Importance of Neurosurg, Burn, NICU rotations in residency...

Can't really comment on importance of a neurosurgery month, however during our SICU/trauma month we got our fill of patients with trauma related neurosurgery problems. Minimizing floor/call months is something I value a lot.

Just finished up my month of burn, and even thought it was the most hours I've ever worked in my life, couldn't imagine my training without it. Its amazing now even little burns will cause some docs to freak out and do some weird stuff. Burns are common and something you want to learn about, I would make sure you pick a program that's going to give you some good training. I doubt your going to find a hospital to credential you for escharotomies though.

I'm glad I don't have a Nicu month, but I do see how in rare circumstances it could be useful

I wouldn't pick a program based on any of these rotations. In fact, I'd strongly caution medstudents against picking residency based on off service rotations. The most important thing is your ER experience, period. My experience with some programs that have a lot of off service specialty time is that when the residents come back to the ER, the ER attendings end up being not at all comfortable managing whatever the specialty complaint is as they are used to just calling "neuro/burn/picu/etc" and letting them run the show (often very differently from how we practice in emergency medicine). Learning how the specialties do things is good, but what's more important is that you learn how to provide good, solid, ER based care.

If you are doing burr holes, you are in bum**** nowhere, and, as such, the incidence of needing to do burr holes is nearly nil (like once, maybe twice in a career). Anything else, you have, or are close to, neurosurgical backup.

That is likewise for burns - if it is critical burns (circumferential, hands/feet/genitalia, airway/facial, high %TBSA), then it's to the burn center. Otherwise, your general surgeons have more training and experience with it (and, if you are doing escharotomies - oh my; that is quite outside MY purview). Beyond that, it is pain control. I mean, I remember a burn I sent to the burn center (from the university hospital): a guy with a full-thickness 8cm x 4cm (but 5cm from his junk) - he had laid his motorcycle down, and the muffler was lying right on his upper thigh. He is quite lucky he didn't end up a eunuch. In thinking about that, I can see colleagues from there treating this conservatively - however, at the burn center, he was débrided, and, either the next day, or two days later, had a skin graft.

Now, the NICU - that is a different beast, ideologically. I don't think there are many (although I can think of a few right here on SDN) that wouldn't think of doing everything for a kid, and even more the younger they are, so they'll learn the neonatal stuff, even if they'll never use it. That is something that, I believe, most EM docs won't use metrics or "evidence based medicine" on - they'll go to excess, even though they will be over-trained for something that rarely (although not never) will happen.

As I say, though, I can think of a few people here on SDN that might likely be perceived as cold-hearted, or just plain heartless, and would say that a coding neonate should get minimal or no intervention (and actually do it, or not do it, as it were). I'm not one, though. Even if the kid is cold and dead, I'm going to try something, or look like I'm trying something, even if I know that it is completely futile, both for parental peace of mind, and my own mental health.

Cerberus said:

I wouldn't pick a program based on any of these rotations. In fact, I'd strongly caution medstudents against picking residency based on off service rotations. The most important thing is your ER experience, period. My experience with some programs that have a lot of off service specialty time is that when the residents come back to the ER, the ER attendings end up being not at all comfortable managing whatever the specialty complaint is as they are used to just calling "neuro/burn/picu/etc" and letting them run the show (often very differently from how we practice in emergency medicine). Learning how the specialties do things is good, but what's more important is that you learn how to provide good, solid, ER based care.

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Concur. Off-service rotations are like rehab: 28 days of detox before falling back in on the wagon.

Or, as others have put it: career affirmation months.

Pick your spot based on the ED; yes, some places are more trauma/zebra-oma/community than others... but they're all accredited, and all need a modicum of this stuff. But you won't likely be practicing in a place where you either don't have appropriate backup, or won't be able to stabilize & ship.

You want to go into EM, so why not maximize your time in the ED...

</end post lecture + nightshift + faculty meeting diatribe>

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doesn't matter at all. you will see burn and nsurg pts in any ED (or trauma dept if yours is separated in residency).

NICU - didn't do it in residency, and have never felt i didn't know what to do w/ a baby. once you leave residency you will literally never see a neonate unless you practice in an austere area - and even then you won't see enough to keep your skills up. they're easy to tube and then you're on the phone getting guidance, trying not to **** your pants.

la gringa said:

once you leave residency you will literally never see a neonate unless you practice in an austere area

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That is just not true. Plainly. What do parents do when their neonate is blue or not breathing? They freak. If they forget the number for 911 (which is not uncommon), where do they go? To the closest ED. And, likewise, if the baby is peri-arrest, EMS may not take them to the children's hospital, but to you, who is the closest facility.

This isn't a reach. Although part of what I say is based on personal anecdote, I extrapolate that across the US (having seen this across the US - from NYC, to the Carolinas, to Hawai'i). I can show you a map of hospitals in Erie County, NY (with a population of 900K), where the closest hospital is a 15 minute ride by ambulance hot/code 2. There is a standalone ED that can cut that to 10 minutes. The starting point is not rural, but strictly suburban, and certainly not austere.

neonate, not newborn... i'm talking about being alone caring for a preterm baby. not the same thing.

la gringa said:

neonate, not newborn... i'm talking about being alone caring for a preterm baby. not the same thing.

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Neonate literally (in this case, used correctly) means newborn. I don't even know what you mean when you saying "caring for a preterm baby. not the same thing". Or are you saying that all pregnant women in non-rural areas get prenatal care? Even in that case, you are flatly wrong.

Or are you talking about a premature birth? Any way you cut it, either you are flatly incorrect, or are not clearly stating what is your point. You are distracting from what this kid is asking (and that is also partly on me, as I, too, am trying to address the OP's issue).

...

I will echo what others have mentioned: your off service rotations can either be great or worthless. An important question to ask is what will be the EM resident's role while on that month? Scut monkey? Allowed to actually manage the patient?

Poor ejemplo, in my program:

- picu was fairly worthless (although I did become comfortable with a lot of congenital hearts, it's not much use in the community so far)

- SICU and STICU: very high yield, lots and lots of procedures, burns, etc. Lots of solo management of critically ill patients on call. Only time that I ever liked being on call.

- We did a Peds surgery month that at first blush was a weird rotation but turned out to be extremely high yield

I cannot imagine that a NICU or nsgy month would be at all useful.

YMMV

EvoDevo said:

I cannot imagine that a NICU or nsgy month would be at all useful.

YMMV

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Says the guy we converted from neurosurgery!

As you can see, different opinions are pretty ubiquitous and each person from each individual program's opinion is likely correct-- for THEIR program. The only way to really get a good answer for this question is to get contact info from a resident (preferably senior) and actually ask them what they felt about their individual rotations.

I did residency at a fairly large community hospital/tertiary care center. We have a heavy emphasis on ICU months, and I learned a great deal on these months. Our MICU months were pretty high yield. Our SICU month varied a lot depending on the team. I, personally had a pretty good experience. Others, not so much. Most of our residents hated our PICU rotation, but I got about 5-6 very young intubations (<3yo) and a handful of lines in young kids. Even working in a children's hospital intermittently I can count on one hand then number of central lines I've placed in young kids since.

Personally, I was always a little leery about the "All EM all the time" residencies. I had plenty of EM months, but after a while I feel like you get into your routine of how you do things and put it on autopilot. Good off-service rotations make you look at situations in a different way and add things to your differential that you never would have though of without them.

Out of the rotations you mentioned, however, I would agree that NICU and Nsgy are likely to be pretty low yield (especially because many places, like ours, the neurosurgery patients were either taken care of by MICU or SICU depending on cause). NICU is low yield because from what I've heard, other than a few umbilical lines, most places won't let you do much and the plans are synthesized without much of your input (and rightly so...) Burn, however, might be useful. We took care of burns in our SICU (we were a burn center) but I still sort of feel like there's a lot of hand-waving in the explanations of why we do what we do. In the end, it likely doesn't matter that much because as mentioned above, if you're in the community - complicated things get transferred to the burn center, and if you're at a burn center, you'll have a burn team as back-up.

Just my 2 cents, but hope it was a little helpful.

I'll echo what others have said in that I don't think NICU is particularly high yield for an EM resident. The things that might prove useful would be umbilical lines (getting them in quickly immediately after delivery can save a life) and small airway management and intubation. NRP guidelines are a little different than PALS, but overall coding a neonate isn't all that different from coding anyone else. ABC. But otherwise it's a lot of calorie calculations and TPN and reflux and neo vent management.

I do think that PICU can be quite useful and it's too bad EM residents aren't included more and treated better during their PICU months. It's an opportunity to see some very sick kids as well as some of the differences in work up/differential diagnosis. It's also worth seeing what we don't worry about as much as what we do worry about in a kid.

But, as everyone else points out, YMMV.

ccfccp said:

Says the guy we converted from neurosurgery!

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So true. I had forgotten about that.

And yes, MICU months tend to be pretty great. Add that one to my list.

EM2013woot said:

Thanks to everybody for the helpful/thoughtful answers.

I get the importance of looking for the strongest possible ED experience...and it seems that this, plus a good SICU rotation and a good PICU rotation (in addition to MICU/CCU time) would make for great training...

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CCU = pfft. The one ICU at my residency that wasn't useful. Glad stony brook had cut that down to 2 weeks when i trained there.
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We do NICU at my program. It has some utility in practicing lines on little babies and responding to deliveries for resuscitation attempts, but there is a lot of down time. Further, I am unaware of anyone in my program who has been allowed to intubate a neonate.

As the RRC will start requiring every residency to do some peds training next year, my hospital is sticking with the NICU for this requirement.

We do burn, too. For many patients, they can be managed outside of the hospital with Silvadene, adaptic, and kerlex to the wounds. Just don't use silvadene on the face due to the potential for staining. Instead, use bacitracin. Anything more serious would likely require transfer to a burn unit. And similar to my NICU experience, I don't know of any residents who have been allowed to do a fasciotomy.