EMPA Residency

[davidr14]

Hello Everyone, 

 

I enjoyed reading the PA Residency threads and am looking to possibly start a new one for any newcomers. 

If there is interest, I will start posting updates in July and do my best to keep you entertained. 

 

[dphy83]

If it is a quality program I think the interest will follow. If it is a program of poor quality I unfortunately think the interest would still be there but you'd ultimately be doing a disservice to the trainees.

What is your facility like (large referral center, non academic community hospital)? What is your ED volume, acuity? Trauma or no? What off service rotations can you offer? Ultrasound and other training opportunities? Co-located physician residency?

I say the more high quality programs there are the better. Interested to hear what you have in mind.

Edited March 23, 2021 by dphy83

[davidr14]

I probably should have mentioned the program details lol! Good point! 

The program is definitely of quality and one of the most competitive programs in the nation. It has been around for over 10 years. It is 18 month EMED PA Residency program. 

Program details: 

- Level 1 Trauma/Critical Care 

- Volume greater than 140,000 per year 

- One of the highest admission rates in the nation

- 2 PAs with 60 MD Residents, we take turns with surgery residents in terms of running traumas 

- Optho, US, Tox, OBGYN, Ortho, Cardio, SICU, MICU, Peds ED, Anesthesia, Gen surg, Neuro

 

I was planning on detailing the application process and giving PAs who are interested a more personal perspective of my experience. 

Edited March 24, 2021 by davidr14

[MediMike]

@davidr14 I think the prior poster misunderstood and was thinking you were trying to start a new residency program rather than detail your experience in the program.

I think most of us love hearing about the residency experience from the perspective of the trainee. It provides great information about the program as well as allows new grads to evaluate if it sounds like a good fit for them.

Also lets us older folks live vicariously

[dphy83]

Oops. I definitely misunderstood and thought you were gauging interest in starting a completely new program, not detailing your experience in one.

Either way I am interested haha. As Mike said, we love hearing about peoples' experience in these things. I almost completely chose my residency based on the threads on this site.

[davidr14]

@MediMike 

Makes sense now, lol. I’ll be keeping the name private for professional reasons. 
 

haha, I’ll make sure to keep you in mind Mike. I am 28 years old and graduated from UWs PA program. If it helps the readers understand my background. 
 

I’ll work on posting in July and relaying what onboarding looks like etc. 

[davidr14]

@dphy83

 

Well that clears things up! Haha Would love to hear more about your residency experience. 
 

Always great hearing from other PAs. 

[davidr14]

Hello My Fellow PAs, 

 

I didn’t forget about you.

These past few months have been really busy, and I haven’t really had the time to sit down and update this thread. 
 

I will be starting Telemetry soon, and will do my best to update you on my first two months in the ED. 
 

the patient presentations are complex. I have managed Urosepsis, CHF that required inotrooic assisted diuretics, NSTEMI, stroke (Neuro loves their NIH stroke scale), PNA, fractures, complex multi layered lacerations, participated in primary and secondary surveys, central lines, USIVs, vaginal bleeding, ectopic, biliary pathology, afib, Major MVCs, COPD/Asthma, covid patients. Etc.. 

 

it has been challenging, and yet ultimately satisfying. I am one PA in a class of 16 interns. There is no distinction between myself and the MD/DO interns. We all work high acuity and low acuity pods (in all honesty, low acuity pods don’t exist in this patient population). As first years, we don’t work fast tack, which is nice.

 

Every attending has their own style and you are constantly adjusting presentations and treatment plans based on how conservative or liberal the doc is. Some prefer more labs, and some simply want an EKG and basic labs. On average you will see 8-12 patients per shift. We rotate through 3 pods and work with a few second years, one senior resident, and an attending. 
 

I highly recommend listening to emrap c3, em basic, emcrit, reading rosens, learning about US, and really honing your radiology skills (X-ray, CT abdomen, CT head). Also, please read a few EKG books, it will really help you.
 

Trust but verify all information that EMS reports. You will deal with more psych patients than you can imagine. Haldol and versed will become your best friends. 

Funny story time:

”Always do good chart review on TIA vs Stroke patients” 

Here I was thinking that my Neuro exam was killer and that I identified various R sided deficits and was elaborating on which cranial nerves were affected.. 

Placed a neuro consult… even provided them with a lovely NIH stroke scale number lol. 
 

Neuro resident comes and appreciates all of the deficits on exam but states that is patients baseline and that her sxs were caused by a hypertensive event…

 

so yea.. hypoglycemia and hypertension can mimic/reactivate/worsen neurological deficits in previously infarcted tissue. Demand and Supply ischemia. It quickly resolves. Make sure you’re aware of your patients baseline and do some chart digging, it will save your ass. 
 

overall, the experience has been humbling. I have learned so much in two months. Cheers to all of my fellow PAs. 

Edited August 20, 2021 by davidr14

[davidr14]

Hello Again, it’s me, sleep deprived and surviving off of cliff bars. My fridge is empty because I haven’t had time to go to the grocery store. 
 

Just finished four weeks of cardiology.  
 

I will post about my cardiology experience soon. Definitely comfortable with Heart Failure management. 
 

consider several things:

1. are they lasix naive? 
2. lasix has a threshold, don’t be afraid to push 80 mg BID

3. Farxiga is a great news drug and is renal protective

4. Entresto is a wonderful HF drug and every patient should be on GDMT

5. Net goal diuresis not reached ? It’s either a documentation issue or you need to add metolazone. 

6. Flash pulmonary edema and HTN emergency ? Nitro gtt and BIPAP. Wean and then resume oral anti HTN. 
 

7. nurses will be tempted to place patients on NC O2, 92% is ok and don’t forget to place communication orders. 
 

8. clinically euvemic means nothing. What is the PCW pressure? RA pressure ? What does recent Echo show ? Are CR and BUN going up? 
 

9. FAILURE pneumonic, should always go through differential in your head as to why they are in exacerbation. 
 

10. Demand ischemia will frustrate you like no other. 
 

11. Know all 5 types of MI. Is it acute and occlusive? Is there a plaque rupture ? Is it restenosis ? Are they on DAPT? 
 

12. Extensive chart review is your best friend. Become comfortable with memorizing 10 new patients every single day. 
 

I am back in the ED this month. Last month I worked 24 days, and each shift was 12-14 hours. I was on call every third day. 
 

Cheers! 
 

If any other PAs are in a residency, feel free to post here and add to the thread. 

[davidr14]

Thinking of maybe starting a vlog. 
 

Good idea ? Bad idea ? Live Q&A session for anyone really curios about what residency is like ? 

[TeddyRucpin]

51 minutes ago, davidr14 said:

Thinking of maybe starting a vlog. 
 

Good idea ? Bad idea ? Live Q&A session for anyone really curios about what residency is like ? 

That would be awesome. I'm a first year student but a residency/fellowship is something I'm interested in.

[JonHendrixx]

\

On 10/7/2021 at 2:26 PM, davidr14 said:

Thinking of maybe starting a vlog. 
 

Good idea ? Bad idea ? Live Q&A session for anyone really curios about what residency is like ? 

I personally would love this!

[davidr14]

I will post an update soon. 

Choosing to do an EMED PA residency is the best decision I have ever made. 

It seems to me that as PAs, we are very supported and appreciated by our Physician colleagues. 

The trauma, procedures, clinical skills, EBM, simulation labs/cases, complex pathophys that you are exposed to is priceless. I am 6 months in and I am comfortable ( but also cautious and afraid) intubating, placing central lines, art lines, chest tubes, POCUS for pregnancy, abdominal pain, FAST exam, RUSH exam, ECHO etc. 

I still remember the first time I pushed TPA at bedside. 

In doing a residency, you get exposure to bread and butter emergency medicine and have the proper support to challenge yourself and perform at the highest level. Prior to starting this program I did not see myself managing 5 patients at one time, and then stepping in and evaluating one afib RVR patient, one sinus tachy patient, and one seizing patient and help guide the resuscitation. 

Little did I know that I would be screaming out my neuro exam and consulting neuro with confidence. DKA? that is just bread and butter everyday medicine. Close the gap and be patient, trust the pathophysiology. Stroke? MI? AMS? cardiac arrest ? Follow your algorithm, know your meds stone cold, think Hs and Ts, consult your specialist early. Anaphylaxis? follow your mental pathway, epi X3, consider a drip, focus on H2 blockade, and reevaluate. 

There will come a point where you will look at a patient that is arriving on bipap and just know they are in flash pulm edema lol. Start that nitro drip high, dont hesitate. You will recognize CHF and asthma/copd from a mile away. 

My last piece before I sign off and enjoy the holidays, be wary of the smiling patient, they will crash and burn. You will never see it coming. They come in for back pain, they will respond to MSK treatments, their vitals will be perfect, they will be ready for discharge. Their pressure will drop and their pulses will become faint. Grab the US and call vascular surgery and pray. 

 

I wish all of you PAs out there a Merry Christmas! Keep fighting the good fight, especially right now. If you are feeling the burnout and covid is drastically changing our outlook on medicine, feel free to reach out. 

 

-Cheers  

[TeddyRucpin]

27 minutes ago, davidr14 said:

I will post an update soon. 

Choosing to do an EMED PA residency is the best decision I have ever made. 

It seems to me that as PAs, we are very supported and appreciated by our Physician colleagues. 

The trauma, procedures, clinical skills, EBM, simulation labs/cases, complex pathophys that you are exposed to is priceless. I am 6 months in and I am comfortable ( but also cautious and afraid) intubating, placing central lines, art lines, chest tubes, POCUS for pregnancy, abdominal pain, FAST exam, RUSH exam, ECHO etc. 

I still remember the first time I pushed TPA at bedside. 

In doing a residency, you get exposure to bread and butter emergency medicine and have the proper support to challenge yourself and perform at the highest level. Prior to starting this program I did not see myself managing 5 patients at one time, and then stepping in and evaluating one afib RVR patient, one sinus tachy patient, and one seizing patient and help guide the resuscitation. 

Little did I know that I would be screaming out my neuro exam and consulting neuro with confidence. DKA? that is just bread and butter everyday medicine. Close the gap and be patient, trust the pathophysiology. Stroke? MI? AMS? cardiac arrest ? Follow your algorithm, know your meds stone cold, think Hs and Ts, consult your specialist early. Anaphylaxis? follow your mental pathway, epi X3, consider a drip, focus on H2 blockade, and reevaluate. 

There will come a point where you will look at a patient that is arriving on bipap and just know they are in flash pulm edema lol. Start that nitro drip high, dont hesitate. You will recognize CHF and asthma/copd from a mile away. 

My last piece before I sign off and enjoy the holidays, be wary of the smiling patient, they will crash and burn. You will never see it coming. They come in for back pain, they will respond to MSK treatments, their vitals will be perfect, they will be ready for discharge. Their pressure will drop and their pulses will become faint. Grab the US and call vascular surgery and pray. 

 

I wish all of you PAs out there a Merry Christmas! Keep fighting the good fight, especially right now. If you are feeling the burnout and covid is drastically changing our outlook on medicine, feel free to reach out. 

 

-Cheers  

Looking forward to it. Thank you. 

[davidr14]

Hello again, hope everyone enjoyed their Christmas. With the COVID surge hitting all of us very hard, I wanted to lay out some resources as an online gift to the PA community. Here are resources I use/study daily and some which are more useful on my days off. 

1. The only EKG book youll ever need by Malcolm Thraler - build a basic foundation and develop your personal method of reading an EKG 

2.Bounce backs ED cases: ED returns 10th edition - review Chief complaints I evaluated and recognize where I could improve next time or possibly things I may have missed or did well. 

3. ECGS for the EM Physician Amal Mattu - i try to do 10-15 EKG reads in my free time and challenge myself to know more and recognize acute pathology 

4. Tintinallis - this is the emergency medicine bible, try and read 10 pages per day. 

Apps: 

1.   EMRA ABX guide - i use this daily , I downloaded the app.

2. Pedistat - helpful to have when running a pediatric code, dosing, RSI meds, critical care 

3. VAD stat - helps guide you with any LVAD patient that comes in. Extremely useful. 

4. RSI wizard - helpful to play around with or when you freeze and need a quick reminder 

5. quick EM, WIkiEM, medscape - helpful with reminding you key things in terms of work up and ddx, especially if you are on hour 13 or 14 of your shift. 

6. Visual DX - because derm is no ones friend, and you dont want to miss TENs, SJS, kawasakis, HIV derm complaints, kids and rashes 

7. MDcalc - PECARN, Nexus, Canadian Head CT, Canadian C spine, Ottawa ankle and knee, curb 65, PSI, chadsvasc, wells, perc, shock index,  CIWA, COWS etc. you will use these daily, good to have on board.  

8. Uptodate - helpful when you just need to remind yourself of some quick pathophys or just need to look something up 

 

Podcasts:

1. EMRAP - C3 podcasts and Right on prime. Listen to all of these and you everything will start clicking. I usually listen while running, driving to work, or running errands. Worth the money. 

2. EMBasic, Internal medicine curbsiders, Internet book of critical care, rebel cast, EMCrit, white coat investors, and Choose FI - all great podcasts.

 

Online resources: 

1. https://www.coreultrasound.com/5ms/ - for those who want to develop a solid foundation in regards to US 

2. https://litfl.com/ - this is a great resource in regards to tox, ECGS, cases, podcasts etc. 

3. https://aliemu.com/ - has so many courses you can do, and its all free. Every resident in EM uses this website. 

4. https://www.youtube.com/channel/UCFHfSDdJrB95ffkKK0n8pNQ - if you want to get better at radiology in general, this is a great resource, and its free. You will earn the trust of your team quickly and feel better about your pre-lim reads. 

5. https://first10em.com/first10em-cases/ - just another free resources with great cases and management plans for common critical care scenarios and EMED complaints. 

6. https://www.emrap.org/hd - this has saved me on so many shifts and scenarios. Reviewing simple tips and lectures will help you become more confident in procedures. There are plenty of pearls and little tips and tricks. 

 

Most of these are free and easily accessible, EMRAP is not, and some of the books I purchased. 

I hope this helps. 

Edited December 27, 2021 by davidr14

[davidr14]

When elderly folks fall or when the family calls states that they have been acting different. 
 

Just scan them. 

[davidr14]

Not much of an update, COVID is burning us all out but the pathology is complex and fun. 

I did have to intubate a stroke patient I gave tPA due to an anaphylactic reaction. That was fun, and slightly frightening. The nurse may have pushed Etomidate and succ simultaneously without telling me. Sats dropped to 80 in seconds, so good BVM technique came in handy lol. All in all, laryngeal and cord edema made it a bit more difficult. 

Working with a lot of new nurses due to a high turnover rate has made the job a bit more tedious. I find myself placing over 10-12 peripheral US IVs, drawing my own cultures, and inputting VS on a lot of my own patients. 

SIde note, make sure you know how to zero an arterial line, most new nurses do not know how. 

Also, with rent, groceries, and gas prices rising rapidly, I truly envy all of you making a real living lol. 

[davidr14]

Will posting photos of crazy cases. 
 

Here is a case of Saddle Embolus! 
 

Don’t anchor on covid. This patient had been to the ED multiple times throughout the week for hypoxic episodes and was discharged home. 
 

 

[ohiovolffemtp]

COVID is a huge risk factor for PE and new onset A-fib, especially with RVR.  I've seen it multiple times.  If I have any clinical findings that suggest PE I pretty much go straight to the CTA.  Dimers aren't valuable, because with COVID they're pretty much always positive, even with age adjustment.

[davidr14]

Totes agree. Previous providers didnt see covid or PNA or effusions on xray and d/c home. They arrived hypoxic to the 70s on RA. COVID neg btw. Good thought though. Of course I went to straight to CTPE and stabilized prior to IR showing up. Covid is a risk factor for sure. Also, POCUS showed some septal bowing. US was def helpful. They are on room air now, and getting transferred from MICU to GMF. Good case. Excuse my lack of detail, been writing over 25 charts per day as of late. Tired from using dragon. lol. 

[davidr14]

Hello everyone,

Just a quick update! 

I have 6 months left and will be graduating January 12, 2023. 

Was it worth it ? Yes. Most definitely yes. 

Am I proficient in US ? yes 

Can I do an LP without shitting my pants ? yes 

Can I drop a crash line within a few minutes ? yes 

Intubating in the trauma bay while the trauma surgeon is breathing down your neck? yes 

Difficult IV access ? not a problem 

Conscious sedations for complex reductions ? yes 

Community medicine experience ? yes 

Reverse takotsubos and cardiogenic showck 2/2 to excessive cocaine and meth? yes 

Giving diuretics to a hypotensive patient with a plethoric IVC with CCU being happy ? yes 

COVID is not scary 

Arterial lines ? yes 

chest tubes ? yes 

fascia illiaca nerve blocks for hip fracture ? yes 

GI bleed with a hb of 2.7 and MTP 2/2 to perforated gastric ulcer ? yes 

hyperthermia with heat stroke 42 c ? yes 

GSWs like they were candy ? yes 

SCAPE that had me holding my ET tube bedside ? yes 

asthma so bad it required Epi and a trial of heliox and bipap ? yes 

pneumopericardium in a 21 yF with anxiety ? yes 

tamponade in a 23 yM 2/2 to covid ? yes 

everyone will have a PE if you look for it

aortic catastrophe in a smiling patient ? yes 

testicular torsion ? yes 

a fetus flying out of the cervix during a pelvic ? yes 

appendicitis is rare but it feels amazing when surgery agrees with your exam

Intraparenchymal bleeds are not scary, subdural bleeds with neurosurgery and radiology disagreeing are 

Not every kid with a fever is sick, but if they are <28 days, do everything and transfer 

Do I love EM ? yes 

Would I do this program again ? yes 

What do I want to do now? Critical care and emed combined. 

Cheers to all of my fellow PAs in critical care and Emed 

[PAEMed]

Hi,

I didn't see you naming your program. I assume you want to wait until you graduate. It sounds like you made a great choice. Until you name your program so I can look up the nitty-gritty details, can you please share:

How many shifts per week/month? 10 hours/12 hours? Any particular duties on your days off, more than self-learning?

Any elective rotations?

What are the core rotations?

Was there a didactic portion to your program? Did you have to write any papers, like research papers, academic papers? Please say....no!

How much does it pay? Does it come with full benefits?

 

Thanks!

[davidr14]

I dont mind sharing if you PM me!

I work 20-22 12 hour shifts while in the ED, and 24 11-13 hour shifts on off-service rotations. 

Elective rotations in US, ENT, Optho, and I chose to do critical care. 

ROSH, self guided learning, articles prior to conference. A lot of self-guided learning, but also following core objectives for physician residency to guide my studying. Five hours of protected conference each Wednesday, SIM labs,etc. 

 

Core rotations: SICU, Cardiology. CCU, MICU, Ortho surgery, Neurology as the stroke resident, Optho, US, Toxicology, OBGYN. 

I did publish in a toxicology blog, which is required for all residents rotating through. No other academic requirements. 

62K before taxes,. Full benefits. 

It is not that bad, and very doable. Taking the pay cut was the best decision of my life. You will have your pick of jobs and actually be able to negotiate salary, benefits, sign on bonus, relocation bonus. 

This is the craziest city to practice EMED, you will be pushed and you will learn to solve problems, make decision, and save lives. You will do bedside echoes, push epi bedside, manage every type of shock, and advance our profession. 

Best decision of my life. 

 

Edited September 6, 2022 by davidr14

[davidr14]

Idk how to process this  so I am posting on here. We lost one teenager, and almost lost four other high school football players. They got ambushed during football practice. Emergency medicine can be hard at times. Philadelphia will teach you a lot. But this, it is difficult to cope with. The violence here is out of control. 

[MediMike]

12 hours ago, davidr14 said:

Idk how to process this  so I am posting on here. We lost one teenager, and almost lost four other high school football players. They got ambushed during football practice. Emergency medicine can be hard at times. Philadelphia will teach you a lot. But this, it is difficult to cope with. The violence here is out of control. 

Damn David I’m sorry man. I hope your team is able to help support each other.