Moonlighting

[Major]

I received approval from my PD to a start moonlighting and got credentialed at a 7bed ER in the middle of nowhere rural area.

First shift is a night shift next week. Nervous but also excited.

Hoping y’all could share some pearls of wisdom and/or advice on a EM resident new moonlighter

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[valianteffort]

probably the best learning and experience you'll get given you're young in your career and don't know everything. I did some work in a rural ER in the midwest during my late 2nd year/through 3rd year and transitioning to attending life was a breeze because of it.

The best things I think i needed to know early on is how to quickly disposition the high acuity stuff.
Sounds like you will need to be best friends w the transfer process, STEMI, Stroke, Trauma etc. Are you a 'tpa for stemi' place or a 'copter ride away to cath place'? Do you have a facility lined up to accept the critically sick already and how do you do that quickly? All the stuff that you won't have time to look up and think about you need to know before you start so a patient doesn't have a bad outcome. The lower level stuff you can hopefully piece together for finding equipment , calling a consult, etc once you start.

good luck! it is well worth your experience to do it. and the paycheck is nice too

 

[Birdstrike]

I remember my first moonlighting shift which was 20 years ago. I was SO CAUTIOUS, lol. But that's okay. It's normal. You'll get more confident as time goes on. It would be abnormal to think you're infallible right now (or ever).

Just think of your favorite attending and their practice pattern. If you get stumped, just ask yourself, "What would Dr. ____ do if they were here right now?" That'll get you there, 99.9% of the time.

 

[AlmostAnMD]

It's so weird going from resident to attending, glad you're making it early so the real jump is easier.

Here's my highlight: I was chief in my program and a decent resident. Very confident at work. On my first shift, also a night shift, a 42 year old male checked in with chest pain.

It was a bull**** story and if it was at my residency I would have done an ekg, maybe a press ganey labwork with xray and had his discharge prepped before any of it came back.

But it was MY license so I spent like 20 minutes interviewing him and did a delta trop I think. Then after I discharged him I texted @Tenk in a panic because I thought he would go home and die.

It takes a while to build that new confidence, that's my point. Now I discharge these guys, half the time maybe with just an ekg if the story is laughably low ACS/real **** likelihood and immediately forget about them when I hit discharge.

Having said that one of them will probably die one day but what am I gonna do, lose sleep over it now?

 

[Tenk]

I received approval from my PD to a start moonlighting and got credentialed at a 7bed ER in the middle of nowhere rural area.

First shift is a night shift next week. Nervous but also excited.

Hoping y’all could share some pearls of wisdom and/or advice on a EM resident new moonlighter

Remember: you can always transfer ED to ED to your mothership when you’re in a pinch. I did that with several traumas and a cerebellar stroke when I was moonlighting as a third year.

 

[Birdstrike]

One other thing I remember about my time moonlighting was that it simultaneously built confidence, while also showing me how much I still had left to learn. It gave me a greater appreciation for the remaining time I had in the protected environment of residency, after I tested the waters of independence a little bit.

 

[JacobMcCandles]

Be confident in your abilities but also but cognizant of the things you don't know. Even the most seasoned attendings run into things they don't know. Familiarize yourself with all the important supplies, etc. Learn, learn, learn. UptoDate even the simple stuff as there is always new/more things to learn.

 

[MechEDoc]

I received approval from my PD to a start moonlighting and got credentialed at a 7bed ER in the middle of nowhere rural area.

First shift is a night shift next week. Nervous but also excited.

Hoping y’all could share some pearls of wisdom and/or advice on a EM resident new moonlighter

Be cautious, do a really good history and exam. I found some strange zebras while moonlighting (that I may have missed later in my career). E.g. back pain s/p slip and fall on ice -> ?? -> ?? -> WTF -> OMG that ESR and CRP -> MRI w/ diskitis and osteomyelitis. Just rely on the fundamentals and you'll be fine.

Also, you're the doctor, the nurses are not. They might push you to do stupid things, be polite, listen to them, explain your thinking, but do your workup, not the easy way at that some burned out nurse is pushing you to do.

 

[Interpolfanclub]

Be cautious, do a really good history and exam. I found some strange zebras while moonlighting (that I may have missed later in my career). E.g. back pain s/p slip and fall on ice -> ?? -> ?? -> WTF -> OMG that ESR and CRP -> MRI w/ diskitis and osteomyelitis. Just rely on the fundamentals and you'll be fine.

Also, you're the doctor, the nurses are not. They might push you to do stupid things, be polite, listen to them, explain your thinking, but do your workup, not the easy way at that some burned out nurse is pushing you to do.

This right here. When you're new, veteran ER nurses will push you to send people home, not work them up, etc etc. It's less work for them when you do that, but they aren't the doctor. Do what you think is right, and what is safe for the patient. Work them up, delta trop, CT, admit them, transfer them, who cares. You should be conservative when starting out, it's peoples' lives.

I was the first one in my entire class to moonlight and I went to a phenomenal residency. I started Sept of my 3rd year, it was insane looking back but I'm glad I did it.

Specific advice: You can call your residency and talk to the attending on duty if you have questions. I did this, it helps.

 

[cyanide12345678]

I received approval from my PD to a start moonlighting and got credentialed at a 7bed ER in the middle of nowhere rural area.

First shift is a night shift next week. Nervous but also excited.

Hoping y’all could share some pearls of wisdom and/or advice on a EM resident new moonlighter

If you’re doubting yourself, just CT it.

 

[Rekt]

This right here. When you're new, veteran ER nurses will push you to send people home, not work them up, etc etc. It's less work for them when you do that, but they aren't the doctor. Do what you think is right, and what is safe for the patient. Work them up, delta trop, CT, admit them, transfer them, who cares. You should be conservative when starting out, it's peoples' lives.

I was the first one in my entire class to moonlight and I went to a phenomenal residency. I started Sept of my 3rd year, it was insane looking back but I'm glad I did it.

Specific advice: You can call your residency and talk to the attending on duty if you have questions. I did this, it helps.

I just want to emphasis this. Especially in small rural ERs. These are the last places that exist where nurses have been for 15-20 years. I moonlit at a ton of small EDs throughout my state and this mindset was extremely common. Always remember it’s your license not theirs.

 

[thegenius]

I received approval from my PD to a start moonlighting and got credentialed at a 7bed ER in the middle of nowhere rural area.

First shift is a night shift next week. Nervous but also excited.

Hoping y’all could share some pearls of wisdom and/or advice on a EM resident new moonlighter

You are a resident and your first shift is single coverage overnight at some rural hospital?

 

[wareagle726]

Moonlighting was the most terrifying thing I went through and in retrospect the best for my confidence in the "real world." I would echo what was said above about not letting nursing staff push you around because they will absolutely try. Be confident in your decision. A few other things:
1.) If you think it possibly needs to be done do it with regards to testing. You probably aren't going to work there in the future. Who cares if you annoy a CT tech. Nobody rewards you for scanning less patients. They are always pissed when you miss a surgical emergency. If the "GFR is too low for a contrasted study" but the patient clinically could have a dissection you need to push back and don't back down.
2.) Before you go on shift talk with your attendings and see who is on at the same time. Give them a heads up you are by yourself and may need some help. They are going to be happy to help. This includes your PEM friends for sure.
3.) Realize that even as a late 2nd/early 3rd year EM resident at even a decent facility you have more of a sick/not sick mentality than MANY of the seasoned people in ER's across this country
4.) If you think a person needs a CVL/Aline/Chest tube/whatever your instinct is probably correct. You will get in a lot more trouble for NOT doing an intervention than doing it and not needing it
5.) Don't be afraid of consulting someone. You are just as much a doc as they are.
6.) If you consult someone for transfer or admission or consult don't say "I'm sorry to bug you, I'm just moonlighting..." You are the doc. Treat it the same way as if your attending had just told you to do it. Who cares is you transfer a semi-sick patient to the adult/peds mothership that gets discharged 3 hours later. You are single coverage and covering your butt and doing what is right for the patient.
7.) If you're spidey senses are tingling listen to them.

As an aside, these are the things that are realities in the community Eds that I work in now. None of that has changed for the most part. Sure, I am more comfortable making that decision but I still scan the crap out of people and transfer really quickly if I think it is necessary. You gain more confidence in the dc process of "what if I missed something" but you also gain a degree of what risk you are okay with taking as you progress in your career.

 

[cyanide12345678]

You are a resident and your first shift is single coverage overnight at some rural hospital?

Very normal to do moonlighting in smaller hospitals. I only moonlighted in single coverage shops. One of the places you could get destroyed and see 30-40 patients in 12 hours by yourself.

But yeah…i moonlighted at 4 places, all of them were single coverage.

 

[JacobMcCandles]

Also, you're the doctor, the nurses are not. They might push you to do stupid things, be polite, listen to them, explain your thinking, but do your workup, not the easy way at that some burned out nurse is pushing you to do.

On the flip side of this, at rural places the nurses often know A LOT about the patient (both medically and socially) and can always give you valuable insight.

 

[Boatswain2PA]

Many 5 bed EDs in the country are covered by NPs with near zero education or experience.

You got this.

 

[Major]

You are a resident and your first shift is single coverage overnight at some rural hospital?

Yes sir

 

[CoolDoc1729]

I received approval from my PD to a start moonlighting and got credentialed at a 7bed ER in the middle of nowhere rural area.

First shift is a night shift next week. Nervous but also excited.

Hoping y’all could share some pearls of wisdom and/or advice on a EM resident new moonlighter

I think in the post covid collapse the most important thing to get from your ED director is where can you send sick people ? If you don’t have an auto accept mothership, knowing what you can keep at your place and where you can send sicker people , stemi, stroke, dissection, who has GI, ENT, etc will save you from spending half your shift on the phone with someone decompensating in front of you

 

[Mount Asclepius]

It's so weird going from resident to attending, glad you're making it early so the real jump is easier.

Here's my highlight: I was chief in my program and a decent resident. Very confident at work. On my first shift, also a night shift, a 42 year old male checked in with chest pain.

It was a bull**** story and if it was at my residency I would have done an ekg, maybe a press ganey labwork with xray and had his discharge prepped before any of it came back.

But it was MY license so I spent like 20 minutes interviewing him and did a delta trop I think. Then after I discharged him I texted @Tenk in a panic because I thought he would go home and die.

It takes a while to build that new confidence, that's my point. Now I discharge these guys, half the time maybe with just an ekg if the story is laughably low ACS/real **** likelihood and immediately forget about them when I hit discharge.

Having said that one of them will probably die one day but what am I gonna do, lose sleep over it now?

It’s not worth saving time by avoiding troponins. I’ve seen some impressive troponin elevations due to MIs in people with burning chest pain that is worse when they eat/swallow. Sometimes the stories are terrible. Patients in general are terrible at telling their stories. Agree though with the main point of your advice.

 

[Apollyon]

Recall that 10% of folks having MIs have reproducible chest pain. What is that, Loeffler's syndrome?

 

[RuralEDDoc]

Moonlighting was the most terrifying thing I went through and in retrospect the best for my confidence in the "real world."…
4.) If you think a person needs a CVL/Aline/Chest tube/whatever your instinct is probably correct. You will get in a lot more trouble for NOT doing an intervention than doing it and not needing it

Phenomenal post but let me give a counter point here. Academic shops do A lines and central lines up the wazoo to questionable clinical benefit. In a rural shop, odds are that no one knows how to manage an A line. If you get push back about a procedure, stop and think why. You’re not a Harrrrrrverd anymore. If you drop an a line and no one manages it, what’s the point? So listen to the staff. Politely ask about limitations. Don’t get crazy and float a pacer when your team doesn’t even know what that is.

 

[MechEDoc]

Phenomenal post but let me give a counter point here. Academic shops do A lines and central lines up the wazoo to questionable clinical benefit. In a rural shop, odds are that no one knows how to manage an A line. If you get push back about a procedure, stop and think why. You’re not a Harrrrrrverd anymore. If you drop an a line and no one manages it, what’s the point? So listen to the staff. Politely ask about limitations. Don’t get crazy and float a pacer when your team doesn’t even know what that is.

Totally agree! I've done only 3 or so a-lines since leaving residency and none in several years.

Also, don't overthink chest pain. EKG + troponin + CXR for each time you're thinking ("could it be the heart?"). You'll find lots of pericarditis, myocarditis, some SCAD and lots of NSTEMIs.

 

[Lexdiamondz]

Phenomenal post but let me give a counter point here. Academic shops do A lines and central lines up the wazoo to questionable clinical benefit. In a rural shop, odds are that no one knows how to manage an A line. If you get push back about a procedure, stop and think why. You’re not a Harrrrrrverd anymore. If you drop an a line and no one manages it, what’s the point? So listen to the staff. Politely ask about limitations. Don’t get crazy and float a pacer when your team doesn’t even know what that is.

I think there should be some nuance to this though.

Rural medicine generally has worse outcomes (for a whole host of factors - not just because of bad medicine obviously) and so just because you're getting pushback doesn't necessarily mean you're wrong. You can just as easily argue that because you're possibly the only person in-house who can do something is a good reason to do it rather than not.

Ex: at my per-diem job I'm the only in-house physician after hours. There's a CRNA for airways in emergencies but overall if someone is sick and needs to be tubed and lined, either I do it or Jenny McJennyson, NP gets to poke at their carotid and cause God-knows what kind of harm. Alors, I end up doing more for the sake of doing it safely. Patients who I wouldn't necessarily line or tube at the Level 1 that I work as my main gig get tubed and lined at my side gig to forego any potential ****shows upstairs.

 

[wareagle726]

Phenomenal post but let me give a counter point here. Academic shops do A lines and central lines up the wazoo to questionable clinical benefit. In a rural shop, odds are that no one knows how to manage an A line. If you get push back about a procedure, stop and think why. You’re not a Harrrrrrverd anymore. If you drop an a line and no one manages it, what’s the point? So listen to the staff. Politely ask about limitations. Don’t get crazy and float a pacer when your team doesn’t even know what that is.

Fair enough! I just have the mindset of if it is a residency trained doc who thinks it would be useful and appropriate in the clinical setting then do it. I just started a new job last week where it's uncommon to do A-lines/CVLs. I'm going to do them because it is my practice pattern. My last job of 3 years isn't an academic place but it's a super sick place that warrants the procedures/interventions. That's all I'm saying. Don't avoid doing something that you think is necessary to treat the patient because its not the norm at a site. I totally agree with the "stop and think why" part though. If you do something that no one else manages, in my mind and especially in our current staffing and holding predicament, if it helps YOU manage the patient how you see appropriately and you are going to sleep better knowing you did it then do it. Especially if it really has low probability to harm the patient. Blind fem/art line combo in a hypotensive patient? 10 minutes tops. Nobody uses it? Pull it. That was my overall point. Your point is equally valid and maybe I need to have more of that mindset. I mean @MechEDoc isn't doing them much so maybe I am a little overkill.

As another aside, doing an awesome life-saving procedure(floating a pacer) when your team doesn't know what that is but you know how to manage it is eye-opening and inspiring for them to learn more. Just a thought.

But you are correct, limitations are everything. Don't go clam shelling someone in the middle of nowhere without any hopes of getting to an OR!

 

[Old_Mil]

I received approval from my PD to a start moonlighting and got credentialed at a 7bed ER in the middle of nowhere rural area.

First shift is a night shift next week. Nervous but also excited.

Hoping y’all could share some pearls of wisdom and/or advice on a EM resident new moonlighter

Remember that the prevalance of a disease is the prevalance the disease. While being in a lower volume department may reduce the absolute chance that something shows up at your door, it does not eliminate it. Level I & II traumas, Strokes, Pelvic Bleeds, MIs all can and will show up just not at the same frequency that they will at a high volume inbound mothership with multiple community EMS services and flight bringing people to your door. If you're in the umbrella of a Level I/II department's scene flight helicopters this will help. But there are bad weather days when they can't fly.

I've worked in departments like this and honestly they are some of the best places to work in Emergency Medicine today because you aren't getting your head kicked every minute you're at work. But when you're in that call room, sleep with one eye open. Oh, and don't take the job if it requires rounding on inpatients that someone else has admitted. Some of the hospital management teams are trying this. Just as a rule of thumb, 3000-3500 visits a year is roughly the cutoff where the overnight trickle rises to the point that you won't necessarily be sleeping through the night, and once you get to the 8000-9000 visit a year level you won't get more than a couple of hour nap (with nights you'll be up the full 24).

Also you'll see some unusual stuff, ie the 20 something guy seen by a community NP coming in by ambulance AFTER stopping by at the Walmart pharmacy for a single Vicodin AFTER being treated outpatient for presumed meningitis with Rocephin injections without an LP with worsening headache who turns out to have a brain tumor on CT scan.

Regarding the A-line discussion, if the patient needs an A-line, it's probably a patient that needs to be transferred somewhere else.

 

[MechEDoc]

Also you'll see some unusual stuff, ie the 20 something guy seen by a community NP coming in by ambulance AFTER stopping by at the Walmart pharmacy for a single Vicodin AFTER being treated outpatient for presumed meningitis with Rocephin injections without an LP with worsening headache who turns out to have a brain tumor on CT scan.

This sounds strangely specific...

Reminds me of a guy who was being managed outpatient for Ludgwig's angina…

 

[CoolDoc1729]

This sounds strangely specific...

Reminds me of a guy who was being managed outpatient for Ludgwig's angina…

They truly have no idea what they don’t know. Being an NP must be like looking in a kaleidoscope. Look at all the pretty colors and shapes. No idea what will happen next or why. He really had {x obvious diagnosis}?!?!? I hear this several times per shift with some of them 🤔

 

[emergentmd]

If you are in a big city with many small rural areas, there should be a bunch of moonlighting opportunities. If it is your first, I recommend finding a sleeping ER to get your feet wet. I covered 6pp/dy sites at first and gradually went to higher paying busier sites. I would never go to a site with single coverage seeing anything over 1pph.

 

[WorkNoteEmergency]

I congratulate you OP on your courage. It will be a good learning experience. The new grad hires in my system have to work 6 months or so at the mother ship before they’re allowed to work night shifts in my rural shop. The nice thing about working independently is you can order (or not order) whatever the hell test you want and if all goes well, you don’t need to explain to anyone why you did so (I know there are quibbles with that but we’re talking micro, short term level here). If you‘re not sure what to do with a patient, just let them sit there a while, order another test to fill the time if you need to. You can even tell the nurse what you’re doing, “I don’t know what to do with this person so let’s just feed and water them a while while I think about it.“ OK gotcha doc”. Often times within a couple of hours it will become obvious what needs to be done, even if the diagnosis isn’t clear. I used this tactic a lot early in my career until I got better at recognizing what needed to be done within a few minutes.

Also, along the lines of above, and a good general practice point, tell the nurse up front what the game plan is and he/she will help you along the way. They also appreciate if you tell them you don’t know what you’re going to do beyond the initial work up.

 

[MechEDoc]

I congratulate you OP on your courage. It will be a good learning experience. The new grad hires in my system have to work 6 months or so at the mother ship before they’re allowed to work night shifts in my rural shop. The nice thing about working independently is you can order (or not order) whatever the hell test you want and if all goes well, you don’t need to explain to anyone why you did so (I know there are quibbles with that but we’re talking micro, short term level here). If you‘re not sure what to do with a patient, just let them sit there a while, order another test to fill the time if you need to. You can even tell the nurse what you’re doing, “I don’t know what to do with this person so let’s just feed and water them a while while I think about it.“ OK gotcha doc”. Often times within a couple of hours it will become obvious what needs to be done, even if the diagnosis isn’t clear. I used this tactic a lot early in my career until I got better at recognizing what needed to be done within a few minutes.

Also, along the lines of above, and a good general practice point, tell the nurse up front what the game plan is and he/she will help you along the way. They also appreciate if you tell them you don’t know what you’re going to do beyond the initial work up.

I did that very thing last night. Parked a gomer in the ER and thought about it while she was on tele. Rechecked labs and sent her home at the end of the shift.

 

[Dred Pirate]

I always preface this by saying I am a pharmacist, and my advice is from my point of view.

My first job out of school was in a hospital that had a four bed ED staffed with one MD, and RN, and an LPN.

Although the vast majority of the time we so super low acuity BS, every now and then **** would hit the fan. Like my second code ever was a 3 month old that the mother drove in, or the night some cattle got out and there were two car vs cattle accidents and one ATV vs cow - two of them had to be airlifted from our little rinky dink place. Or the time our one doc literally had dueling codes and was running back and forth from one bed to the other giving orders.

I quickly learned to know what I don't know. I think that has been emphasized by many of these posts.

Also your resources are to be limited - at my place we only had a pharmacist on duty 44 hours a week, and after that there was a some rural nurse who graduated 15+ years ago and probably has done nothing but the bare minimum in training since then. So know your resources. I was on call after hours, but rarely did anyone ever call me other than a nurse trying to find some drug in the pharmacy.

Like others - familiarize yourself with their transfer protocols. We had a "stat heart" program (this was 15+ years ago) and boxes set up for STEMI. One for ground transport (tnkase) and one for air ambulance (integrelin) as that made a difference from a time perspective. Knowing things like that before you need to can come in handy

 

[Major]

Thanks for all the advice

I’m about to start my first shift. I simultaneously feel like I am going to puke and **** my scrubs.

 

[Boatswain2PA]

Thanks for all the advice

I’m about to start my first shift. I simultaneously feel like I am going to puke and **** my scrubs.

Good luck Doc. You're gonna do fine.

 

[emergentmd]

Thanks for all the advice

I’m about to start my first shift. I simultaneously feel like I am going to puke and **** my scrubs.

You will be fine. When I did my 1st moonlighting shift, I had to open Rosen. You got google and youtube. You can find anything online

 

[emergentmd]

Busy night. If this was 12 hrs, doubt you slept. I hope you got 200+/hr for this.

 

[Major]

Busy night. If this was 12 hrs, doubt you slept. I hope you got 200+/hr for this.

12 hr shift. About 1.5hr drive.

Pay is $100/hr. ER director told me usually see 4 overnight and get “plenty of sleep.” I have my doubts. I signed up for 2 more shifts to see his numbers are True. If not then I will look elsewhere

 

[BoardingDoc]

Busy night. If this was 12 hrs, doubt you slept. I hope you got 200+/hr for this.

I think busy is relative. In your FSED, yeah that's probably crazy busy. 11 patients on my solo coverage 10p-7a shift (have a PA until 2a) would be stupid slow.

Agree that that volume deserves at least 200/hr for an overnight though. Especially if moonlighting. If you're paying me 100/hr for an overnight, I better be seeing 3 patients max.

 

[wareagle726]

I think busy is relative. In your FSED, yeah that's probably crazy busy. 11 patients on my solo coverage 10p-7a shift (have a PA until 2a) would be stupid slow.

Agree that that volume deserves at least 200/hr for an overnight though. Especially if moonlighting. If you're paying me 100/hr for an overnight, I better be seeing 3 patients max.

Gah I need to re-evaluate my life

 

[BoardingDoc]

Gah I need to re-evaluate my life

Why?

 

[JacobMcCandles]

Finally recovered. I couldn’t sleep at all last night, even though they have a nice call room for the ER doc to sleep in.

Last night definitely taught me how ****ing spoiled I am at my level 1 mothership teaching hospital.

Patient count
1.mechanical Ground level Fall in 70yo-ct head/neck negative. Multiple neuro exams. DC home with daughter
2. Vag bleed 12 weeks pregnant. She declined pelvic exam. DC home w/ OB follow up
3. Nursing home apt, non verbal Cerebral palsy-“seizure like activity.” Work up neg. PCP tells me her NH staff are too nervous, send her back.
4. Rash-DC
5. COPD exacerbation-admitted
6. Diarrhea-DC
7. Diarrhea-DC
8. Prox Fibula fracture-Knee immobilizer DC home w/ Ortho follow up
9. Abdominal pain- she states Hx of ectopic. Fml. No formal US. She tells me this pain is similar to ectopic pain but no vaginal bleeding or Dc this time. The ER US is first generation GE from the Junior Bush Administration. This is the one that made me have pucker factor. I did bedside US. Found the yolk sac/iup. I doubted me US skills. I watched her for about 5 hrs, gave her fluids and zofran. She said pain resolved. I got her formal US appt at 7am that confirmed IUP. Thank God.

10. Sinusitis
11. Dyspnea

Definitely eye opening experience being solo. Made me grow a pair and become resilient.

The sinusitis probably had a cerebral venous sinus thrombosis.

Ok, I kid.

 

[alphaholic06]

The sinusitis probably had a cerebral venous sinus thrombosis.

Ok, I kid.

Why do this?

 

[RustedFox]

Why do this?

He didn't elaborate on (11. Dyspnea).

 

[Rekt]

Honestly I would not do that for 100hr. Not worth it at all. Every moonlighting place i worked was at least 140hr and that was 11 patients in 24 hours. Usually 160-180 for that shift. 60 minutes away. You’re getting taken for a ride.

 

[JacobMcCandles]

Why do this?

The same reason OP did multiple neuro exams on a patient after a fall with a negative head CT. It's all a part of growing as a physician and finding out what you're comfortable with and establishing your own practice pattern.

 

[emergentmd]

Good first shift but your will learn to be more efficient

A pain of a shift b/c you didn't sleep. All of these pts should have been a 2 min visit, orders, D/C. Prioritize your sleep over multiple rechecks b/c nothing likely to change and thats why you have nurses. In my FSER, if I That oldie fall would be a 2 min exam, CT, back to bed, wake up to discharge. Abd pain would have been labs, back to bed, D/C when U/S ready.

I think Standard pay would dictate $50/hr for overnight shift. $ 25/hr for a drive greater than 1hr. Assuming they only see 3ppd (verify), I think $75/hr is reasonable. Plus looks like this is a place without support like no U/S overnight prob adds another $50 for my risks. $200/hr minimum. If it averages 10pts overnight, that equates to little sleep.

 

[johhnybgood]

Good first shift but your will learn to be more efficient

A pain of a shift b/c you didn't sleep. All of these pts should have been a 2 min visit, orders, D/C. Prioritize your sleep over multiple rechecks b/c nothing likely to change and thats why you have nurses. In my FSER, if I That oldie fall would be a 2 min exam, CT, back to bed, wake up to discharge. Abd pain would have been labs, back to bed, D/C when U/S ready.

I think Standard pay would dictate $50/hr for overnight shift. $ 25/hr for a drive greater than 1hr. Assuming they only see 3ppd (verify), I think $75/hr is reasonable. Plus looks like this is a place without support like no U/S overnight prob adds another $50 for my risks. $200/hr minimum. If it averages 10pts overnight, that equates to little sleep.

I am very focused on pay/ compensation but I think moonlighting in residency is not so much about how much money you make but getting comfortable with your practice patterns. I think it is a good thing to see a moderate volume on shift. 12 patients in 12 hours is pretty simple. Gives you plenty of time to think about each one and be comfortable with your decision.

 

[Janders]

Yeah I'm not sure the $/hr equation that attendings with years of experience would accept holds for the limited number of places that accept residents as moonlighters.

I'm not going to go to work in an ER for $100/hr, especially overnight, unless I'm truly sleeping all night 85% of the shifts; when I was a resident I would have crawled through glass to see an endless line of elderly dizzy vaginal bleed psych patient fecal impactions (whatever stereotype you guys don't like seeing...) for $100/hr.

 

[Mount Asclepius]

Agree that you are being underpaid and they could be taking advantage of you.

That isn’t the primary goal though of moonlighting a few shifts prior to graduation. Learn from your experience. Also don’t accept rates like that ever when you graduate.

Interestingly I find that it’s not the ones I worry about on shift or immediately afterwards that have a surprising bounce back. It’s the rare ones where I anchored on the wrong thing and was errantly reassured. You were trained to catch the ectopic pregnancies (granted your US availability at your training program and moonlighting gig may have thrown you for a loop). It’s catching the rare venous sinus thrombosis in the sea of sinusitises and viral URIs that’s hard. I’m sure it was just sinusitis this time. Don’t worry about it. Just food for thought.

 

[lucid_leprechaun]

Phenomenal post but let me give a counter point here. Academic shops do A lines and central lines up the wazoo to questionable clinical benefit. In a rural shop, odds are that no one knows how to manage an A line. If you get push back about a procedure, stop and think why. You’re not a Harrrrrrverd anymore. If you drop an a line and no one manages it, what’s the point? So listen to the staff. Politely ask about limitations. Don’t get crazy and float a pacer when your team doesn’t even know what that is.

Good point on a lines. Do any procedure you can manage yourself. A line needs a nurse/monitor that can run it. Cuff works fine in cases you can’t do one. Even in big centers some nurse/monitor combos can’t make it work. Otherwise yes you will never be faulted being too conservative with procedures. Just make sure you can manage complications because you are likely the only one around who can.