well be much different than what someone else may think.

Boats, family just insistent on continued efforts?

[Boatswain2PA]

2 hours ago, MediMike said:

Boats, family just insistent on continued efforts?

Yes.  And hard to call it when she keeps getting ROSC. 

[MediMike]

27 minutes ago, Boatswain2PA said:

Yes.  And hard to call it when she keeps getting ROSC. 

Yeah, those are the situations you memorize the anoxic injury rates for...Was it hypoxia driven bradycardia? You thinking PE? Mentioned tPA...

[Boatswain2PA]

Presumed Inferior stemi.  Never got reperfusion rhythm.

Just a long fight that nurses thought went so well cause she made it tertiary care, but virtually zero chance of meaningful recovery.

I just bring it up as example of how oftentimes CC doesnt really "make a difference".