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EM Fellowship Experience

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Hey everyone! I’m currently an EM PA fellow, and I've been inspired by others who document their experiences. So, I decided to share mine. I’m about one-third of the way through my fellowship, and here’s a glimpse into my recent 10-hour night shift covering the high acuity zone in the ED with a second-year resident and an attending physician.

Start of the Shift

I grabbed a COW and began the signout process, taking over from afternoon attendings and residents. Here’s a quick rundown of the patients I inherited:

  • 5 psych patients: Medically cleared and pending placement. 
  • One elderly patient: Anemia due to chronic disease, transfusing 1 unit of blood and pending SNF placement.
  • Pregnant woman with constipation: Manual disimpaction completed, pending UA 
  • Elderly woman with jaw and neck pain, SOB: elevated dimer, pending CTA to rule out PE.
  • Elderly male with hyperglycemia and hyponatremia: Pending electrolyte panel before starting Glucomander and ICCU admission.
  • Middle-aged man with a seizure disorder: Ground-level fall, lab workup unremarkable, pending CT scan of the head before discharge.

The first patient of the night

Just as I was about to round on my patients, two motor vehicle accident victims rolled in, prompting a moderate trauma call. The attending and I each took a patient. I completed the primary survey while the nurses started lines and collected blood work. After that, I placed orders for labs, meds, and imaging. The attending and I conducted a FAST exam.

While waiting for CT scan to complete, I discharged the pregnant female with PO abx due to positive UA. The elderly woman's CTA was negative, and she was discharged home with PO abx for potential pneumonia on imaging. 

Critical Trauma

A critical trauma came in: a young man assaulted with a baseball bat, tachycardic, hypotensive, and with altered mental status. I completed the primary survey while the surgical team assisted. While the surgery team took him to CT, I placed orders for lab work, meds, and scans.

Fractures and Reductions

While waiting for the trauma patient to return from CT, the attending and I reduced a Colles' fracture with a hematoma block. Splint, xray then d/c home. 

More Patients

  • Older gentleman with multiple comorbidities: Presented with weakness, ordered a heart failure workup. Elevated BNP, increased diuretic dose. D/Ced home with PCP f/u. 
  • Young man brought by police for jail clearance: Agitated and yelling profanities, only had hand pain, X-ray negative. D/C
  • Critical trauma, GSW to the head and chest, GCS 3: I intubated the patient, the resident placed a chest tube. ICU admission
  • Older woman with meth and alcohol intoxication, GLF: Severely dislocated ankle, imaging showed a fibular fracture and talus dislocation. I reduced the ankle with procedural sedation. D/Ced home
  • Older man with A-fib from jail: Presented with syncope and fluctuating bradycardia and tachycardia. Ordered cardiac labs and consulted cardiology for pacemaker placement. Med surg admission
  • Young woman with chest pain and anxiety: Ordered a cardiac workup and anxiolytic medication. She left during treatment.
  • Frequent flyer for intoxication and SI: Ordered prescreening labs and consulted social worker for mental health screening.
  • NSTEMI transfer from outside facility: Called MedSurg for admission, but due to elevated troponin, started a continuous heparin drip and repeated troponin. Eventually admitted to ICCU.
  • Middle-aged man with SI on psychiatric hold: Examined the patient, ordered screening labs, and consulted a social worker.
  • Older intoxicated man brought in by PD: Punched in the mouth, ground-level fall. Labs and CT were unremarkable, however persistent hypertensive.
  • Female infant with seizure-like activity: Febrile, tachycardic, and vomiting. Ordered antipyretic and antiemetic. Vital signs improved significantly. After evaluation, the patient tolerated p.o. challenge and was discharged with outpatient follow-up.

End of the Shift

Morning crew arrived, and I signed out the psych patients pending placement and the baseball-bat patient due to elevated CK, pending fluid administration after a negative CT scan and large scalp laceration closure. Another patient, the older gentleman punched in the mouth, had persistently elevated BP despite medication; I handed off to the day team to trial his normal antihypertensive medication.

I went home, charted for two more hours, and finally went to bed.

We saw around 70 pts in total between the attending, the resident, and I. It was a whirlwind shift, but it's the norm in our department. Every moment is a learning experience, plus the attending doc tonight was especially kind. Thanks for reading! 

Edited by a98139
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