ER to Ecosystem 3

Author’s Note: While all of the events described here are technically fictional, they are also realistic. Although mentioned only briefly, some topics herein could be distressing for some people to read. Please use caution if you have particular sensitivity to the topics of seizures, vomiting, cancer, drunk-driving, or suicidal ideation. 

Working a shift in the Emergency Department (or more colloquially, the “ER”) often feels like a 12-hour “long take” from a TV show like The West Wing or True Detective. 

The next several paragraphs take you through a portion of what it can actually be like when I work in the ER. This story is structured based on the various skills required to successfully navigate this job. In Part 4, I will share how these skills are transferable into a Salesforce career. 

Okay, buckle in. Here we go! 

1. Self-Care: Before every shift, I take slow, meditative breaths while putting on the black Memory Foam Skechers I only wear while on duty--my “ER shoes.” I repeat a few affirmations in my head, then insert earbuds for a quick boost of energy from an upbeat song while doing some stretches. 

2. Adaptability: From the moment those shoes hit the floor of the ER until I’m wiping them down and placing them back in my locker, anything can happen. Practically every single ER shift, I have experienced at least one unique situation I would not have expected. Life truly is stranger than fiction.

3. Preparedness: My stethoscope hangs on my neck, my badge is clipped to my chest pocket, and there are two pens in that pocket. In my work backpack, I have protein bars, two travel mugs (the black one holds coffee, the blue one water), and a travel thermos for my smoothie. I grab a medical mask and stuff a few pairs of non-latex gloves into the right side lower pocket of my scrub pants.

4. Situational Awareness: Everyone in the department looks busy. There’s a cacophony of sounds: telemetry alarms, call-lights, copy machine running, phone ringing, people talking, a psychiatric patient yelling at the air, the radio of a nearby police officer blasting out muffled static. I see the triage nurse look at me, recognizing that I have arrived. While she looks intensely focused, she is not waving me over to go see an especially urgent patient. That is a good sign. 

5. Organization: I use my badge to log in. Error message. “Must reset password.” I quickly go through the reset process, then update the password manager on my phone so I won’t forget. In two short minutes, all of my favorite apps and digital tools for medical practice are open and ready.

6. Time Management: After log-in, the health system’s digital bulletin board has an urgent pop-up message: “New required CME due at end of this month.” I click “OK” and add a reminder to Asana on my phone. I don’t have time for that right now.

7. Prioritization: The large digital grease board on the wall displays all of the cases in the ER and the waiting room, and today, there are even some cases in the overflow area. Each case includes a triage number, based on something called ESI (ESI “1” is most severe, like a cardiac arrest; ESI “5” is least severe, like a torn fingernail). Sometimes, the flow of the ER is such that my colleague and I will be able to quickly see a few 3’s and 4’s while waiting for another ESI 2 to be placed in a room and initial protocol to be performed. Prioritization is a constant process, and the ESI triage system helps our team be aware of the urgency of every patient in the department. 

8. Critical Thinking: However, I must be careful because it is not unusual for further information to change the triage number to more or less urgent. For instance, a patient who fell might initially forget to mention that they hit their head, they lost consciousness for several minutes, and they take blood-thinners. Now that case requires more urgent evaluation. Thankfully, there are no cases like that right now. There are no ESI 1’s, only a few 2’s which my colleague has already seen, and then a lot of 3’s and 4’s.  

9. Teamwork: I review the grease board, and sign up for the next appropriate patient, triaged as a 3 and not yet assigned to a provider. At that moment, my colleague exits an exam room and sees me. She says, “Oh good, you’re here! It’s worse than usual! I know I signed up for Room 6 but I got pulled into Room 8 so haven’t seen 6 yet. Can you take it?” I tell her “Of course, but I did just sign up for Room 11. When you have a sec, can you take a peak at that one, and keep it if I get stuck in 6?” She says, “Sounds good.”  I ask her what she knows about Room 6. She says, “All I know is the wife called 911 saying he had a seizure--first ever--this morning. Paramedics said he does appear post-ictal, and sugar and vitals were good. They think the wife said he is an alcoholic. No effect with Narcan, so not as worried about an OD.” On the computer, I assign myself to Room 6 and take off my colleague’s name.

10. Calm in High-Pressure Situations: I enter Room 6 just in time to see the patient seizing in the exam bed. His wife is screaming “He just started doing it again! Help him, please! Help him!” I grab a pair of gloves out of my pants pocket, and quickly and calmly examine him. I observe seizure activity and confirm good airway protection. 

11. Decisiveness: I roll the patient on his side, press a button to request a nurse to the room, and keep a close eye on him while quickly glancing at his chart, confirming no medical allergies, planning to order some Ativan as long as no allergies to Benzodiazepines.

12. Team Leadership: Just as the patient’s nurse and a patient care tech enters the room, I observe an IV in the patient’s arm, established by the paramedics en route to the ER. I confirm to the nurse a STAT order for a dose of IV Ativan, and request that the tech perform a fingerstick glucose check. I place the patient on oxygen while the nurse gets the medication. I also order a STAT CT scan of the head to be performed as soon as he receives the Ativan and is no longer seizing.

13. Building Trust: With the nurse closely watching the patient, I take a moment to sit beside the patient’s wife and introduce myself. “Hi, I’m the treating provider for your husband. I’m a PA, which is like an ER doctor, and I work alongside ER doctors who are also available to help care for your husband if needed. I’ve practiced for over a decade, and I’m very comfortable taking care of your husband.”

14. Summarizing Information: The patient’s wife nods and asks me, “What’s happening now?” I respond, “He is indeed having a seizure. We are giving him a medicine called Ativan to help control it. We are gathering information as quickly as possible to try to determine why he is having seizures.” 

15. Eliciting Information: I re-evaluate the patient. The seizure has stopped, but he briefly vomits. I confirm the airway is still open and protected. I order STAT Zofran IV, and the nurse administers this just as the Radiology tech arrives to take the patient to the CT scanner. I spend a few minutes interviewing the patient’s wife about what happened and if there is any background information she thinks I need to know. For instance, I ask when the patient last drank alcohol. “Oh, he doesn’t drink at all. I think the paramedic misheard me and thought I said he was a heavy drinker. No, he won’t touch the stuff.” I continue to ask additional questions, ruling out recent injury, drug use, etc.  

16. Data Analysis: Just then, some of the patient's blood work returns, and the alcohol level is negative. Either he is a closet drinker in withdrawal or his wife is telling the truth. Curiously, the patient’s Liver Function Test levels are quite elevated. I also notice that his kidney function and electrolyte levels look normal, and there is nothing to suggest infection. A liver problem could be affecting his brain. Or perhaps the CT scan will help us figure this out.

17. Problem-Solving: As I submit more lab orders, I notice one of the monitors alarming about high blood pressure in Room 3. Because Room 3 is close to the desk, I am able to see directly into the room. I notice that the patient is an elderly woman with dementia who is flexing her forearm, probably in response to the blood pressure cuff that was inflating around it. There are no nearby staff members available to help, so I quickly enter the room, help the patient relax her arm, then restart the blood pressure machine. Aha! Now the blood pressure is almost perfect. I pass that patient’s nurse in the hall and notify her of the issue, requesting that she remove the erroneously elevated numbers and watch for any further issues with that patient flexing as the cuff inflates. 

18. Documentation: On my way back to my desk, I check the grease board again. A few new cases, all triaged as 4’s except one as a 3. I have enough time to document a brief version of the case in Room 6’s chart. I use a combination of dictation, typing, keyboard shortcuts, and clicking to capture the essence of the case. I refer to these as “breadcrumbs” because I have enough of a trail to follow so I can pick up where I left off in order to document more comprehensively later on when there is time. Sometimes, that can be hours later, or even not until the end of the shift. 

19. Language Acquisition: Documentation in a patient’s chart must use professional medical language. Like many industries, Healthcare has its own vernacular. In fact, it is not unusual for medical schools to require the completion of a medical terminology course prior to matriculation. And like many industries, we also use “shop-talk” jargon to efficiently brief each other about situations. Such fluency is essential for this type of fast-paced, complex work.

20. Collaboration: My colleague returns to her desk beside mine and asks me how it went with Room 6. I give a quick recap, entirely shop-talk: “Seized again as I entered, grand mal, sugar and vitals good except soft O2 at 93%, placed on 2 liters, brief emesis, gave Ativan, in CT now. Wife denies ETOH and level zero, but I doubt it’s withdrawal. No trauma, good lytes and creatinine, but LFTs up. Ammonia pending.” We go back and forth for a moment, thinking about the possible causes. I mention that his records show he hasn’t seen his primary care provider in several years, and his wife mentioned that he has been losing a lot of weight recently without trying. We both pause and look at each other for a single second, and we both know what the other is thinking. We will wait for the CT before saying anything more. 

21. Precepting Students: Just then, a medical student and a resident arrive. I am assigned to precept (teach practical skills and concepts, as opposed to academic learning) the medical student. My colleague will precept the resident. I discuss the case of Room 6 with the student, then he follows me as I go see other patients as well as keep checking in on Room 6. Thankfully, the patient in Room 6 looks better, his wife and his nurse tell me no further seizures or vomiting have occurred. There are so many patients to keep track of at the same time. This skill is something a student could never learn from a textbook.  

22. Intellectually Curious: A staff member calls me out of a room because I have a phone call. It’s the Radiologist. She says the CT shows a large intracranial mass consistent with a glioma but also a curious shadow on the cerebellum. She asks if that patient had any signs related to cerebellar mass, and I mentioned that the patient did have a vomiting episode. We both agree that this could be related to a second, smaller mass on the cerebellum. The radiologist mentions a specific type of brain cancer that is relatively rare, and states, “I actually just read an article about this in a journal last month.” I ask her to email me a copy of the article when she has a moment, and she agrees. 

23. Patient Education: I notify my colleague of the news and explain that I might be in Room 6 for a while. She nods in understanding and says “Take your time. No one is critical right now. Go for it.” The student and I enter Room 6. The patient is still resting comfortably, vital signs are okay. His wife says he has been resting like this ever since he received the Ativan, no further seizures. She asks for an update on the case. She is already seated. The student and I find seats and sit down as well. I carefully explain to her about the lab results. It turns out that the Ammonia level was normal. However, the CT scan revealed two masses in the brain. I gently make a point to mention that there is the possibility of cancer, in his brain and maybe in his liver. 

24. Compassion: I pause to give her ample time to react to this news. As is usual for these situations, the patient’s wife breaks down crying when she hears the word “cancer.” I had already located the tissue box when we entered the room, so I took this moment to stand up, get it, and hand it to her. She asks me to continue. We continue the conversation, and occasionally I pause to let her cry. I discuss with her the options, explaining that her husband requires hospital admission and evaluation from a Neurologist and likely an Oncologist as well.

25. Active Listening: The wife of Room 6 explains that there is a significant family history of cancer in the patient’s family. As she tells some other details about the patient, she casually makes a side comment about how that patient used to work at a nuclear power plant. This catches my attention. Besides the family history, the patient’s exposure to radiation definitely increases his risk of cancer. During our conversation, I notice that the wife occasionally checks her phone and presses a button as if she is declining a phone call. At one point, she mutters something about how “his sister keeps calling but I don’t want her to know anything.” 

26. Integrity: During our conversation, a staff member calls me out of the room because I have another phone call. He states the caller didn’t give a name, just asked to speak to whoever is taking care of the patient in Room 6. Suddenly, the patient’s wife blurts out, “If that’s his sister, she knows better than to try to pry for information. He doesn’t want her to know anything, and I don’t want her to know anything, especially about something like this.” I confirm to the wife that patient confidentiality prohibits me from sharing anything without specific permission. The wife sighs. I ask the staff member to confirm if it is the sister calling, and if so, do not tell her anything and let her know I will not be telling her anything either. 

27. Presentation Skills: After my conversation in Room 6, I check in on my other patients, and manage to discharge two patients before sitting back down to call the hospitalist about Room 6. He answers the phone, but sounds impatient and perturbed. This is not a good start. I feel briefly rattled by this, then regain my composure and present the case. Unlike the shorthand-filled chat I had with my colleague, this presentation is structured and thorough, starting with a clear HPI (History of Present Illness), moving through each section smoothly, and finally wrapping up with my recommendation for the patient to be admitted upstairs for Neurology and Oncology to be consulted in the case.

28. Patient Advocacy: The hospitalist initially pushes back, stating there is a staffing shortage and this patient might need to be transferred to another facility. I happen to know that the closest facility with available beds would be over 2 hours away. This is not ideal for the patient for multiple reasons. 

29. Professionalism: The hospitalist begins to raise his voice and interrupt me. I try to explain to him that his reasoning does not make sense to me, and perhaps we should have this conversation in-person, ideally after he evaluates the patient in-person. I remain calm as I gently but firmly state my case. The hospitalist begins to yell at me over the phone then abruptly hangs up. I decide not to call back immediately, and instead I explain to my colleague what happened, then I go see more patients. 

30. Interpersonal Communication: Fifteen minutes later, I am returning to my desk, and the hospitalist is standing there waiting for me. He takes a breath, then apologizes for his behavior and asks to resume our conversation. With my colleague listening in from her nearby seat, the hospitalist states he evaluated the patient and he still has some concerns but they are fairly minor. We politely discuss the case for a few more minutes. Ultimately, he agrees to accept the patient. The in-person conversation was better not just for us, but also for the medical student to observe.

31. Written Communication: After I place the admission orders, I take a moment to write a message to the patient’s primary care provider. I make it clear that the patient has not been seen in their office for several years, and there is strong suspicion for intracranial and maybe hepatic malignancy. I also mention that I am working for an additional nine hours today if she needs to call me at the ER to clarify anything.

32. Employee Training: After several grueling hours, the volume of patients has started to decrease and I am able to take a moment to go to the bathroom. Then I grab my smoothie and take a few sips in the break room. One of the newly-hired nurses is there and says, “I heard you are the go-to guy for tech stuff. I’m having trouble with the EHR. Whenever I enter the patient’s medications, they are only recognized as free-text, so the allergy alert does not work.” I take a moment to explain the solution to him, then offer to email him a playlist of tutorial videos I made. I explain that our specific edition of the EHR has some functions that are not very well explained in any of the EHR company’s own tutorials. 

33. Discipline: The nurse thanks me for the help, and tells me he just brought in 3 large boxes of Crumbl cookies and I should grab one before they are all gone. I tell him I will have to save it for later.

34. Sense of Humor: I tell him that I have learned the hard way when it comes to eating sugar and carbs in the middle of a shift. “My tastebuds love it, but the rest of my body forms a rebellion, especially my brain.” We both laugh at my stupid joke. Laughing feels good, especially after all of the tension surrounding the Room 6 case.  

35. Endurance: I look up at the clock in the break room. Ah! How did I forget? Ever since its batteries died, someone set it to 5:00 as if to say “It’s 5:00 somewhere.” Unfortunately, I look down at my phone, and the real time tells me I still have over 7 hours to go. Phew, I’m glad I didn’t eat a Crumbl cookie! But I put one in a Zip-Loc bag and put it in my backpack for an end-of-shift snack. I take a few more sips of smoothie, then walk back to my desk and look up at the grease board to determine what case I need to see next. 

Seven hours later, my shift is officially over. I saw a total of 18 patients, all with various problems and complexities. To illustrate the wide assortment of cases an ER provider might see in a single shift, during the fictional shift we just experienced together, I also took care of: 

• A toddler who stuck a plastic bead in his nose. It took 4 staff members to help hold him down so I could use a special suction device to safely remove it.

• A middle-aged woman in DKA (Diabetic Ketoacidosis) who needed close monitoring and careful dosing of insulin before she was finally admitted to the hospital.

• A drunk twenty-something man involved in a head-on collision with a tree. We stabilized him then flew him by helicopter to a Level 1 Trauma Center. He probably won’t survive the night. 

• An elderly woman with a “mysterious” rash on her back that looked like textbook shingles. Onset was yesterday, so I was able to prescribe her Valacyclovir, strongly emphasizing to her the importance of starting it immediately. 

• A middle-aged man with sudden severe abdominal pain. His labs and CT images indicate acute diverticulitis, no perforation or abscess. I prescribe antibiotics and medications for pain and nausea, and arrange for follow-up with GI.

• Two twin boys with runny noses and notably dehydrated. Both tested positive for RSV. I consulted with a Pediatric Hospitalist, and we both agreed that both boys should be admitted overnight in the Children’s Hospital. 

• A teenage girl whose mother brought her in because she was threatening to kill herself. One of our Psych Response Team members evaluated her, and we agreed that the patient will require psychiatric admission for acute suicidality based on several very concerning factors.

• An older man brought in by County Sheriff officers, under arrest and requiring jail clearance. I evaluate him and ultimately discharge him to law enforcement as low-risk medically.

• A woman in her 30’s wearing a military uniform, injured while on duty in the National Guard. I ordered labs and X-rays, all unremarkable. She has several forms for me to fill out. I tell her I doubt I can complete them during the shift, but I can get to them late tonight to have them ready for her tomorrow morning. In the meantime, a work note must suffice. 

Unlike the scheduled appointments at a doctor’s office, an ER shift involves navigating the overlapping flow of tasks that require various combinations of the skills listed above, and more.  

Thanks to the lessons and life skills I’ve accumulated through the years, such work is much less daunting than when I was a rookie. However, I have also done this type of work long enough to realize it is not best for me long-term. The older I get, the more the physical and emotional demands of these long ER shifts, and of medical practice in general, take a toll. It is time for a change. It is time for another kind of meaningful work that involves problem-solving, broad inspiration, and balanced collaboration. It is time for a Salesforce career. Carpe Diem.

How might the aforementioned skills come to play in Salesforce work? I answer that in Part 4. And in Part 5, I tie it all together by telling the story of my journey from a certified PA to a certified Salesforce professional.