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NEW ER PA.. Any and alll advice!

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I'm a new grad PA 1-2 weeks into a full time ER position in an urban area, which I feel extremely grateful for. I rotated at my current hospital and completed an elective in Emergency Medicine at a different trauma center. I received great experience and worked for 7 years in Ortho before PA school. I am getting my feet wet and fortunately have fantastic mentors and bosses at my current position. I operate in the fast track area but all areas of the ER are fair game and we assist in pediatrics as well. I have multiple physicians on site and other PAs during most shifts except night shift.

I know I am brand new and great things take time to learn. However, I am frustrated with my lack of familiarity and distrust in my own judgement. I am questioning things I feel like I should trust myself with and find myself asking colleagues a lot of questions to validate myself (within reason). I am trying to pick up patients that make me uncomfortable and challenging myself with variable acuity of patients while I word tandem shifts. But I have this lingering feeling of doubt in almost every patient, is this normal? Is it just new grad jitters? I am completing additional education materials through my company, including EM Boot Camp and High Risk EM. 

I would love any and all advice for how you felt as a new grad PA in the ER. What did you use for resources? What study materials did you use? Any favorite reference texts? How long did it take for you to feel like you knew what the hell you were doing? Are there do's and don'ts you wish you knew or were told when you started?

Just curious and appreciative of any and all advice. 

Thank you!

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I did not spend much of my career in the ED, but I will address this from my angle. I'm sure others who did spend their career in ED will chime in.

The clinical rotation that our PA program feared the most was a big city (Louisville) ED-trauma unit. I volunteered to take it as my first. I was scared shitless, not even knowing how to suture or not ACLS or ATLS certified. I had a wonderful senior ED resident, confident and knowledgeable as hell. It took six weeks, but my confidence improved greatly.

Then, after graduation and spending the first decade in headache medicine and care in the developing world (more public health than ED type work), I transitioned back to ED. BUT, first I did a 3-week bootcamp in ED at the University of Nebraska (I don't think it exist now). I did fine in the job and enjoyed it a great deal. I was the solo provider in an Air Force hospital but did have MD back up within the hospital.

Then I transitioned back in headache medicine (because I saw so many headache patients coming to the ED and were receiving terrible care by their PCP and neurologists). A few years later I did fill in one 24 hour shift as a solo provider in a rural hospital's ED, while the scheduled doc was actually admitted and upstairs after a skiing accident that day (Nordic) with a fractured femur awaiting ORIF the following day. I had to go up to his room once for advice on a patient. Then I moonlighted in a "fast track" ED while a headache specialist at Mayo Clinic.

So, my point is, yes it is new grad jitters. A bootcamp would do wonders for your  confidence. A good mentor a godsend in the early days. Good luck. I'm looking forward to those with more experience in the ED to comment with better advice.

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1. Second-guessing is to be expected because your clinical gestalt isn't developed. Look at it this way: it means you're at the bottom of the Dunning-Kruger curve, which is probably where you should be at this time (and isn't a bad thing).

2. Your Ortho experience (while valuable) probably didn't expose you to the same acuity as individuals who worked in those settings before school, which may also contribute to these initial jitters. I'm guessing former Athletic Trainer or MA (not relevant, just like to see where my gestalt is)?

3. References = Tintinalli's (for home reading and beefing up on issues from your last shift), EMRA booklets (relatively cheap and very valuable for knowing how to manage presentations), WikiEM (easy basic info on ED issues during your shift), UpToDate [for more in-depth info [your hospital probably provides this for free]). 

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First, EM is probably at least a 3 year learning curve.  It was for me, and I had 30+ years in fire/EMS, including 15 as a medic when I started.


  • The EMRA books are very helpful.  Their ABX guide is very good and I still use it often.
  • Medscape: free subscription, unlike UpToDate, very well organized by presentation, workup, treatment, etc.
  • Alexander Trott's book: Wounds and Lacerations - very helpful, $70 on Amazon
  • Habif's Skin Disease Diagnosis and Treatment - very helpful, lots of pictures, $75 on Amazon

My reco is to pick a subset of the high volume complaints and procedures and get skilled, comfortable, and quick at them, then gradually expand on them by additional complaints and procedures vs trying to push yourself to see to many new things all at once.  This will result in your co-workers gaining confidence in you more quickly and you gaining confidence in yourself more quickly.

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4 years a night shift main ED PA here who transitioned from student to Trauma II community hospital nearby a city. The struggle is real and I can definitely relate to some of the things you are saying/feeling. I think it is important to hold yourself to a high standard, like it seems you are, but also understand that your coworkers and your organization--if they are being realistic--know you have an immense learning curve. 

We are all still learning, a paraphrased quote of humility I very much enjoy is: if you still think you have nothing left to learn then medicine is not for you. However, there is definitely a fine line of requiring assistance and being a nuisance. Attendings only have so much time to see their patients, your patients, and maybe even a resident's patients. Your learning isn't necessarily most paramount and thus being considerate of their time is also important. 


Things I found helpful:

- Mixing lower level acuity and higher level acuity patients simultaneously

         Time management is hard, but this permits you to both be helpful to throughput as well as learn from more in-depth thinking. 

- Shadowing procedures your attending/fellow PAs/Residents have that you haven't done

         Not only will this show you techniques real-time, but will likely make your attending more comfortable with you completing this yourself--see one, do one, teach one.

- Offering to do lower level procedures for your attending

         Lacerations/I&D's/Splinting/US IV's/non-sedation reductions are all things that you can become more comfortable with that can also maximize your attending's time.

- Balancing self-sufficiency and teamwork

        Asking questions, especially when you know you should, will build trust between you and your attending. If there was something you needed help with, make sure you are ready for it the next time so as to not be TOO reliant on others. Picking patients up only to be ancillary to their care could definitely be frustrating for anyone supervising you. 

- Work when there are lower volumes

       You may hate me saying this, but night shift and weekends are a sweet spot for new grads for a reason. Less patients means more time per patient, more time an attending can dedicate to teaching, less pressure for throughput. While I do not mean to have you work hella overtime--resting and digesting is essential to not get burned out--being amenable to working these shifts will surely offer more opportunity.

What did you use for resources? What study materials did you use? Any favorite reference texts?

Uptodate!!, EMRA, Tintinalli's, Robert and Hedges (highly recommend using CME and you will get online access to videos for many procedures). PalmEM is a good quick reference app. I would NOT use this as an absolute guide, but for some reassurance, WikEM website is very good as a curb-side like reference. 

Your PA director/Emergency Medicine Chair may also have resources like procedure labs for central lines, intubation, I&D, Suturing, Ultrasound. Shoot a text/email and you may be surprised.

How long did it take for you to feel like you knew what the hell you were doing?

Remain confidently skeptical of yourself, your patients, your staff. I was a scribe in Emergency Medicine before I went to PA school, while transitioning to a provider may have been easier for me than most (same EMR, some attendings I scribed for in the past) I can say it was probably a year before I was comfortable with most complaints, most procedures. Now I function at a PGY3 EM resident-like level, relied upon to teach students almost every other shift, and frequently have attendings ask me for my opinion/intervention on their own patients. That said, I ask attendings to see my patients mostly in circumstances that are gray area of admission/discharge and sometimes just as a second-opinion for more unstable patients. Medicine is both daunting and extremely rewarding--I found myself enjoying it most when I act in a team-oriented approach, meaning you must have some humility but also take the reigns as a leader.

Are there do's and don'ts you wish you knew or were told when you started?

DO get yourself out of your comfort zone, but DON'T risk patient's well-being

DO call that specialist overnight, and DON'T feel sorry about it--it's their job and they are being paid to be on call

DO talk to your nursing staff, technicians and keep them in the loop about your differential, your plan, but DON'T become too friendly with them because they will take your time for granted

DO look at all and I mean ALL of your radiology studies including plain films, CT's, MRI's--commit to learning how to read them on your own so that if something needs to be done emergently you can either act on it with your attending or contact the specialist.

DO NOT overextend yourself with throughput, you are not a machine and you will burn out if you do not maintain a reasonable work-life balance.

***Some necessary credentials you should have, or should be looking into getting:
- ATLS (should be required for trauma center designation, essential and very helpful)

- PALS (ditto the above)

- FCCS (Not absolutely required, I do not have this but am looking to get)

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Thank you all SO much. I truly appreciate the advice and resources!!! I wish clinical gestault could be bottled or pill form so I could ingest all that knowledge and confidence now haha. I have my ACLS and PALS. I am planning on an ultrasound and airway course this fall. I was planning on ATLS next year with my CME money, but I do not currently work at a trauma center. 

I was an Athletic Trainer for 7 years, to answer the question above. I worked on the field, in surgery and clinically. But you are 100% correct-- the acuity of the patients and the mindset is so different. I am rewiring my brain to make sure I have an ER mindset, which is a transition. But, I have been trying to work on that the past few years in school as well. I am very excited to utilize and learn beyond one scope of medicine in an ER role and it's why I chose this path instead of a more comfortable one in Orthopedics.

I will be starting night shifts next month. I already work on weekends but I am on a mid shift so that I have support this next month. I have nothing but great things to say about my coworkers who have already helped me so much. Not a single person has treated me like a burden and they all do their best to check on me and help me. I just want to do my due diligence in and outside of work to become more efficient and a better team member. But, I know it will take time.

I can't thank you all enough for taking the time to respond (and future responses). I am very excited to grow and develop as a PA in Emergency Medicine. It means so much that you all shared with me and to know I am not alone in my feelings. I a very motivated to do well and do hold myself to a high standard, which I think is necessary in this field. I truly care about being a great PA for my patients and coworkers. I really want to excel in this field and I want to take responsibility for doing the work and coming up with a game plan to succeed. With all of your help and advice, I feel much better about getting organized and prepared. 

My best to all of you!

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