New Grad-1st Job in the ER with minimal training-Disaster waiting to happen?

[Batman]

I have recently been offered an ER position right out of school. Although this is exciting, it sounds like I will have less than a month of  "training shifts", on top of that they are understaff and I am concerned that I may not have the ability to have a direct supervisor since they have their own caseload. Im currently advocating to have at least 3 months of training. Am I being unrealistic with my expectations or does this raise serious red flags?

I should also state they are planning on hiring at least one other new grad. Some say the best way to learn to swim is by jumping in the deep end. I just dont want patients to get hurt in the process. 

Any advice or tips will be appreciated. Im just concerned about being set up for failure at my first job. Thank you!

[Cideous]

How good is your malpractice insurance.....?

[EMEDPA]

Get a bunch of good reference books , like Rosen & Barkin, and consult frequently when you don't know something. There are no stupid questions. Does a pregnant lady with a kidney stone and a uti get admitted? (Yes) Ask that kind of question.....

[muchi]

Hi there. I was in a similar situation when I came out of PA school. My job offered three months of training and I didnt feel like  even that was enough so I would definitely, absolutely, positively push for more. I feel like in the 1st month youre just getting used to the emr, how things work, etc etc in addition to trying to learn the medicine. Read, read, read. I remember using tintinallis and listening to podcasts like EMRAP religiously (they have a section called C3 that goes over core knowledge on bread and butter EM topics). Lean heavily on your fellow APs and friendlier attendings and ask many many questions. It will be a challenging first 2-3 years. Did i say you should ask for a longer training period?!

 

Good luck!

[Batman]

1 hour ago, Cideous said:

How good is your malpractice insurance.....?

Is it safe to assume that you believe this is an awful idea?

[Batman]

59 minutes ago, muchi said:

Hi there. I was in a similar situation when I came out of PA school. My job offered three months of training and I didnt feel like  even that was enough so I would definitely, absolutely, positively push for more. I feel like in the 1st month youre just getting used to the emr, how things work, etc etc in addition to trying to learn the medicine. Read, read, read. I remember using tintinallis and listening to podcasts like EMRAP religiously (they have a section called C3 that goes over core knowledge on bread and butter EM topics). Lean heavily on your fellow APs and friendlier attendings and ask many many questions. It will be a challenging first 2-3 years. Did i say you should ask for a longer training period?!

 

Good luck!

It sounds like they will only give me 9-10 "training shifts" and that is more than what they originally wanted. From then on I would be on my own. I will definitely continue to listen to podcasts and read. I know I will have to put in immense time out of work to really adequately prepare. 

[ohiovolffemtp]

I have a slightly different take: it's not so much about how long the official "training period" is as it is about the availability of more experienced providers: PA's, docs, NP's to ask for help 1-5 minutes at a time.  Questions like: "I've got this 32 y/o/f with abdominal pain.  I'm doing x, y, and z.  Is there anything else I should be thinking of?".  See if you can speak to PA's that have been there 1-3 years.  Ask them how their 1st years went.  For me, it was about a 3 year learning curve before I was reasonably proficient on the common complaints.  Most folks will tell you the same.  I actually probably learned much more from the experienced PA's than from the docs.

Another question to ask is what patients you will be expected to see early on, vs after a year, vs later.  If there's enough lower acuity, you can be productive while learning the EMR, the overall environment in your ED, managing your work flow, etc.  You can then gradually grow the range of patients you feel comfortable managing.

[Batman]

1 minute ago, ohiovolffemtp said:

I have a slightly different take: it's not so much about how long the official "training period" is as it is about the availability of more experienced providers: PA's, docs, NP's to ask for help 1-5 minutes at a time.  Questions like: "I've got this 32 y/o/f with abdominal pain.  I'm doing x, y, and z.  Is there anything else I should be thinking of?".  See if you can speak to PA's that have been there 1-3 years.  Ask them how their 1st years went.  For me, it was about a 3 year learning curve before I was reasonably proficient on the common complaints.  Most folks will tell you the same.  I actually probably learned much more from the experienced PA's than from the docs.

Another question to ask is what patients you will be expected to see early on, vs after a year, vs later.  If there's enough lower acuity, you can be productive while learning the EMR, the overall environment in your ED, managing your work flow, etc.  You can then gradually grow the range of patients you feel comfortable managing.

I have a follow up call tomorrow to ask about the acuity that I will be seeing. I had a rotation there and although I was with a Dr. most shifts I could tell the PAs had a variety with the acuity. 

They claim that I will have the ability to present to a provider but I have serious concerns since the providers are already stretched fairly thin. Thank you so much for bringing those points up!

[Cideous]

If you get sued and lose, are you in a state where you can loose your house?  Just a question....

[Boatswain2PA]

Do you have any real medical/life experience before PA school?  Are you good at making critical decision?

If so, you will be fine. 

If you have no real medical or life experience before PA school, and have never been in the position of making critical decisions, then proceed with caution.  If you have real-life experience making important decisions, based on limited information, that could result in life or death then you will be fine.  

Be PARANOID.  Worst first.  If you don't have a good idea of what the worst case scenario for every patient when you see their triage note, then proceed with great caution.  If you can see "headache and confused" and the first thing you think of is "meningitis, sepsis, SAH, CVA" then you'll be fine.  If you think "I wonder what this could be", then proceed with caution.  If you see a 24 yo F with abdominal pain and think "ectopic, torsion, appy, cholangitis, obstruction" then you'll be fine.  If you think "I bet it's a UTI" then you might want to proceed with caution.

EM isn't rocket science.  It's 95% traffic cop with a high level of paranoia about what kind of disaster this could be.  Know your disasters and be prepared to jump on them, overtreat, overtest, and overcall.

Do you care about bothering your attending, hospitalist, or specialist?  If not, then you'll be fine.  I don't care if the attending is busy, if you are over your head on a patient that needs something NOW then you stop them.  They are paid 2-3 x what we are, they get paid to take those interruptions.  If you are too meek to interrupt your attending because your altered patient's paCO2 is 95 and you don't know what to do...then proceed with caution.

And in today's job market flooded by NPs with 2 years of part-time online training with 500 hours of clinical "experience", be lucky that you have a job offer.

[Boatswain2PA]

Addendum:  Go slow.  Look things up.  1 pph should be your goal for first year.  Make sure your boss is happy with that.

Look EVERYTHING up on Wikem.  At 1 pph you will have time.  What's the dose of amoxicillin for otitis?  Look it up.

[ohiovolffemtp]

11 hours ago, Boatswain2PA said:

EM isn't rocket science.  It's 95% traffic cop with a high level of paranoia about what kind of disaster this could be.  Know your disasters and be prepared to jump on them, overtreat, overtest, and overcall.

Do you care about bothering your attending, hospitalist, or specialist?  If not, then you'll be fine.  I don't care if the attending is busy, if you are over your head on a patient that needs something NOW then you stop them.

This!   Don't try to build a herd of albino zebras or even of zebras.  Just make sure you're very attuned to when something may not be in your herd of horses and know where to get help and be very willing to ask - especially when you feel embarrassed for doing so.  It's way better to look dumb but be recognized for knowing the boundaries of your knowledge.  Those boundaries will grow with experience and time, but not before then.

[Cideous]

OP....do you know how to run a code?  I mean REALLY run a code.  Have you ever ran a code by yourself?  That shit can go sideways incredibly fast.  How about lumbar punctures?  Intubation?  How about treating a 89 year old in CHF with multi organ failure with the family standing right there telling you to do everything to keep them alive...

The question is not whether these scenarios will happen but WHEN.  In my ER days I did these things almost every shift.  If they give you help and most importantly HAVE A DOC ONSITE then you can start slowly, but if you are expected to be set loose and god forbid see ER patients without immediately having a doc onsite?  Gawd no.  You are setting yourself up to destroy your career before it even begins.

[CAdamsPAC]

I was less than a year out from PA school along with another new grad PA were hired into a busy university ED. We had an exceptionally supportive SP/ED who taught us constantly as we worked, we attended lectures with the Residents. I don't know your circumstance but if you can fall into a good supportive and teaching ED position I say go for it.

Edited August 21, 2021 by CAdamsPAC

[Lucy199]

I started out of school just before covid came around. I had about 7 "training shifts" where I essentially saw about 5-7 patients per shift. Almost 2 years later I see 18-24 in a 10 hour shift, mix of fast track and much sicker patients winding up in fast track due to no rooms available in main ED. The first few months were terrifying. Best advice I could give, as somebody with very little experience, is ask as many questions as you need to and don't feel bad doing so. I honestly don't care anymore if my attending has 8 super sick patients and is stressed out. 

To this day I see something each shift that I have not seen before and will run up to my attending and run it by them. Use your on-call specialists whenever you need to. 

You can get through it if you start slow and accept that it is going to suck for a few months. Treat 1 patient at a time and don't worry about your total patients per shift at this point. If I have a shift that turns out to be all "express" patients, I could see 30 in 10 hours safely, but I have had shifts recently where I saw 10 because 8 of them were chest pains with elevated trop's and ICU consults.... Just do what you can do early on and get the "right" kind of experience and not "fast" experience

[EMEDPA]

check out the thread " It's probably nothing: Fast track disasters" at the top of the EM forum. It is a permanent thread. Lots of good stuff there.