ER work after CCFP ..... do I have what it takes to work in the ER ?

[MD_scientist]

PGY2 FM resident here ( rural site )

During med school I was interested in FM and did not give any extra thought about doing EM after my FM training. However, during my PGY1 I started becoming more and more into EM and I am currently considering doing ER shifts beside my office hours. I choose 2 of my 3 elective rotations to be in EM ( 3rd one I am thinking of doing ICU ) and I will apply for the +1 EM this cycle ( I doubt I have a shot in getting in but don't want to regret not applying ). Basically, I am trying to get as much exposure as I can before becoming an independent attending as I feel I still need a ton of exposure to have enough confidence working in the ER by myself ( for example, I haven't had a patient needing a central line to date and I only intubated once an adult patient, did not lead a code till now ....etc )

I understand I still have 1 year left in my training, However, as the time passes, I find myself more and more in doubt of whether or not I had enough exposure/training in EM to be able to handle every possible situation in the ED ? performing procedures, managing critical patients ...etc with or without the +1 EM year

For those of you CCFPs who are doing EM without CCFP-EM, how confident were you during your first few months of practice as attending ? is there a minimum list of procedures/pathologies that one need to perform/see at least once during residency before start working as an attending ? and what should I do beside electives in order to maximize my exposure in the ED ? can I -from the medico-legal point of view- show up in our ER during my off time/weekends and ask to see patients after getting the permission from the attending ?

[medigeek]

Your experience is probably the norm. Especially with covid affecting training for residents. 

Things like running a code are pretty cognitive and don't need a lot of practice on real patients necessarily if your nursing staff is good. And central lines are not necessarily a vital skill either (can always place an IO while also attempting central access etc.). 

But I'd say airway management skills are very important. Having an anesthesia block and getting 50 ish airways in + doing a couple airway courses would probably be the bare minimum (plus lots of practice in a sim lab). And of course you need some basic vent management skills. The other thing to consider are reductions. Not difficult to learn but you need to perform a couple to get them down. This is probably one of the most important skills in rural settings since most docs are typically comfortable performing it and you see it very commonly. The critically ill patient who is crashing and has an ultra difficult airway isn't as common in rural areas.

I'd say try and do an anesthesia block and also get some reductions in as well. Plus do a couple relevant courses for each. The rest is all cognitive and you can learn it as you go. Would also take an US course. With that said... it's almost always the cognitive part and medical decision making that leads to lawsuits/bad outcomes. 

[Arztin]

Hi there, my case is most likely more of an exception than the general rule. I finished FM with 3 extra months (not in a ccfp em program) and now I work in 2 high volume EDs in large urban community settings, where we see paeds at both sites, and one being a level 2 trauma center and the other is not a designated trauma center.

I pretty much did the equivalent of about 15 months of EM by the time I finished FM residency.  I took as many EM electives as possible, as well as extra shifts as I could during residency (as in shifts outside of my workhours pro bono). I did my residency in a smaller city with a high volume ED with fairly frequent sick trauma patients. I did as many EM electives as possible in different academic centers. I did as many CME and procedure courses as I could through my training. Pretty much read about 85-90% of the Rosen's. I did 3 months of adult ICU during residency towards the end in large ICU units in the community. Intubated about 70-80 times by the time I was done.

It's been almost a year that I'm a staff now and I can say that I really feel like a staff since perhaps only a month or two. Every week I see something I've never seen or heard of before. Working as an attending is truly something else. On my first shift, I had a myasthenic crisis. My first code ever in my first month of practice in the ED was a 40 year old with a massive PE that coded that I thrombolyzed empirically who luckily enough survived without any sequelae. I've been humbled countless times. Despite everything I did before starting as a staff, the learning curve this year was definitely insane, especially in the first 4-5 months. Am I comfortable? No. I don't think one can ever really get fully comfortable in the ED. There are certainly things I have never done or not feeling super comfortable with. There are certainly things that are so rare that even if you did 5 years of residency, you might not have encountered it during your training.

In general, I don't recommend doing EM full time EM after a FM residency, esp if you want to work in a bigger hospital and do EM full time. The training is just not sufficient IMO for the average FM trainee who does the bare minimum.

Now if you will do EM full time after FM, I would recommend you the following:

For many FM programs, you can prolong your residency by 3 months, which is what I did. Try to see if you can do that in order to have more elective time. Apply for the EM year if possible, or the SAEM (?) or what's it's called, if you are in ON. In ON, I thought they also have a mentorship program for the first 3 months if you work in the ED after FM?

Try taking as many courses as you can. Airway courses, CME, resusc, CASTED POCUS procedure courses etc... Start by looking at the courses on the CAEP website. Yeah it costs $$$ but you are investing in yourself.

Do as many rotations as possible in ED, paeds ED, ICU, and related rotations. Most high yield would be anesthesia and ortho, and whatever you feel weaker (cardio, IM consults etc..). Do as many procedures as possible. The 2 most important life-saving procedures that you absolutely need to know are intubations and chest tubes I would say. You simply cannot do EM if you don't know how to intubate. (Although certain extremely remote hospitals don't have that kind of volume, so anesthesia does it, but otherwise, you need to know). Depending where you work, most likely you won't insert the central line yourself so it's not as important. Knowing how to apply plaster splints and the most common reductions are fairly important too (wrist Fx, shoulder dislocation, ankle Fx-dislocation).

I would argue that it's important to build a solid foundation of knowledge before reading blogs (emcrit emrap etc...) and the latest articles. Either Rosen's or Tintinalli is a must IMO. It's dry and boring, but there is a reason board exams are based on these books. It takes time but it's definitely a must.

Do as many shifts as you can. I don't know how it works in your province, but throughout residency and clerkship, I asked to do extra outside of rotation hours. I did quite a lot of extra ED shifts pro bono and I don't regret it at all. I learned tons by doing that. Preceptors usually won't say no if you are someone motivated who goes there to learn.

At this point, if it's your final year of residency, you are learning for yourself. There is no such thing as going above and beyond to try to learn as much as possible.

 

[icewine]

Queen's University has a Resuscitation and Reanimation Fellowship which may be an option: https://emergencymed.queensu.ca/academics/fellowships#resuscitation

 

Quote

Each year of the Resuscitation and Reanimation program is divided into thirteen four-week blocks. This includes nine blocks of Emergency Medicine/ RACE, two blocks of critical care, and one block of research. There is also a longitudinal resuscitation-focused ultrasound curriculum. There is also a block for an elective which can include any special interest, for example an additional block of critical care, toxicology, trauma, or a transport medicine elective with ORNGE.

 

Quote

Applicants from emergency medicine are typically in their fifth year of a five year program. The program is also open to residents in other programs (internal medicine, anesthesiology, etc.) as long as this is approved by the resident’s home program. We also accept applications from practicing physicians in Canada (with or without formal CCFP-EM training) as well as international graduates who have completed their specialty training in their home country.

 

[MD_scientist]

Thank you all for your replies, these were bot helpful and reassuring

 

[MD_scientist]

19 hours ago, Arztin said:

In general, I don't recommend doing EM full time EM after a FM residency, esp if you want to work in a bigger hospital and do EM full time. The training is just not sufficient IMO for the average FM trainee who does the bare minimum

Totally agree, My plan is to go for a part time EM practice + doing walk-in clinic or having a roaster of fairly uncomplicated clinic patients

 

19 hours ago, Arztin said:

Do as many rotations as possible in ED, paeds ED, ICU, and related rotations. Most high yield would be anesthesia and ortho, and whatever you feel weaker (cardio, IM consults etc..). Do as many procedures as possible. The 2 most important life-saving procedures that you absolutely need to know are intubations and chest tubes I would say. You simply cannot do EM if you don't know how to intubate. (Although certain extremely remote hospitals don't have that kind of volume, so anesthesia does it, but otherwise, you need to know). Depending where you work, most likely you won't insert the central line yourself so it's not as important. Knowing how to apply plaster splints and the most common reductions are fairly important too (wrist Fx, shoulder dislocation, ankle Fx-dislocation).

I will probably need 1 anesthesia rotation ± ortho rotation ( we do see Fx in our ED from time to time but not high volume though ). I also have 2 ER rotations coming in academic centers + 1 ICU rotation in an academic center too

I am applying for the +1 CCFP-EM this year but if not that 3 months residency extension is definitely an option, I know people who have done it here in Quebec, not sure though how it works or how to apply ? may be if someone from Quebec can comment on how to apply or how to ask for an extension ? 

I am doing a lot of self learning currently, I have Tintinnalli's and I absolutely love this book, I probably spend more time reading it than on my FM readings. I also watched tutorials on POCUS and know my way around it but looking into registering for a good POCUS course + registered for an ECG interpretation course for primary care physicians. May be an airway course would be also very helpful as you guys mentioned above.

[Arztin]

1 hour ago, MD_scientist said:

Totally agree, My plan is to go for a part time EM practice + doing walk-in clinic or having a roaster of fairly uncomplicated clinic patients

 

I will probably need 1 anesthesia rotation ± ortho rotation ( we do see Fx in our ED from time to time but not high volume though ). I also have 2 ER rotations coming in academic centers + 1 ICU rotation in an academic center too

I am applying for the +1 CCFP-EM this year but if not that 3 months residency extension is definitely an option, I know people who have done it here in Quebec, not sure though how it works or how to apply ? may be if someone from Quebec can comment on how to apply or how to ask for an extension ? 

I am doing a lot of self learning currently, I have Tintinnalli's and I absolutely love this book, I probably spend more time reading it than on my FM readings. I also watched tutorials on POCUS and know my way around it but looking into registering for a good POCUS course + registered for an ECG interpretation course for primary care physicians. May be an airway course would be also very helpful as you guys mentioned above.

Talk with your university to see if that can be done. I guess it's not something that can be done at every university. 

Best thing for POCUS is to take an entire bootcamp for the EDE1 material and be certified. You need to practice a lot to become proficient.

Airway courses are good but definitely do an anesthesia rotation if you haven't done one. Intubating plastic mannequins is not very realistic.

[medigeek]

4 hours ago, Arztin said:

Talk with your university to see if that can be done. I guess it's not something that can be done at every university. 

Best thing for POCUS is to take an entire bootcamp for the EDE1 material and be certified. You need to practice a lot to become proficient.

Airway courses are good but definitely do an anesthesia rotation if you haven't done one. Intubating plastic mannequins is not very realistic.

A cadaver based airway course can be useful.

[MD_scientist]

8 hours ago, medigeek said:

12 hours ago, Arztin said:

Talk with your university to see if that can be done. I guess it's not something that can be done at every university. 

Best thing for POCUS is to take an entire bootcamp for the EDE1 material and be certified. You need to practice a lot to become proficient.

Airway courses are good but definitely do an anesthesia rotation if you haven't done one. Intubating plastic mannequins is not very realistic.

A cadaver based airway course can be useful.

I have found an interesting airway course by the CAEP, not sure though if it's done on cadavers or mannequins but sounds like they cover lots of things from intubation prep to surgical airways

[medigeek]

6 hours ago, MD_scientist said:

I have found an interesting airway course by the CAEP, not sure though if it's done on cadavers or mannequins but sounds like they cover lots of things from intubation prep to surgical airways

There's definitely a couple cadaver based courses out there, would take them for sure. Doing 100 reps on those (with coaching) with a variety of tools will definitely help.

Learning from airway experts is also very valuable. In community practice, ER docs and even anesthesia have variable practice patterns and not all of those will be helpful for you (can even be detrimental). Learning from the experts live is definitely helpful.