Becoming more proficient

[TheRaftingGuy]

I am interested in becoming a very proficient ED provider (Think solo ED coverage proficient).  Looking for some advice on best steps moving forward to achieve this.

Background information:  I am a few years out of school with 6 years rural EMS (BLS) experience prior.  I happened to dumb into a ER job, working in a small rural critical access Hospital double coverage with a doc, as a part-time employee working full time hours as my first job out of school.  Hospital partners with the University teaching hospital in our area.  Great environment, extremely proficient and kind staff, supportive docs.  Initially treated like a resident, presenting every case, but having the ability to cover any patient I felt comfortable handling, with requirements for case presentation decreasing as I became more comfortable.  Huge learning curve.  I read and studied more in the first 3 months then I did all of school combined.

Fast forward a little over a year, a full time concierge family medicine clinic job with a 10 minute commute, pay raise and benefits opens (one of my ED Doc's recommends me for the job before I even knew about it), so I have been working here full time for a year  and moonlighting in the ED a few shifts a month.  After a year of moonlighting I am much more comfortable in the ER now.  For example, my last shift I precepted a PA-S and fully managed a 75-year-old P2 trauma MVA from door to dispo, while the doc removed an ingrown toenail on his patient and similar acuity patients.  Later that shift I managed a 83 year old female with dementia found lying on the floor for two days, elevated troponin, CK>1000, new onset Afib w/ RVR in the 150s, no cardiology at our facility and tertiary center on 24 bed hold (consulted the ED doc when she became mildly hypotensive after first 10mg bolus of cardizem).

My plan:

currently ACLS, PALS, ATLS.  I plan to take FCCS, Difficult airway course and a ultrasound course (unsure which) in the next few years.  I would like to be EM CAQ certified (unlikely to get pay raise, more of a personal goal I suppose)

Problems:

I am only in the ED a few shifts per month, and haven't done major procedures (Intubation, LP, Central line etc) since school.  Are my goals even realistic?

I appreciate any thoughts

[SedRate]

You need lots of reps to become proficient. I don't think you'll get there very fast working a few shifts a month. Ultimately, how badly you want to get there and how much you put into it is up to you. If you want to be a solo provider in the ED (or at least in terms of proficiency), go full-time EM and do/learn as much as you can. 

[EMEDPA]

I like your plan. Add in an ALSO (OB) and ABLS (burns) course. If you can take acls for experienced providers at your next recert it covers all the stuff not normally focused on in acls , like hypothermic arrests, tox, etc.

The difficult airway course is great. If you have to pay for it yourself take the prehospital course for $350 instead of the ED physician course for 1300. I have taken both. There are a few more fiberoptic options taught in the physician course, but not many. What really sets someone apart for working solo is being able to have a plan for managing any airway by yourself. 350 lbs and angioedema, 6 months old with Down's and a big tongue, gross trauma bloody airway, etc I know a lot of otherwise great EMPAs who can't make the jump to solo because they are afraid of bad airways. See if you can spend some time in the OR with your local anesthesiologists. Have them work you from easy to hard airways. Our local CRNA sometimes grabs me for impromptu lessons in the OR. Last one was morbidly obese, huge tongue, and no chin. His pointer was use a much smaller blade than you think you need and ramp the pt up to 30 degrees to take their belly off their airway. It worked. Don't be afraid to use an Igel or King LT if your first intubation attempt(or 2) fails while you gather your wits and optimize conditions for a second attempt. Take criticism. Be willing to offer suggestions to others once you get good. A few days ago one of my attendings was struggling to intubate a six yr old. I stuck my head in the door and said hey, try a towel roll under the shoulders. Bam, success.   

u/s is important. You need to do more than a course. Ideally, you pull out the machine for every trauma and every sob pt you see and rack up #s. u/s your friends and family. Get good at lung u/s, fast, and looking at the IVC. If you have lots of cme money, buy yourself a small u/s. Many folks have the butterfly or v-scan. I got the sonoque for 1/2 the price from my limited cme funds. In a perfect world, do a fellowship or residency. Solo slots are really hard to break into without a background as a paramedic, ER nurse/resp therapist, or as a residency grad. Best of luck. 

[TheRaftingGuy]

53 minutes ago, EMEDPA said:

See if you can spend some time in the OR with your local anesthesiologists. Have them work you from easy to hard airways. Our local CRNA sometimes grabs me for impromptu lessons in the OR. Last one was morbidly obese, huge tongue, and no chin. His pointer was use a much smaller blade than you think you need and ramp the pt up to 30 degrees to take their belly off their airway. It worked.

 

I have considered looking into this.  Haven’t built up the stones to ask if I can.  Mostly, wasn’t sure if this was a normal request or not.

55 minutes ago, EMEDPA said:

Solo slots are really hard to break into without a background as a paramedic, ER nurse/resp therapist, or as a residency grad. Best of luck. 

I was certainly not a paramedic, but (if nothing else) working in rural WV ems as the only ambulance for an entire county definitely instills a “cowboy” mindset lol.  For better or worse.  
 

any recommendations for u/s courses?

 

 

 

[EMEDPA]

I took the sempa course at their conference and the beginning and critical care courses with the resuscitation group in Vancouver, WA.

Take an in-person course. You won't learn much from an online video course. You need live models and someone grabbing your hand and saying "here, not here" and "that's not the IVC, that's bowel". . 

cowboy mindset is more important than you think. It is amazing how many providers(including residency trained and boarded docs) lose it when they don't have every specialty available in house for consults. It is always fun explaining to a tertiary care ctr that I can't just have peds, gi, urology, ortho, cardiology, etc "just see them in house" because we have a six bed ED with family medicine in house 4 hrs a day to round on inpts. 

[rev ronin]

4 hours ago, EMEDPA said:

If you have lots of cme money, buy yourself a small u/s. Many folks have the butterfly or v-scan.

Butterfly probes are getting spendy now. They jacked up the price of the iQ+ to like 2700 now, and the iQ3 is going to launch at just under 4000. I was going to consider upgrading to the 3, but I just can't justify that for how few scans I do.

[ohiovolffemtp]

Some thoughts:

• All the courses mentioned are great intro's, but it takes frequent use of those skills to actually become proficient.
• You'll need actual hands on experience with a wide variety of EM complaints before you're ready to work solo.  I did 5 years in a busy level 3 trauma center and still (am) learned alot when I started to work solo.
• Another key skill that's not been mentioned here is the management of the whole ED, especially how to be reasonably efficient handling a mix of acuities during a busy shift.  You have to be able to keep the dept moving, including things like either empowering nursing to order based on their assessment of the patient, or fitting in starting, reviewing, and discharging the lower acuity patients while still monitoring the really sick one.   You'll need this skill every shift while the procedural skills you'll only need occasionally.

[SedRate]

7 hours ago, TheRaftingGuy said:

Haven’t built up the stones to ask if I can.  Mostly, wasn’t sure if this was a normal request or not.

Yes, it is. I've asked anesthesia, lines team, critical care, neurosurg, Ortho, CTS, etc if I can help them with their procedures and if they have a couple minutes to explain a concept I'm not well-versed in. Offer to work late and help whenever you can. 

[TheRaftingGuy]

 

4 hours ago, ohiovolffemtp said:

Some thoughts:

• All the courses mentioned are great intro's, but it takes frequent use of those skills to actually become proficient.
• You'll need actual hands on experience with a wide variety of EM complaints before you're ready to work solo.  I did 5 years in a busy level 3 trauma center and still (am) learned alot when I started to work solo.
•  

Totally agree.  Practice makes perfect.  

I love my current gig (concierge FM/UC for some local coal mines).  I'm in a solo office, I have the max autonomy that is legally allowed.  I get to be home for breakfast and dinner every day with my family, and even bring my older kids to work with me occasionally, have a ~10 minute commute, and don't have to worry about billing at all.  These guys don't really do ER's, so we occasionally get some interesting stuff show up for a clinic.  We've had a partial finger amputation (happened 3 days prior and didn't want take time off work), Bi-Mal fracture after a 6 foot fall (happened 5 days prior, hoping it would heal on its own), a classic cardiac chest pain that we caught Wellen's syndrome on an EKG (had to convince him he would die if he went back to work, which was not as easy as you would think), etc.  The trade off is no critical patients.

I am a "have your cake and eat it too" kind of guy, so I don't want to choose one over the other, but this may not be realistic.  I'm also curious of trying to think of ways to use POCUS in this setting to maybe justify the purchase.