My thoughts as a new attending

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pinipig523

I like my job!
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Just did 50h of work over the past 4 days. First day was rough, second day got better, third day got better, fourth day was smooth.

After 2 hours during my first day of work, I thought to myself - "this is going to be a looooong day." I ended up staying 2h after my first shift tidying things up. I work 12h shifts at this part time gig.

I felt nauseous several times prior to walking into work, I could barely eat my lunch before my 3rd shift.

Whenever I felt like I nervous, I kept reminding myself of my training and that I was a very well read resident.

Every patient I saw until my 4th shift, I felt nervous and my hands were perpetually cold. It wasn't until my 4th shift that I found my rhythm again.

It is scary when you are making the dispositions and your chart does not have the backing of another attending and is not cosigned. It's scary when you have to make the decision of intubating or not... without anyone agreeing or disagreeing with you.

Anyway, hopefully the worst is over and I'll be transitioning into a more calm state. I know it'll take me months or every a couple of years to be truly comfortable, but I'm glad to say that I bit the bullet, I worked hard for 4 straight days as a new attending and I'm now less "rattled".
 
Pin, congrats on graduating dude and being a full fledged attending.

Did you moonlight at all during residency? I wouldn't have expected you to be that nervous if you did... was just curious. Either way, glad it's going smooth, keep us updated.
 
Congrats! I remember reading one of your other posts where you were going over your schedule for srudying for the inservice -- you are super well read! Congrats on being a new attending and let us know how it goes!
 
Thanks guys!

I had not moonlighted as a resident - maybe that's why I was nervous. But yeah, the more you read, the better for sure.

I start my full time gig on Monday, so I'm looking forward to how that goes. :xf:
 
Where-ever you work is lucky to have you. Good luck!
 
pinipig523 said:
Thanks guys!

I had not moonlighted as a resident - maybe that's why I was nervous. But yeah, the more you read, the better for sure.

I start my full time gig on Monday, so I'm looking forward to how that goes. :xf:
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You work a part-time position and also another full-time?!
 
I'm hoping to have as smooth a transition as you did Pinipig. Today's my first attending shift.
 
Getting more comfortable and no longer nauseated before a shift.
 
EM_Rebuilder said:
This is not that uncommon in EM. I have my full time position, but also am credentialed at a few other horpitals that I may or may not work at on occasion...
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If you have any concerns about the stability of your job, being credentialed at other hospitals is essential. The credentialing process usually takes 30-90 days, which is a long time to be without income. Being able to pick up 5-6 shifts a month to pay for expenses until you get back into a full-time gig is extremely useful.
 
I'm currently credentialed at 7 hospitals. I'm sure I could be "emergency credentialed" at 300 more in the state of TX within a week. (Temporary credentialing isn't hard, and since Texas has a standardized form, it works out pretty quickly).
 
pinipig523 said:
Getting more comfortable and no longer nauseated before a shift.
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Pinipig, I'm glad you posted this before my job started this month. I"m having the exact same experience, now 5 shifts into my new job.
 
Intubated my first patient as an attending - definitely kept me "high" for the rest of the day and definitely a confidence booster. No attending looking over my shoulder, no junior resident to steal my procedure.

I felt like I got my 2nd wind.
 
pinipig523 said:
Intubated my first patient as an attending - definitely kept me "high" for the rest of the day and definitely a confidence booster. No attending looking over my shoulder, no junior resident to steal my procedure.

I felt like I got my 2nd wind.
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It is a GOOD feeling. Strong work.

I placed an ultrasound-guided IJ last night in a crash situation. The nurses looked at me like I was performing some sort of alien necromancy at first. After all, I used that machine in the corner that has had the dust-cover over it for like, ever.

Then, boy were they glad to have a reliable line.
 
Well done, yall.

I ran my first code as an attending last nigh. It was pretty exciting. And Lord help me, but I do love me some critically ill patients. It makes up for the endless round of belly pain plus vag discharge we get at my shop.
 
Had my first massive septic shock the other night. Difficult airway, but intubated and SC line (which we rarely did in residency).before xray got there. Now gotta get some sleep before first solo night shift.
 
It's really fun doing crash procedures. A few weeks ago I intubated a patient, placed a central line and an arterial line, and had the patient out of the ED in 28 minutes. I doubt I'll ever see that number again. The stars were in alignment: easy intubation, easy line, easy a-line, bed available with an intensivist foaming at the mouth for a septic patient (basically describes all our intensivists when it comes to septic patients).

Thank God I got the central line on the first attempt without hitting the subclavian artery. She had E. coli sepsis with HUS. Her platelets were 40 and her INR was 2.7 (not on warfarin), both of which came back after I placed the line.
 
southerndoc said:
It's really fun doing crash procedures. A few weeks ago I intubated a patient, placed a central line and an arterial line, and had the patient out of the ED in 28 minutes. I doubt I'll ever see that number again. The stars were in alignment: easy intubation, easy line, easy a-line, bed available with an intensivist foaming at the mouth for a septic patient (basically describes all our intensivists when it comes to septic patients).
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Can't imagine what it's like to have the ICU interested in a septic patient. We see so many here that we often send them to the floor intubated on pressors.
 
Cerberus said:
Can't imagine what it's like to have the ICU interested in a septic patient. We see so many here that we often send them to the floor intubated on pressors.
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Ours are pretty aggressive. They usually do the lines themselves, but I was in a playing mood that day. It's great when you're busy and they do the line in the ED or ICU!
 
My most recent fun as a new attending- transvenous pacer! Sweet.
 
Congrats to all.

It is a high when things go right.

I caution all that Karma is an uncaring SOB.

Be ready for the bad ones: the walking in ----> morgued out. It will happen. Maintain composure.

Meanwhile, raise a toast for job well done.

I know, I know....I always expect the worst.
 
one of my first crashing pts as an attending was a former white house chief of staff with a screaming wife. no pressure there 😉

you will still have moments of "oh ****" for years... it's normal, don't worry. to me, if that ever goes away, i'm probably too bored and need to do something else! patients will almost never cease to amaze you... medically/socially/in every way, for better or worse... that's one of the things i most enjoy about EM.
 
80 minutes into my first shift as an attending they brought back a chest pain pt. Subtle ST elevation in the lateral leads, but the patient looked like s**** so I called an acute MI. He had restenosed his 5 day old stent. Welcome to work.

Day two as an attending. Bicyclist v. car. GCS declining so we elect to intubate with versed and succ. He was a difficult tube, and the resident had trouble getting it. Right as I step in, the succ wears off, and he vomits more than I have ever seen a patient vomit before. We filled two canisters. Scrub change please. Lesson - always use rocc. 🙂

Otherwise, it has been a smooth transition.
 
southerndoc said:
Thank God I got the central line on the first attempt without hitting the subclavian artery. She had E. coli sepsis with HUS. Her platelets were 40 and her INR was 2.7 (not on warfarin), both of which came back after I placed the line.
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I once got a call from the lab for an INR of 7 just as I finished placing a subclavian on the same patient. What's that saying? "Better to beg forgiveness than to ask permission."
 
Cerberus said:
Can't imagine what it's like to have the ICU interested in a septic patient. We see so many here that we often send them to the floor intubated on pressors.
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Did I read that right? Floor patients who are newly mechanically ventilated and on pressors that are being titrated?
 
It happens in our hospital as well due to the octogenarians and older folks who come in from home or the nursing homes in sepsis. The internal medicine residents and attendings accept them on the floors with central lines and either dopamine or phenylephrine running as the MICU is at capacity.
 
My training institution allowed dopamine, BiPAP, and insulin gtt in the IMU.

These are all ICU criteria at my current hospitals.

Rarely start arterial lines in the ED unless boarding is prolonged and there's an appropriate indication.
 
SoCuteMD said:
Did I read that right? Floor patients who are newly mechanically ventilated and on pressors that are being titrated?
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Yup. Our patient population is very old and sick and our unit is pretty much always at capacity. I'd say I send a patient to the med floor on pressors/ventilated or both probably every shift.
 
Cerberus said:
Yup. Our patient population is very old and sick and our unit is pretty much always at capacity. I'd say I send a patient to the med floor on pressors/ventilated or both probably every shift.
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But you are a resident..... with residents on the floor as well I would assume.

Try that in a community hospital lacking 24hr hospitalist coverage and see what happens when the overnight donut eaters ignore the patient for an 8 hr shift.
 
Cerberus said:
Yup. Our patient population is very old and sick and our unit is pretty much always at capacity. I'd say I send a patient to the med floor on pressors/ventilated or both probably every shift.
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No. No. No. They need to stay down in the ED until your 40 bed ED has 5 rooms in which to see new patients.
 
Groove said:
:laugh:
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Yep. It got even better. Guy was a polysubstance ingestion/overdose in a legit attempt at suicide. Nurse Nasty (I was warned about her by my director) says to me "I cant' feel his pulse" and can't get a radial or a femoral (granted, guy was fat and hypotensive). I look at the monitor. HR = 55, sinus. BP = 50/xx. 100% SaO2, good waveform, guy has good color. Nurse Nasty rolls her eyes at me and folds her hands over his chest, assuming the CPR position.

"What are you doing?" I say.
"Waiting for you to tell me to start compressions. DOCTOR."
"Start compressions? With NSR @55 and a good waveform?"
*Bats eyes* "Its called PEA, DOCTOR."

I grab the ultrasound, slap it on the chest. Show her the heart. Squeeze. Squeeze. Squeeze. Granted, it wasn't the best squeeze, but.

"No, I don't code people who are alive and in NSR. NURSE."

Nursing at my shop has nary seen ultrasound being used for anything, and now I hit the scene, and I want it tied to my ankle.
 
RustedFox said:
Yep. It got even better. Guy was a polysubstance ingestion/overdose in a legit attempt at suicide. Nurse Nasty (I was warned about her by my director) says to me "I cant' feel his pulse" and can't get a radial or a femoral (granted, guy was fat and hypotensive). I look at the monitor. HR = 55, sinus. BP = 50/xx. 100% SaO2, good waveform, guy has good color. Nurse Nasty rolls her eyes at me and folds her hands over his chest, assuming the CPR position.

"What are you doing?" I say.
"Waiting for you to tell me to start compressions. DOCTOR."
"Start compressions? With NSR @55 and a good waveform?"
*Bats eyes* "Its called PEA, DOCTOR."

I grab the ultrasound, slap it on the chest. Show her the heart. Squeeze. Squeeze. Squeeze. Granted, it wasn't the best squeeze, but.

"No, I don't code people who are alive and in NSR. NURSE."

Nursing at my shop has nary seen ultrasound being used for anything, and now I hit the scene, and I want it tied to my ankle.
Click to expand...

As a resident I had a much more conciliatory approach to this sort of horse****. Less so now that it's my name on the chart.

I've been picking up a few shifts a smaller community hospital, the RNs there have gotten pissed at me for every line/intubation I've done, "can't you just send them to the ICU?"

No, sorry, I can't. Because I was trained as a resus MD and don't think this 88 year old woman with PNA and RR = 50 is going to do that well on her own. She isn't DNR and when she has a respiratory arrest I can't say in my deposition, "well they nurses just really didn't feel like getting off facebook that day."
 
i can't even send an insulin gtt to tele at my current shop... and we have to transfer out if we don't have a bed. half of DKAers will be out of DKA by the time i discuss transfer with pt and family, get an accepting doc, arrange transfer, and the pt gets to said hospital. really annoying.
 
Yep. Then it's time for the "close the gap with insulin, then switch to sliding scale and admit to floor."

I'm not sure what is worse, working at the rurals where you can only admit DNR patients, or working at the tertiary where everything that isn't DNR is transferred in. Apparently in Texas you can't direct admit people.
 
AmoryBlaine said:
I've been picking up a few shifts a smaller community hospital, the RNs there have gotten pissed at me for every line/intubation I've done, "can't you just send them to the ICU?"
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I work at a "smaller community hospital". Funny, the ED nursing staff b!tched and moaned about having to hustle to pull meds and help me tube/line/whatever.

Then I went to the unit to check on my patient, and the nurses there acted like I could walk on water. - "You were the one who placed the central line ?! Wow, thanks so much! We usually only get two really positionally-dependent peripherals, and end up having to call a surgeon to place a central line, who won't even do it half of the time."

Also: you said the "F" word... "Facebook". Our shop has it 'blocked' so they can't access it, but no matter.... most go to the lounge to facebook on their phones and ignore their patients from there. There are a few standout nurses, but...

I wanna scream: "Seriously, girls... this is the phucking ER. Put that **** away. It'll be there when you get off of work."
 
RustedFox said:
I work at a "smaller community hospital". Funny, the ED nursing staff b!tched and moaned about having to hustle to pull meds and help me tube/line/whatever.

Then I went to the unit to check on my patient, and the nurses there acted like I could walk on water. - "You were the one who placed the central line ?! Wow, thanks so much! We usually only get two really positionally-dependent peripherals, and end up having to call a surgeon to place a central line, who won't even do it half of the time."

Also: you said the "F" word... "Facebook". Our shop has it 'blocked' so they can't access it, but no matter.... most go to the lounge to facebook on their phones and ignore their patients from there. There are a few standout nurses, but...

I wanna scream: "Seriously, girls... this is the phucking ER. Put that **** away. It'll be there when you get off of work."
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What is funny is that they seem to think they are teaching me some alternate, superior, "community style" of practice. "That's not how we do things here" is a fairly frequent refrain. As if my up to date training is somehow lacking.

Well, sorry, but it is exactly how we do things here today since it's my license and my patient. A lot of the attendings there are clearly not that comfortable with intubating or doing lines so the RNs think that is the only way to go.
 
Those necessary, emergent procedures are what define us.

Those other attendings do not sound like Emergency Physicians.
 
As an update to my trek into attending hood... I have to say, 6 months out and I feel happy with my jobs. My part time gig affords me the luxury to work with another ER doc and I get to see cooler pathology, my full time gig affords me a great group to work with along with good compensation and good patient base (i.e. good paying) who are mostly kind and educated.

I feel much more comfortable. I feel confident once again.

I love doing what I do.

The charting? Not so much.
 
pinipig523 said:
As an update to my trek into attending hood... I have to say, 6 months out and I feel happy with my jobs. My part time gig affords me the luxury to work with another ER doc and I get to see cooler pathology, my full time gig affords me a great group to work with along with good compensation and good patient base (i.e. good paying) who are mostly kind and educated.

I feel much more comfortable. I feel confident once again.

I love doing what I do.

The charting? Not so much.
Click to expand...

Get scribes.. All i have to do is document the MDM.. super easy..
 
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