We've all been there. My first 1 to 2 years as an attending were the hardest of my life. That said almost everyone gets through it. Here are a few tips:
-You are right to be intimidated about the culture and the logistics. That part is way more disorienting than the medicine. Try to corral your director and ask about who admits what, what consultants you have and don't have, where to transfer when you don't have a specialist and so on. Take notes and carry the notes with you.
A few more logistic things to know before you're on your own:
Do you go to in house codes or intubations? What happens if a code gets called upstairs while you're doing a code in the ED?
What do you do when consultants start to fight? For example a pregnant patient with an appy. Is that an OB admit with Surg consult or vice versa? What happens when someone refuses a consult or an admission?
Do you lose capabilities at night or on weekends? Do you have an ultrasound tech at 2am or can you get an MRI on a Saturday?
-Know that you are well trained. That stuff we tell the med students about how every program will give you good training is actually true. Airway and vascular access disasters will happen. If you have to cric then cric. We all have to every now and then. Know if you have IO in the ED. In a pinch you can place the IO, give a few liters and then try the central again. Or admit the patient with the IO, they're good for 48 hours in a pinch.
-Don't worry about your colleagues laughing at you maliciously. We do chuckle about some of the things our younger colleagues do but those are mainly logistical things. The truth is that we are to some degree intimidated by your recent state of the art training and we second guess ourselves when you do it differently than we have been doing it.
-Many groups have more than one hospital. That means there's a colleague out there you can call to ask questions even at 2 am. Most academic attendings are also cool if you call them up to bounce something off them.
-The nurses, admitting clerks and secretaries can really help you out too. For example the secretaries probably know more about who admits what than anyone. The nurses know how all the other docs deal with whatever situation you're facing.
-Hang around after your shift and chat with the next doc about how he would have dealt with some of the stuff that came up. That way you can learn some of the easier paths of least resistance in your shop.
-Try to courtesy call primary docs when you see their patients. It introduces you to them in an easy, non stress way when you say "Hi. I'm one of the new docs here in the ED. I saw your patient Mr. X. He looks fine so I'm going to send him home and have him follow up with you." That way they know who you are when the tougher conversations about admitting difficult patients happen. Once you know everyone you can quit doing this. And don't do it at 2am. It works the opposite way then😉.
-Grab one of the nurses and ask how they stock common drugs. For example most hospitals stock MS in either 5 or 10mg vials or 4 mg tubex syringes. If you are used to tubexes and order every MS dose in 4 or 8 but you new place uses vials it will create a lot of extra work for the nurses. They will probably tell you pretty quick anyway but if you can preempt the issue altogether that's good. Check out your top 10 drugs. What PPI do they stock. If you order Prevacid and all they have is Protonix it'll slow you down.
