Night Shifts

There’s no getting around night shifts in the emergency department. Most of us work nights to some degree or another and find them less than pleasant. Are there ways to mitigate the misery? Haney Mallemat joins ERCast to discuss nightshifts and so much more….

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In this episode

Finding your niche and following your passion in medicine and life

Tranexamic acid (TXA) used for oral mucosal bleeding

Listener emails

  • Acute care nurse practitioners in the emergency department
  • Warming patients after hypothermia

Night Shifts

  • Complex decision making
  • What’s the deal with caffeine?
  • Optimal shift sequencing
  • Zolpidem (Ambien) and melatonin
  • Casino Shifts

Important links mentioned in this show

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Register for Essentials of Emergency Medicine, Oct 13-15 Las Vegas

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  1. Clint Kalan

    For some reason, in our EMR for nosebleed, TXA is listed as “last line secondary to cost”. Is it getting more expensive? Thanks for also talking about the advanced practice provider questions. I see my whole career as PGY- (years post graduation). Lifelong resident, with better hours and better pay.

  2. danielle

    Thank you for your answer to the NP/PA question. As a PA in surgery, I often encounter many doctors (and other health care providers) that do not fully understand or appreciate our abilities and potential. I completely agree with your point about NP/PAs requiring additional job training and motivation in order to succeed, but the investment is often worthwhile because they can become highly experienced in the specialty over time.
    Thank you!

  3. Pingback: LITFL Review 193 | LITFL: Life in the Fast Lane Medical Blog

  4. Hakkon Rosendahl PA-C

    Hey Rob,

    My name is Hakkon Rosendahl PA-C. I am an APP EM Fellow at Mayo in Rochester, MN. I love your show. It’s useful, entertaining, and to the point. Things I’ve learned on your show have helped me many times in the ED. Your show and EMRAP keep me sane as I drive across Minnesota and Wisconsin for my fellowship each week. They also both keep me up-to-date on extremely important advances in changes within emergency medicine. I just wanted to comment on your most recent episode, which I had the pleasure of listening to on my way to Eau Claire, WI for my CCU rotation.

    I agree with your assessment of midlevel’s lack of appropriate EM training in school. I can’t speak for NPs, but I do know PAs are only required to do 1 month of EM. In PA school, I did 2 months of EM and another 3 months in urgent care and was still completely unprepared to be an affective EM provider.

    Fortunately, Mayo Clinic decided to start a mid-level Emergency Medicine fellowship in September 2014, roughly 3 months after I graduated from PA school in Des Moines, Iowa. My Fellowship classmate Matt, who is an NP, and I make up the inaugural class.

    The fellowship is 18 months long, and every rotation is geared toward toward emergency medicine. We have rotations in radiology, ophthalmology, ultrasound, trauma, ortho, ENT, CCU, and anesthesia. Plus multiple fully dedicated EM rotations. We also get access to things that other places may not have such as the lumbar puncture clinic and Rich Levitan’s one day crash course in difficult and surgical airways.
    Our classroom learning includes Tintinalli, Roberts & Hedges, Hippo EM board review, Rosh review quizzes, and EMRAP. It’s excellent and very up-to-date.

    The point of our fellowship is to create competent mid-level providers who can function in emergency medicine. There is a currently a large shortage of properly trained/experienced mid-level’s and emergency medicine trained physicians in the Mayo Clinic Health System.

    So far the program has been excellent. I now feel comfortable and have the proper foundation of skills to perform lumbar punctures, intubations, chest tubes, and surgical airways etc. The medical education from this program has thus far been excellent thus far. I often laugh/cringe when I look back and realize all the things I didn’t know when I first started the fellowship.

    You and your guest were talking about being able to access the doctor to learn during a shift. Your guest was exactly right in stating that that ability to talk about a patient and learn things as the patients come in is hugely important to become a better provider. My classmate and I have found that most of our learning comes from the conversations we have about our patients with our preceptors. One huge benefit of the fellowship is that were able to sign up and take care of critically ill patients under direct supervision from the emergency medicine trained physician. It’s much easier for us to learn and take care of these patients because were not expected to move the patients through the ED like a regular employee.

    I personally believe if mid levels want to break out of the fast track and function as competent emergency medicine providers they need further training. Whether it be by Fellowship/residency, personal study, trainings/classes, or a combination.

    Looking forward to the next EMRAP and ER Cast.

    Let me know if any questions about the program.

    Hakkon Rosendahl PA-C
    APP EM Fellow
    Mayo Clinic

    1. Post
  5. Craig Button

    There a few of those fellowships out there. Hopkins has one also. With both NPs and PAs is going to depend a lot on their previous experience. Although many times they pull it off, many times they are poster child for the Dunning-Kruger effect. To often they think that having been an EMT-P or an ED/ICU nurse for years is going to be enough.

    The scary ones are the ones that get rural jobs right out of school and don’t have adequate experienced supervision. Last hospital I worked a brand new PA, fresh out of school, military medic before PA school. Sole provider with no MD in the building. disaster waiting to happen.

    Nurses could have dealt with this if we had directed the DNP to specialty work instead of basic core education.

  6. des carmak

    On the podcast you say that you have found NPs to be “a cut above the residents.” If that is the case, do you think there is any reason to spend all the money and time in medical school and residency if you can be just as competent as a fellowship trained M.D. with on-the-job training?

  7. Alex

    As requested in the pocast -- Question for the illustrious Kenji Inaba at Essentials:

    There’s been increasing ‘chatter’ in the FOAMEd world [Hinds, Weingart, Le COng] about ‘finger thoracostomies’, but every time I talk about them, people start looking for a straight jacket and some thorazine for me. What gives? Are we behind the times? Is it a bad idea? Wax poetic on the pros/cons. As a Trauma surgery / remote medicine / swat team / small tactics military / search & rescue -- medical kinda guy, it seems like a great tool to have in the pre-hospital & early rescusc tool box.

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  8. T

    Disclaimer: PA/NPs are a necessity in modern emergency medicine. I greatly enjoy working with and teaching them, and consider many to be close friends.

    That said, why do you bend over backward to describe them as equivalent to physicians? Haney apparently felt it necessary to take it even further, discussing a case in which an NP was superior to him. Not that it needed to be stated, but Rob pointed out the fact that physicians go through rigorous medical school and residency in order to formulate complex differential diagnoses that someone with lesser training would be unable to. Despite this, Haney still needed to bring up an anecdote about a cardiac ICU NP who was better trained than him and could formulate a larger differential.

    Let’s do a “when the rubber meets the road.” Haney: should experienced PA/NPs (such as in the cardiac ICU) supervise physicians (such as yourself)? Second, should they be able to practice independently? Last, should PA/NPs assume a physician salary? Currently, they’re paid approximately 1/3 as much in a given field. Is this what you’re implying?

    I for one take great pride in my knowledge, abilities, and skills that can ONLY be obtained through a physician pathway.

    Dr. Leap has a great article this month about what it means to be a physician. It seems timely to this podcast: Lab Coats Don’t Make the Physician (

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