Emergency Internship

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.

Seawolf420

Vet Student c/o 2024
7+ Year Member
Joined
Jun 5, 2017
Messages
77
Reaction score
101
Hello all,

I made the decision to go from GP to an Emergency internship after 6 months because the practice wasn’t a good fit and I didn’t have mentorship.

I am in ER now and am at times overwhelmed. I feel like the breadth of information and application of it has been … a lot.

For people who similarly struggled: 1) how did it get better for you? (I.e. CE, reading textbooks, etc) 2) what was your initial case load and how did it progress throughout your internship

Thank you in advance!
 
VIN used to have a good “getting through the night” CE module. It’s been a long time so I can’t speak to current quality but it used to be good.

It’s been a long time since I was an intern, but feeling overwhelmed is essentially normal, imo. Just keep going and hope your mentors are there to keep you from making really big mistakes. My internship didn’t ever leave interns alone, so we had the luxury of taking cases a little slower at the beginning. Like as you finished one you’d grab another and the main ER doc would keep the others churning along. Then as we got more experience we were expected to see more and more of the caseload until at the end we were seeing most and the ER doc was mostly just there for busy times and to supervise. But not every program runs like that, for sure.
 
I didn't do an internship, but I switched straight into ER after four years in GP. (Mid-COVID, because I'm a masochist apparently lol).

What I recommend:
- get a vet girl subscription and go through the entire basic emergency CE. Honestly if you do this and can reference it, you can manage like 95% of what walks through the door.
- RECOVER CPR training
- FASTvet online ultrasound training (and see if you can get your hospital to swing you doing in-person instruction, too).

The VIN getting through the night is also a good suggestion and you can peruse multiple years to cover all the different topics.

Get a good quick reference book - Plunkett's used to be the go-to but is a bit outdated nowadays, I'd ask around your hospital if they have a fave.

Grow a tough skin because you can ask three different docs the same question and get three different answers. Some doctors are better at tolerating others doing things differently than others, and you'll sometimes get in the crossfire. It sucks but it's not personal.

And enjoy! ER can be overwhelming and sad, but also often really ****ing fun. My PMs are always open if you have any specific questions.
 
Just commenting here so I don't forget. Picked up a random half shift and headed to bed 🤣
 
Hello all,

I made the decision to go from GP to an Emergency internship after 6 months because the practice wasn’t a good fit and I didn’t have mentorship.

I am in ER now and am at times overwhelmed. I feel like the breadth of information and application of it has been … a lot.

For people who similarly struggled: 1) how did it get better for you? (I.e. CE, reading textbooks, etc) 2) what was your initial case load and how did it progress throughout your internship

Thank you in advance!
For context, I did a rotating that was extremely heavy on ER and then went to FT ER after. Continued to train interns for a few years. What you're feeling is pretty normal. I actually started my rotating on overnight ER and we did not have good oversight - my caseload for that was whatever was already admitted (including specialty service patients) and whatever walked through the door, which could be 30+ cases a night for me and maybe one other doctor. Days, particularly weekends, could be much higher but we usually had 2-3+ doctors on the floor. As I got more efficient and confident, it was easier to juggle multiple cases at once.

Getting the hang of ER can take a while, maybe close to a year if you're doing it full time and have decent mentorship now. CE and textbooks help for sure, but you just need experience and time to increase your efficiency. Once you learn how to work quickly and whip out your records, things get a lot better. A lot of ER is working as an air traffic controller - knowing when to treat and street, admit but doesn't need a specialist, or refer to a specialist. At the end of the day, you just need to know how to stabilize and manage the acute life-threatening stuff. For some ERs, that will include surgery and really critical cases, other ERs will do less intense surgery and boot the more critical stuff to the nearest specialist. IMO the clinics that either don't have the ability to refer out, or just will not for whatever reason, are harder to get the hang of because they're asking you to play surgeon/criticalist/ophthalmologist/internist/etc (I'm talking going beyond stabilizing/managing the acute presentation) when that's not really what ER is for imo.

+1 on Plunkett's being a good quick reference for a lot of things. Anything that needs more detail though (CRI trees, for example) will need critical care textbooks which your clinic should have.
 
Went from mostly GP with a little ER to full time ER pretty fast. The mentorship is key. I wish I'd just started at this place from the beginning tbh. We do internal rounds (topic rounds one week per month, M&M rounds the next week) and a lot of us are pretty motivated folks outside of work.

Knowing your skills set and what you don't know is important, especially with more complicated problems. Never wrong to offer specialty for the clients who need or want it. Don't be afraid to call for help. I have plenty of the local GPs and Urgent cares call me and ask for tips on if they try to handle something themselves. Figure out who the nice specialists are in the area, particularly dental and ophtho folks since that's the shady shenanigans that scares me 🤣

Efficiency is the name of the game. Let your techs have autonomy and don't micromanage them. Spend your time doing doctor things, not tech or assistant things unless the staff truly needs the help
 
Went from mostly GP with a little ER to full time ER pretty fast. The mentorship is key. I wish I'd just started at this place from the beginning tbh. We do internal rounds (topic rounds one week per month, M&M rounds the next week) and a lot of us are pretty motivated folks outside of work.

Knowing your skills set and what you don't know is important, especially with more complicated problems. Never wrong to offer specialty for the clients who need or want it. Don't be afraid to call for help. I have plenty of the local GPs and Urgent cares call me and ask for tips on if they try to handle something themselves. Figure out who the nice specialists are in the area, particularly dental and ophtho folks since that's the shady shenanigans that scares me 🤣

Efficiency is the name of the game. Let your techs have autonomy and don't micromanage them. Spend your time doing doctor things, not tech or assistant things unless the staff truly needs the help
Not trying to be arrogant here but I was arguably the fastest/most efficient doctor on my team, and every single case of mine walked out the door with a printed record in hand. Can count on 2-3 fingers the times I had to finish a record at home. Also led to me being the highest producer/highest caseload out of 25ish doctors, so if you ever end up on production in an ER setting, it literally pays to be efficient.

If I was not performing an exam/procedure and was not in a room talking with a client, I was sitting at my computer making estimates, whipping out records and dealing with inpatients. That's it. I had techs placing central lines, PICCs, NG tubes, idk what else. If we were short techs I would help, and I know that not all clinics have techs that can do these things/have enough techs, but doctors shouldn't be doing things that a skilled tech is absolutely capable of. I don't think I drew blood or placed a single catheter in my entire time there, rarely helped restrained, controlled how much time I spent in a room, etc and those are the things that some doctors get caught up doing.

If your clinic isn't setting you up for success in this way, your efficiency drops dramatically. And truthfully, if they are that short staffed or the techs are that untrained, they should focus on hiring/training techs instead of another doctor. ER/ICU is not a setting where a very green tech can succeed.

I was the only doctor on a day or night shift more times than I can count, but I was able to see however many cases/inpatients as long as I had enough techs. It wasn't fun, but I definitely left a 40-60 case shift as the only doc on that day with all of my records done (maybe had to stay an hour or two late on those particularly rough days) because I had enough techs with enough skills to handle everything. Tech and assistant support is absolutely the key to ER success. Those that didn't rely on their techs didn't produce as much, stayed late consistently, and were doing records over their weekends consistently.
 
Last edited:
I absolutely wish. Part of it is a me problem cause I'm too social with some clients. But yes, we honestly don't have the best tech or assistant levels out there. We have a corporate update meeting today, so I might bring that up.
 
I absolutely wish. Part of it is a me problem cause I'm too social with some clients. But yes, we honestly don't have the best tech or assistant levels out there. We have a corporate update meeting today, so I might bring that up.
I was pretty lucky at my BPs - we had a lot of very experienced techs, and they were used to interns and I could absolutely trust them to be my second/third/fourth sets of eyes. I could not have accomplished that kind of case load without them.

As for getting trapped in rooms, yeah I just don't let it happen. I'm not shy about telling an owner that I don't have the luxury of the time it takes to hear about how their great great great grandma once died in some obscure, probably made up, way while I am trying to tell them that their dog needs an ultrasound. All while the lobby that they just walked through is standing room only.
 
I'm slowly getting better about it. They've been having me spend a lot more shifts at our busy hospitals and I've learned (again) that I simply don't have the time or emotional bandwidth to get as involved cause it's literally 2-3x the cases compared to my home hospital
 
I was pretty lucky at my BPs - we had a lot of very experienced techs, and they were used to interns and I could absolutely trust them to be my second/third/fourth sets of eyes. I could not have accomplished that kind of case load without them.

As for getting trapped in rooms, yeah I just don't let it happen. I'm not shy about telling an owner that I don't have the luxury of the time it takes to hear about how their great great great grandma once died in some obscure, probably made up, way while I am trying to tell them that their dog needs an ultrasound. All while the lobby that they just walked through is standing room only.

I've been begging them to teach techs on how to kind of cut off owners and move on. You don't have to be rude just have to not let them take over the conversation, you direct the conversation and keep it on track. But they refuse to tell the techs to go faster. Which doesn't work in urgent care, we need to move along especially since we're short staffed. I don't care how nice the client is, you don't need to hear about their grandma's fourth cousin's cat.
 
I really hope the efficiency comes with time because I am just not there yet. I was told 6-9 cases per shift for the first few months is reasonable and I’ve been taking around 8 in a 12 hour shift. I’ve gone up to 9 but that seems to be my ceiling right now with a decent amount of records to do at home.

I think I have been getting better with coming up with plans but estimates take me forever to get together because our system has a lot of redundancy.


And it is such a struggle to accept that exposure to cases is going to be the best learning opportunity because I really like to be prepared, because I’m not always the best on the fly thinker. Again, getting a little better, but not the progress I had hoped for myself at this point and I feel like I’m a burden on the staff for not being faster, but I try to ask what I can be doing better for them and they say I’m doing alright, so I have to believe them.

I was told if I stay on then the conversation about seeing about 15 per shift will come up, but it doesn’t seem like I will be expected to see that many for some time.
 
really hope the efficiency comes with time because I am just not there yet. I was told 6-9 cases per shift for the first few months is reasonable and I’ve been taking around 8 in a 12 hour shift. I’ve gone up to 9 but that seems to be my ceiling right now with a decent amount of records to do at home.

How many cases does your hospital see in a 24hr period?

Spend time making yourself templates that you can either auto populate or copy/paste in for exams, plans, discharges, etc.

think I have been getting better with coming up with plans but estimates take me forever to get together because our system has a lot of redundancy.

You should not be the person making an estimate. There should be premade estimates that a technician can use to tailor to the specific patient. I absolutely only make estimates for a patient only what that tech is doing something else for me. Otherwise, that's not a doctor thing. Or at least shouldn't be
 
I really hope the efficiency comes with time because I am just not there yet. I was told 6-9 cases per shift for the first few months is reasonable and I’ve been taking around 8 in a 12 hour shift. I’ve gone up to 9 but that seems to be my ceiling right now with a decent amount of records to do at home.

I think I have been getting better with coming up with plans but estimates take me forever to get together because our system has a lot of redundancy.


And it is such a struggle to accept that exposure to cases is going to be the best learning opportunity because I really like to be prepared, because I’m not always the best on the fly thinker. Again, getting a little better, but not the progress I had hoped for myself at this point and I feel like I’m a burden on the staff for not being faster, but I try to ask what I can be doing better for them and they say I’m doing alright, so I have to believe them.

I was told if I stay on then the conversation about seeing about 15 per shift will come up, but it doesn’t seem like I will be expected to see that many for some time.
How many cases does your hospital see in a 24hr period?

Spend time making yourself templates that you can either auto populate or copy/paste in for exams, plans, discharges, etc.



You should not be the person making an estimate. There should be premade estimates that a technician can use to tailor to the specific patient. I absolutely only make estimates for a patient only what that tech is doing something else for me. Otherwise, that's not a doctor thing. Or at least shouldn't be
It depends, I made my own estimates for a reason because I knew they'd be correct. I was also very fast at it though (Cornerstone was very user friendly, especially compared to some other softwares out there). If you can trust your techs, that's great, but I found it took more time for them to make one and me correct it than for me to just do it.

It really will take time. Sometimes you have to be bombarded to really get the hang of it. Trial by fire. It sucks and is really grueling, exhausting work.

I do want to ask, what made you jump to ER after a single (I'm assuming based on your graduation year) GP job that didn't work out? I feel like ER is currently not in a state where jumping to ER is a casual move, so I'm just curious
 
If you can trust your techs, that's great, but I found it took more time for them to make one and me correct it than for me to just do it

My first job, we did all the estimates as doctors, including presenting them. When I started here, I went to do an estimate and it was already in and I thought I was in love 🤣 It's definitely a trust thing. They know a lot more of the associated charges compared to me (like remembering the CRI fee when you have a CRI).
 
My first job, we did all the estimates as doctors, including presenting them. When I started here, I went to do an estimate and it was already in and I thought I was in love 🤣 It's definitely a trust thing. They know a lot more of the associated charges compared to me (like remembering the CRI fee when you have a CRI).
I never presented unless we were extremely short staffed, for what it's worth. By the time an estimate was being presented, I was already examining the next 2-3 cases waiting and/or in the next room going over another patient's exam findings (to point out to OP that he/she should be moving on to the next task whenever possible)
 
next room going over another patient's exam findings (to point out to OP that he/she should be moving on to the next task whenever possible)

Another pro tip that PP just reminded me: put your PE notes in ASAP. You can always look up what drugs you sent home and such; but the PE gets hazy. So put those notes in first, even if you haven't finished the notes from the previous patient
 
Another pro tip that PP just reminded me: put your PE notes in ASAP. You can always look up what drugs you sent home and such; but the PE gets hazy. So put those notes in first, even if you haven't finished the notes from the previous patient
Excellent tip.

I don't really know how else to describe how efficient one has to be to do ER-paced work quickly. Truly if I my hands were not on a patient or I was not in a room with a client, I was on my computer writing records. Having discharge templates helps immensely, especially if your software lets you ctrl+F and replace symbols with names and she/he. My templates has @@ for names and ## for she/he. Or just keep it super generic and don't put any names/pronouns and stick with 'your pet.' It' is 100% okay to use discharge templates, idk why some people get so hung up on the idea that they have to scratch write every single record. Honestly not using templates makes it far more likely that you'd forget key home care info.

Having a running checklist for each patient helps too. If your clinic runs on triage sheets/paper, either draw in your own boxes (estimate, diagnostics, admit vs. wrap up convo, charges in, record finalized and printed/sent) or ask your clinic to add them to triage sheets/come up with another piece of paper for that. I just used plain printer paper on a clipboard at my workstation, and had everything paper-clipped together by patient with my checklist sheet on the top. Once everything was checked and the patient was discharged, it went to my 'done' pile which helped my mental momentum throughout the shift.
 
I do want to ask, what made you jump to ER after a single (I'm assuming based on your graduation year) GP job that didn't work out? I feel like ER is currently not in a state where jumping to ER is a casual move, so I'm just curious
*deliriously laughs after swapping to ER mid-COVID*

C'mon it's fun to jump feet first into a maelstrom.
 
*deliriously laughs after swapping to ER mid-COVID*

C'mon it's fun to jump feet first into a maelstrom.
You had years under your belt, though! I'm just curious why a new grad would essentially scrap GP after 6 months at one job they didn't like. Not to say it wasn't the right move, it's just not something I've come across many new grads doing after a single job that didn't work out
 
Last edited:
It' is 100% okay to use discharge templates, idk why some people get so hung up on the idea that they have to scratch write every single record. Honestly not using templates makes it far more likely that you'd forget key home care info.
Tbh I’m pretty sure they straight up *recommended* it in school
 
Top