OK need advice...

[NOLAboy]

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Yes I created a new ID to stay anonymous, but I need help.

I am finishing my 1st year at a small to medium size university program. We have a good mix of pathology, and trauma but the major flaw is WE HAVE NO COMMUNITY HOSPITAL experience.

I do not plan on going into academics, and I plan on living in a much bigger city when I am done. I am afraid that without community hospital experience I will not be prepared for the real world of emergency medicine.

Does anyone have any recommendations aside from moonlighting my ass off in 3rd year that can help me.

Don't get me wrong, the university is great. My problem is that there are WAY too many subspecialists. We consult out everything, and end up taking care of nothing on our own. That's not real world medicine. I haven't even seen one cardiac arrest managed in the ED since starting residency because they all go to the closest community hospital and get transfered in (or die). Again we do not rotate at any of the community hospitals.

Please help!! I'm driving myself crazy! All recommendations are appreciated.

 

[Apollyon]

I trained at a big ivory-tower university program, and had one month of community EM in the intern year, but then, due to budget stuff, went away. I'm now working in a busy (90K) community ED in an academic hospital with several smaller community EDs, and I jumped right in, and am doing fine. It's not that much of a change, except for a lot more stuff goes outpatient, or the specialist gets a call. I'm doing a lot more neuro and ortho than I ever did in residency.

Believe me, you'll do fine.

 

[USCDiver]

Don't you have elective time?

 

[DrQuinn]

Don't worry about it. My experience was similar to Apollyon's, albeit not at the ivory tower. I did ALL my EM months at a Level 1 900+ bed hospital, tertiary care, blah blah, subspecialists up to wazoo. We had all specialty back up (and used it, a little too much< I beelive), except plastics (although they added that residency).

Now I'm at an academic place that also has a touch of community flair.... and I am doing fine.

We had ZERO community ED months, and my three colleagues who all work at 3 busy community EDs throughout the country, Ohio, FL, and Georgia, all are doing great and have had no problems. Again, we had ZERO community experience.

I do think the one thing that would have scared me a bit would be the ortho, as we generally called ortho for nearly everything in residency. But, ortho honestly isn't that hard, just use etomidate if you need to.

Q

 

[drewpydog]

"Moonlighting your ass off" is not a bad idea. At my program we get 2-2.5 months at a community hospital - and it was great, but I learned a lot more while moonlighting at two other hospitals during residency.

 

[Quimby2]

It really isn't that much of a problem, you will more than likely adapt pretty quickly and painlessly --even if you stumble a little at first.

In thirty days, I will be graduating from the same sort of program. I think moonlighting in your last year would help (though, not "your ass off" --unless, of course you bought that BMW a bit early in your career). During my first few shifts moonlighting at "Community BFE Hospital" I had to feel my way around the consultants a little, but if your polite and explain "I'm the new guy", they will help you adapt.

Also, as you do your reading and you come across patients, ask yourself what the other management options might there be. Maybe bounce some of these ideas off your specialists while you are training. e.g. "Hey Bob, you think 'on the outside' you might consider seeing this fracture in your clinic in the AM instead of admitting it tonight?"

...I just re-read your post and now have a different feel for the magnitude of your concerns: are any of the senior ER guys managing the sick patients (cardaic arrest, sepsis, etc)? Are you just in a low acuity section/pod because you're the intern? If not, maybe your residents need to meet with your PD/ED chairman and discuss who is to manage the sickies (airway by ED, etc.). Also, maybe some rotations can be altered to supplement weaker areas.

Just remeber, most of us EM guys are very adaptable!

 

[NOLAboy]

Thanks for the replies guys. My seniors are really great. That's the one thing that makes me feel really good. They all seem to handle pretty stressful situations flawlessly. We all see sepsis and what not and all of the airways belong to the ED resident.

I guess I was only worried that I might not be prepared to work in a community hospital in a larger city, but it seems that other have had similar experiences and are doing fine.

You guys really know how to make someone feel better.

Thanks!!

 

[edinOH]

Maybe I'm biased because I came from a program with more of a community feel where we had alot more autonomy in the ED as well as offservice, but I think the moonlighting option has some merit.

I think moonlighting is where you really learn to stand on your own. You have to make decisions as an "attending" and you have to know how to talk to consultants who aren't your medical school classmates. I think it helps you mature.

By the time I was finished with residency I could easily tell the difference between my classmates who moonlighted a great deal and those who moonlighted none or little.

My current group places a huge emphasis on previous moonlighting experiences while a resident when making hiring decisions.

Take it for what it's worth.

 

[docB]

I think moonlighting in your last year would help (though, not "your ass off" --unless, of course you bought that BMW a bit early in your career). During my first few shifts moonlighting at "Community BFE Hospital" I had to feel my way around the consultants a little, but if your polite and explain "I'm the new guy", they will help you adapt.

I agree with Quimby. Moonlight but don't do it to excess. You don't want to be trying to learn procedures and patient management while moonlighting because you're on your own. Moonlighting is a good way to learn how to manage ED flow and make (and live with) your own decisions.

For the things you feel weak on because you consult out I suggest being aggressive about trying to do your own reductions, splinting, nasal packs and so on. Since you want to work community ortho and ENT are the majority of the procedures most of us do that could be consulted out.