angie30 Posted February 13, 2007 Share Posted February 13, 2007 Hello All, I have had an interest in EM and thought I would build up first with urgent care. I'm proabably selling myself short, but somehow I landed an ED job and having JITTERS. I'll be the one showing up with a pocketful of books and looking as green as Ireland but any words of advice that my PDA can't provide? For most new grads - wouldn't they "work you in" easy? Thanks guys!! Link to comment Share on other sites More sharing options...
Guest PAMidge Posted February 13, 2007 Share Posted February 13, 2007 Hello All, I have had an interest in EM and thought I would build up first with urgent care. I'm proabably selling myself short, but somehow I landed an ED job and having JITTERS. I'll be the one showing up with a pocketful of books and looking as green as Ireland but any words of advice that my PDA can't provide? For most new grads - wouldn't they "work you in" easy? Thanks guys!! Depends on where you go. I am currently in "orientation". That means I am an additional person on for the day. The idea is that I am to get comfortable with the computer system, charting system, and routine of working in a system that gets 100,000 patient visits a year. I see patients as i can handle, which as an additional person on means I really see no more then 3 at a time just due to the dynamics of the department. After my orientation I will then first orient in the Urgent Care center, allowing me to get patients in and out quickly. Once I have expressed comfort with my role I can orient on trauma and such. My suggestion, just don't be afraid to ask questions, and remember that you are ultimately in charge of most of what goes on with the patient. No more safety net of preceptor... if you don't do something, it won't get done. Expect to start getting a bit comfortable after 100 hours. Good Luck! Link to comment Share on other sites More sharing options...
andersenpa Posted February 13, 2007 Share Posted February 13, 2007 For most new grads - wouldn't they "work you in" easy? Any new workplace has an interest in you not doing harm as a newbie. In general there should be a system in place with plenty of oversight/backup as PAMidge describes. The key thing for you is to speak up if you are in over your head or even doubtul. Anyone will tell you that they'd rather have a coworker who is open, shows an interest in learning, and is honest about their scope of knowledge- instead of some cowboy who has no fear..... Link to comment Share on other sites More sharing options...
Guest gbpa@adelphia.n Posted February 13, 2007 Share Posted February 13, 2007 a few words of wisdom: vital signs are vital, pay attention to them and address significantly abnormal values immediately. observation can be your best friend. follow up instructions should be time specific and condition specific. everyone gets follow up. remember your abc's. have faith in yourself, lack of confidence is a mindkiller. nothing replaces a good history and physical. a clear logical verbal presentation will usually get you a clear logical consultation. before you discharge someone, take a minute to ask yourself if you: a. are missing something b. are doing the right thing. if a pt cant walk, they cant go home (unless not walking is a chronic condition). if a pt cant drink, they cant go home. if the pt is going to hurt themselves or others, they cant go home. they are pregnant unless you prove they arent. if you institute a treatment in the ed, does it improve, no change or worsen? you are striving for improvement. always think, what is the disposition here? if you dont know, look it up, you usually have time. never be afraid to ask for a little bit of help. prior records, prior ekgs, prior xrays, prior consultations are your friend too. lastly, education is a lifelong endeavor in medicine. good luck to you. Link to comment Share on other sites More sharing options...
angie30 Posted February 14, 2007 Author Share Posted February 14, 2007 Thank you for your support - I'm sure you can remember the first job and feeling we still did not know enough. What is the one thing/source you wouldn't be able to live without as a beginning EMPA? Link to comment Share on other sites More sharing options...
Guest pizzapizza Posted February 14, 2007 Share Posted February 14, 2007 Angie, I'm with you on the jitters! Every day I go to the ED nauseous. I work my butt off and constantly bug my ED doc. They say they appreciate that I ask a lot of questions, but it can be very difficult at peak hours when the doc is handling multiple serious patients. I jumped at the chance for a job in ER right out of school, even though I have no ER background. If you don't get a job right out of school, it seems hard to ever break in. My ED is handling a serious increase in volume, which doesn't help with my being slow. Unfortunately right now is the busy season and everyone is sick. I can't tell you how many times a patient comes in with these vaque complaints and I am lost at where to begin! Sometimes I will ask for help with what work-up to order, sometimes I will ask for help with med orders, sometimes I will ask for help interpreting results-common denominator is I ask for a lot of help. I am responsible for 6 hospital beds and fast track. The docs always say if fast track gets backed up they will come and help-yeah that hasn't happened yet. I document the heck out of my charts. I know that I can't keep this up in the ED and be productive, but it is the only way I can paint a visual of the patient after they've gone. I also document all about the involvement of my SP-"X rays interpreted by Dr X" "Dr X examined pt and recommends current tx plan and d/c home" "Dr X was heavily involved in medical decision making of this patient". With only a handful of shifts under my belt, I can already see some physician preferences and am working on satisfying that beast also. My ER company does a chart review, and the physicians do to, so someone is looking at my charts and so far I've only gotten good reviews. I got the orientation and the help with the flow of things in the ED, but my insides churn everytime a patient looks me in the eye and expects me to pinpoint what is going on. Do what you can, I expect I will either get fired, sued and fired or become a great ER PA. So far I've worked through my lunch every shift and stayed over to clean up my mess, I take that with the territory and hope this will change at somepoint. All the docs tell me I will feel like this for 1 year, until I reach my comfort zone. That is a long time to feel like a complete goof, but I guess thats the process. In the meantime let the charge nurse and everyone else whine that fast track is not flowing smoothly. I hear it every shift. I'm new and green and I carry my Tintinalli with me everyday. The only advice I can give you that I have learned so far that you probably are more than aware of but I will share anyway--beware of those quick fast tracks that the triage nurse puts in a chair for you to examine and isn't really a fast track and keep your docs very informed of any serious patients you have. Any CPs I get, I run to the doc as I get the EMT for a stat EKG. I'm not going down alone! I wish you all the luck in the world. We're gonna need it. Overwhelmed Link to comment Share on other sites More sharing options...
Esmerelda Posted February 14, 2007 Share Posted February 14, 2007 PizzaPizza, What I would like to see is you keep a copy of your reply and then, a year from now. I'm curious what your reaction will be. I bet you will read it again and laugh. EVERYONE has the jitters on their first jobs, it's natural. Link to comment Share on other sites More sharing options...
JenGintheED Posted February 14, 2007 Share Posted February 14, 2007 I'm in the jitters club too, and I have 15,000 ED tech & urban EMS hours experience before PA school :p Some of my docs are really supportive; others answer questions because they have too... pt care never suffers but I know some wish i were more independent. One even said, "I'm tired of your annoying questions"... He's not mean, but I'm glad I don't work with him too much right now. I am responsible for procedures (lacs, I&D, LP, etc) and what little fast track there is. When not busy with those, I see whatever else is around. We are smack in the middle of a large retirement community, so I see a lot of the over-55 crowd with AMS, weakness, fever, belly pain, CP, etc. But I get wierd things all the time that I just don't know what to do with. Like a lady 2wk s/p TAH-SBO who says there is urine coming out of her hyst incision... a 20yo diagnosed w/Huntingon in childhood by pcp, never seen neuro, now in for first-time seizure... things that just make me sit back with a dumb look and say, "huh?" What's really scary to me is that I'm catching big things in pts that I work up just because... not because they have big-monster-diagnosis written across their forehead. I tapped a lady who comes in all the time with "the worst headache of my life"... the current one is always worse than any before... CT neg like all her previous ones... and she had grossly bloody CSF through all 4 tubes this time, multiple clean taps before. I sent an 11yo to CT over a vague mild abd pain that she's had for months, seens pcp multiple times... and she had a pelvic abscess the size of a grapefruit. So if that's what I find on the ones that present fairly benign and I work up anyways... what am I missing in those that present fairly benign and I don't work up??? If I'm not worrying about getting fired for being incompetent, I'm worrying about getting fired for being slow. Most shifts I see 20 pts in 12h, but not always... is that enough to cover my salary and make the company a profit (important, because if it doesn't profit them they'll find someone who will)... Ugh... it WILL be interesting to re-read these posts in a year. As for what's helpful so far... I carry a Tarascon pharmacopeia, Sanfords, and Tarascon ortho pocketbook. The ortho book is great for telling me which fxs to call ortho for and which to send home. I also have a two-ring binder that I'm slowly filling with notecards of things I want to remember that aren't in the other three. Like risk factors for contrast-induced nephropathy since I send a lot of geriatrics to CT; differential for back pain, belly pain, CP, SOB (I just want to look at a list while I'm ordering my w/ups); pedi doses on my favorite drugs, etc In the mean time I study a lot. I read about all the abnormal things I see. I subscribe to emedhome's question-a-day, and read the emedicine article on the topic of the question (that's been more helpful than I expected!). I also keep track of all my diagnoses and am doing an in-depth review of the things I see most often. I think I'll feel better when I can stone-cold master the top 40 things I see. Wow it feels good to vent... back to climbing Mt. Learning Curve... here's to all my fellow climbers! Link to comment Share on other sites More sharing options...
ezetimibe Posted February 15, 2007 Share Posted February 15, 2007 I've been in the ER four months now. I have also been having a strange chest pain for four months. I am doing better than when I started. 40% of the patients I am comfortable with, 30% worry me, and the other 30 % scare the bejesus out of me. Thats better than when I started. BOOK ADVICE, BUY Rosen and Barkin's 5-minute Emergency Consult. open it and leave it at your workstation. It provides you with all the information you need and is easy to reference while at work. Leave the heavy reading for when you have time. As for feeling embassed to ask questions, remember, if you get sued, the supervising physician gets sued. They would much rather you ask about a fluid bolus than find out too late that you sent somebody into CHF. Look up your question in 5 minute consult and if you are not satisfied ask your doc. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted February 15, 2007 Moderator Share Posted February 15, 2007 la- 20 in 12 hrs is great for a new grad. we have docs who see less than that. one doc in particular sees between 8-16 pts in 12 hrs. to her every bronchitis gets a PE workup..... working fast track I have seen 56 in 12 hrs. working mixed acuity 25-35 is more typical. it's not that you get faster at seeing individual pts, you just get better at multitasking and seeing more pts at the same time. it is not uncommon for me to have 8-10 workups going at once in 2 different parts of the dept. just make good use of your downtime. before you assume you are caught up and it's time for coffee ask yourself are there any charts I can document on now instead of later? are there any pts far enough into their workup that I know they are getting admitted and can start on that now? is my student setting anyone on fire :) ( if you are going to use an electrocautery for a subungal hematoma don't prep the site with a flammable agent)..... I use magnets with my name on the chart rack-helps keep everything orderly-some of my colleagues don't and I don't know how they keep things straight. we have a 77 bed dept with a 12 bed obs unit and if I don't use magnets I lose pts......also try to pace yourself towards the end of a shift. if possible have one of your partners start the female belly pain 10 min before your shift ends while you sew a lac instead, etc our shifts start out in a high acuity area then when the next shift comes in a few hrs later we move to lower acuity areas for the remainder of the shift but finish workups we have started. this means in general that we don't get high acuity pts the last few hrs of a shift. if we are close to divert though everything goes out the window. any pt can be triaged to any room or a bed outside of any room so 5 min before the shift is over( as happened to me yesterday) I got a 60 yr old htn/dm/cva pt with a complaint of 24 hrs of vomiting, weakness, and chest pain.....yeah, that's a 5 min workup..... Link to comment Share on other sites More sharing options...
JenGintheED Posted February 15, 2007 Share Posted February 15, 2007 Thanks for the info! How does 5 Min Emergency Consult compare to Minor Emergencies: Splinters to Fractures http://www.amazon.com/Minor-Emergencies-Splinters-Philip-Buttaravoli/dp/0323007562 E, I think you were the one who recommended this book? Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted February 15, 2007 Moderator Share Posted February 15, 2007 Thanks for the info! How does 5 Min Emergency Consult compare to Minor Emergencies: Splinters to Fractures http://www.amazon.com/Minor-Emergencies-Splinters-Philip-Buttaravoli/dp/0323007562 E, I think you were the one who recommended this book? I don't like 5 min consult. it is way too basic and leaves out a lot of things in the workup and dx of many conditions with phrases like"draw appropriate lab studies" -how helpful is that if you have never treated xyz before? there is a condensed version of tintinalli called" the emergency medicine manual " that I have been using a lot lately as it is the required text for the postmasters em course at ashs that I am doing right now anyway. I like splinters to fxs as well as it is like a powerpoint presentation of info that is actually helpful. Link to comment Share on other sites More sharing options...
Guest PAMidge Posted February 16, 2007 Share Posted February 16, 2007 totally agree... that and skyskape on the Palm is borderline useless. If you graduated PA school, 5 min ER consult is blah... great for students though. Link to comment Share on other sites More sharing options...
Guest pagirl1 Posted February 17, 2007 Share Posted February 17, 2007 Great suggestions so far. My two cents: Always evaluate anyone you become responsible for (sign-outs from colleagues) and put a note on the chart that you saw the patient. Don't assume your colleague has the right diagnosis, lay your eyes and hands on the patient yourself. If a colleague signs out a belly pain awaiting CT and says" can dispo to home if neg" eval pt yourself. Work up pts at the end of your shift as you would at the beginning of your shift. Don't try to "fix" everyone who comes to the ER. Rule out emergencies and send chronic complaints back to PMD. Explain nicely to pt, "We are not dermatologists. Your rash of 6 weeks needs to be seen by a dermatologist, but try this medicine inthe meantime, etc.... Touch base with primary docs regarding pts who need quick followup and document such in your chart. Don't assume your fast track back pain is muscuolskeletal bc its in fast track and the nurse thinks its musculoskeletal. Listen to the nurses when they express concern over a patient's condition, vital signs, etc. Always read the nurses notes prior to dc. This can be a killer in court! Ask the nurse for help when you aren't clear on whats going on with a patient. They often spend a lot more face time with the patient and see and hear a lot more during pt stays. Never dc a pt just bc a consultant advises you to. If you are uneasy, ask the consultant to come in and dc the pt his/her self. Link to comment Share on other sites More sharing options...
Guest gbpa@adelphia.n Posted February 17, 2007 Share Posted February 17, 2007 on reflection, some other things i carry or feel were important and got me through the early days: tarascon's pharmacopeia, still buy it every year airway card from airwaysite.com acls/pals folding algorithm card 2 working pens i always eat lunch or dinner or both if the shift runs that long (a recommendation from our radiology instructor) a quick telephone call to my wife just to touch base every shift i bought a lot of chocolate for nurses over the years coffee wit and humor good working relations even with those i could not stand, nothing more disarming than a smile and a hello Link to comment Share on other sites More sharing options...
angie30 Posted February 21, 2007 Author Share Posted February 21, 2007 Whew! Thanks for all the information. I though I was the only one wanting to vomit every shift - yet remain calm of course.. I've been seeing 10-12 pt per shift. Now that does not mean that I have left out tests to be done, recommendations that I should have given., etc.:( Yes, I got excited when I ordered a CXR for the first time, and yes I do not know how to order meds, fluids, etc on sheet - I should've been past this already! Training in school useless but I have to overlook that and put all my books out to review what I should've done. I wake up every morning thinking CRAP! I should've ordered this test and this lab for this pt. it has only been a week! It is great advice to just let things go slow to not miss anything. I made the mistake of filling out all my paperwork orders ahead of time and pt was d/c so i didnt get to FU on a pt after a nebulizer tx. This is a great experience - yes I know i also have to remember treatment styles of each doc, PA, etc. until I find my own. My main problem, haven't seen FP type pts in over a year. Just let me know when this grapefruit-sized ball will get unstuck in my throat. The staff are supportive - but what else can they seem after the first few days. They have to answer my questions right? so Ima keep askin' for the smallest little thing. I'm tempted to get a PT job in urgent care to keep the learning curve from twisting upon itself. (deep breath) PIZZA PIZZA, I've experienced the same thing. I just need to find a blank spot somewhere on this ER sheet to put everything down on. I'm sure I'll hear it when i get back. Thanks for all of your support! Don't wanna get fired, Angie Link to comment Share on other sites More sharing options...
kristone86 Posted June 16, 2011 Share Posted June 16, 2011 I know this post was written over four years ago now (holy crap), but how are you guys feeling about your skills/knowledge/career choice in emergency medicine now?? I ask because I'm a new grad and start my first PA position in the emergency department in 2 days, and feel EXACTLY like what you guys are talking about. I will be in charge of fast track, and will be working only with one other doc who is in charge of main... yeah, I'm nervous. Looking back, is there any advice you can give me now that you are well established in the field???? ANY advice would be greatly appreciated! Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted June 16, 2011 Moderator Share Posted June 16, 2011 http://www.physicianassistantforum.com/forums/showthread.php/4501-quot-it-s-probably-nothing-quot-fast-track-disasters see the above thread for common pitfalls. good luck-e Link to comment Share on other sites More sharing options...
Moderator ventana Posted June 16, 2011 Moderator Share Posted June 16, 2011 I know this post was written over four years ago now (holy crap), but how are you guys feeling about your skills/knowledge/career choice in emergency medicine now?? I ask because I'm a new grad and start my first PA position in the emergency department in 2 days, and feel EXACTLY like what you guys are talking about. I will be in charge of fast track, and will be working only with one other doc who is in charge of main... yeah, I'm nervous. Looking back, is there any advice you can give me now that you are well established in the field???? ANY advice would be greatly appreciated! hate to say it - but this is a bad idea....... first job you need lots of mentoring and guidance. I tried ER as an 8 yr PA with a lot of varied expereience and loved the medicine but hated the place for administrative reasons - "oh we forgot to tell you you are the overflow capacity and need to stay till the ER gets calmed down - 5 hours AFTER you were supposed to leave..... and no teaching what so ever - was a productivity mill and not gold standard care...." read other threads and educate yourself and above all try not to kill anyone Link to comment Share on other sites More sharing options...
Devildog Posted June 16, 2011 Share Posted June 16, 2011 I don't like 5 min consult. it is way too basic and leaves out a lot of things in the workup and dx of many conditions with phrases like"draw appropriate lab studies" -how helpful is that if you have never treated xyz before?there is a condensed version of tintinalli called" the emergency medicine manual " that I have been using a lot lately as it is the required text for the postmasters em course at ashs that I am doing right now anyway. I like splinters to fxs as well as it is like a powerpoint presentation of info that is actually helpful. I think Butravolis Splinter's ....book is very good. they will likely start you out in minor care and I found this book an invaluable resource there..a word of advice, start logging in your procedures in case you decide to go the EM CAQ test route.. good luck, Dog Link to comment Share on other sites More sharing options...
dreamin2baPA Posted June 19, 2011 Share Posted June 19, 2011 A good background with SEVERAL years experience in Emergency Medical Services or Emergency Nursing is always a good start. If you have that background, go back to your basics and always trust your intuition! A "gut feeling" has saved my patients several times and attendings were VERY thankful! Remember your ABC's and that, "bleeding always stops!" If you do not have previous and intense healthcare experience, you will have to depend very heavily on DAILY reading of the EM bible (OR the short version) and the EM/Medicine literature. You must also carefully "staff" your patients with the attending in your department until you become comfortable with your patients, depending on how your practice works. Now, here is a great lesson in fast track medicine that most recently occurred: 40 y/o male with HA X 2 days with no trauma and recent Hx of VTE. Pt has "horrible" allergies to pollen. His "hay fever is at its worst." In fact, he has started to use a "Nettie Pot" despite the discomfort it gives. He denies any head trauma. It is allergy season in this part of the country and we have seen at least 11 people in this shift with URI/allergy symptoms. The patient is in the midst of a "total" allergy exacerbation. This season is miserable.....He can't seem to control his symptoms. Plus, was hospitalized for a blood clot. This is where your experience, schooling, and clinical acumen, all come together. Is he a simple sinusitis or do you do more? Stop! This is not a fast-track patient. This is a patient that needs emergent CT Brain to R/O intracerebral bleed! He has a recent Hx of VTE and is taking Coumadin. Result: Bilateral Subdural Hematoma! So...,fast track is a challenge AND not every HA should be scanned! Develop good working relationships with your attendings. Staff cases as you can and build your confidence in Dx. Good luck. Read carefully. Read regularly. Learn from "staffing." Link to comment Share on other sites More sharing options...
Superfundee Posted August 21, 2011 Share Posted August 21, 2011 I'm still in the JITTERY side, and I get chest pain at least once or twice a day during 10-12 hr shift. I've been working as EM- PA for about 2 years, started working right out of PA school. I remember when I first started at community hospital in the ED, I had to took care of pt who had coumadin overdose, PE, ACS, pneumo, CHF even respiratory failure and sepsis you name it. It was nerve wrecking let alone the volume of patient. I now work in a much bigger academic setting, and it's a little different. Here, we have lot more help and more time for ED attendings to teach you. Overall, working in the ED can be overwhelming especially if you don't have much experience as a PA. It's crazy, hectic, and you are constantly interrupted by so many people. HOWEVER, I do believe that it all depends on which ED attending you work with that day. Even the most horrible day, you feel less stressed if you work with SP who doesn't ask you all kinds of personal tasks or say "mean" stuff. IF you work with ED doc who is soooo approachable and doesn't mind being asked question, it would definitely help reduce the burden. Personally I like working with ED doctors who are like friendly BUDDHA, (calm, relaxed, laidback, even-tempered, non-judgmental) but get things done fast. These doc make my day just fine despite the madness. Seeing 20 main patients in 12 hrs shift is a KILL, though it all depends on pt's condition. But as you gain more experience in the ED, seeing similar stuffs, things will get much better. I agree with EMEDPA. Rosen and Barkin's 5 min EM is too simple and basic. Me, my director and other ED physicians in NYC are working on better version of "quick guide to EM". Stay Tuned. Link to comment Share on other sites More sharing options...
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