Trauma Surgeons: Lifeguards at the Shallow End of the Gene Pool

[SouthernSurgeon]

In an attempt to pre-empt the excited pre-meds and medical students who don't understand why surgery residents frequently lack excitement about trauma, I present the following article:

http://www.physiciansweekly.com/trauma-surgeons-role/

Some highlights:

-Out of 518 Level 1 traumas in the past year, this attending performed 21 major surgical procedures, for a 4% operative rate. This number is in line with national averages. This also means that for us as general surgery residents, for every trauma operation we can expect to perform, we have to attend and supervise 25 level 1 traumas.
-86% of these patients presented intoxicated
-47% of these patients presented with a positive urine drug screen

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[jthedestroyr]

Best Topic Title ever. SS wins the internet today!

 

[jthedestroyr]

None the less, that topic title wins the internet today.

 

[Winged Scapula]

Yeah, Phoenix representin'!

 

[SLUser11]

Not mine; credit goes to the blog author...

Only 294 of the 518 were admitted to the hospital. If this was due to a high rate of celestial discharge, then the operative rate would have been higher. I think this demonstrates the sample bias...his "Level 1" traumas may not be very sick. It would be interesting to see the ISS for these patients.

I'm not motivated enough to do an exhaustive literature search, but this article suggests that 1 in 4 spleens still go in a bucket: http://www.ncbi.nlm.nih.gov/pubmed/20622580. Anywhere with high rates of penetrating trauma would also have higher operative rates.

His EtOH intoxication numbers are also a little too high to believe that it represents a random sample of "trauma these days." I think it's a compelling story, but still anecdotal at best.

Don't get me wrong, though. I'm not signing up for trauma call anytime soon.

 

[Winged Scapula]

We have a ton of Level I trauma centers here. Scottsdale Osborn is a pretty busy facility but I'd venture most of the trauma is Ortho; some of Neuro probably gets shipped to Barrows. For knife and gun action, downtown and the western state (i.e., Kingman, Yuma) are the places to be.

For anyone interested, the most recent "S.T.A.B" report (LOL): http://www.azdhs.gov/bems/documents/reports/2013-stab-annual-report.pdf

 

[LucidSplash]

I still have another 2 months of trauma chief to face but on my run of 4 consecutive months last summer I decided that I was done admitting geriatric patients with isolated tiny head bleeds. Neurosurg sees the head bleeds and manages those and so I was able to selectively get the hospitalist service to admit those patients. Doesn't take care of the other social issues that come along with trauma like lack of insurance, difficult placement/discharge planning, and overall shadtasticness, but that was definitely a step in the right direction.

 

[ThoracicGuy]

We have a maddening number of policies regarding isolated ortho and near injuries and who goes where. For a class 1 even with an isolated injury they come to us for 24 hours for initial monitoring/care and tertiary survey. But at that 24 hour mark the subspecialties are quite wily about finding excuses not to take them...

Our hospitalists would flip if we tried to send any trauma patient to them. It gets rather ridiculous. A syncopal geriatric 90 year-old with a fall from standing would be better served on a medicine service with a geriatrics consult, but they are a "trauma" because of their tiny head lac or subdural.

For us, it was often a race to who could sign off first and leave the patient with the other service. About the only thing we could get away with as the trauma service was isolated single system ortho or neuro. Even that, there was so much effort made to find a second system that was marginally abnormal to dump onto the trauma service. You couldn't pay me to go into trauma now.

 

[TomC727]

Per American College of Surgeons verified trauma centers, if more than 10% of your trauma admissions get admitted to non-surgical services, then this goes for review. This is the main reason for the "babysitting" you hear about trauma. It is part of trauma center verification.

 

[dpmd]

We have a maddening number of policies regarding isolated ortho and near injuries and who goes where. For a class 1 even with an isolated injury they come to us for 24 hours for initial monitoring/care and tertiary survey. But at that 24 hour mark the subspecialties are quite wily about finding excuses not to take them...

Our hospitalists would flip if we tried to send any trauma patient to them. It gets rather ridiculous. A syncopal geriatric 90 year-old with a fall from standing would be better served on a medicine service with a geriatrics consult, but they are a "trauma" because of their tiny head lac or subdural.

Luckily we had an official "ground level fall with head bleed" goes to medicine policy without trauma ever even knowing anything about them (because ground level fall does not meet trauma activation criteria). It was key to elucidate history if ER called for a consult on a old person found to have a head bleed because not every ER resident knew or cared about the policy so sometimes you had to guide them.

 

[Raryn]

We have a maddening number of policies regarding isolated ortho and near injuries and who goes where. For a class 1 even with an isolated injury they come to us for 24 hours for initial monitoring/care and tertiary survey. But at that 24 hour mark the subspecialties are quite wily about finding excuses not to take them...

Our hospitalists would flip if we tried to send any trauma patient to them. It gets rather ridiculous. A syncopal geriatric 90 year-old with a fall from standing would be better served on a medicine service with a geriatrics consult, but they are a "trauma" because of their tiny head lac or subdural.

Strange. At our hospital all of the ground level falls, up to and including head bleeds and hip fractures get admitted directly to medicine... with ortho or neurosurg or whomever as a consultant. I can't tell you how many hip fractures I've babysat over the last couple years.

 

[womp]

Isn't it free money though? Most of those ortho patients are fairly straightforward. PT sees them, they get rehab screeened, and patient is gone. It's the easiest progress and discharge notes. You don't even have to change the dressing. Discharge planning can be painful, but how involved are attendings in that?

 

[ACSurgeon]

Well at my institution at least that's pretty much what happens. It's very little pain for the attendings so their willingness to fight the battles with ortho is super low.

But for the residents who have to round on 40 floor patients...that's the pain...

Plus a lot of those patients who move in and stay for 6+ months are at risk for having some complication during their impatient stay, and sense they are less sick, you wind up missing something silly once in a while.

 

[womp]

Edit: Also, this is classic ortho. Aren't we just doing y'all a favor by dumping those patients on you?

lol yup.

Part of the reason is that ortho trauma is incredibly short staffed. Very few orthopedic residents want to go into trauma (in the last 10 years of classes in my program, only 1 went into trauma and he's now at a Level 2 hospital). Most Level 1 trauma centers have maybe 1-2 ortho trauma guys covering the hospital. Many general surgery traumas are now non-operative, but it's the opposite with orthopedic injuries, more and more are operative. Most hospitals did the math and found it more cost effective for the ortho traumatologist to do cases than round and replete potassium on his 40 patients on the floor.

It will all end probably with capitation and bundled payments.

 

[womp]

It's cost effective because if you throw them on a medicine service the hospital ends up getting to basically double bill. they get the global payment for the ortho side which is supposed to include postoperative care as part of the bundle, then they also get to bill for the hospitalist consult. This is a big part of why the payers are eliminating the global payment period.

Same thing happens with the ED. The ED spends 2 seconds on the patient, hasn't even put the patient in a gown yet. Belly pain? vomited? Surgery consult! The ED doc bills for a level 4 ED visit, writes an EMR autopopulated note 1 day later with "MDM: Surgery consulted", the hospital also gets a Level 4 ED facility fee ($260+). That's a lot of money the ED doc makes for a phone call to the surgery consult resident. And when surgery sees the patient for a consult, you get to bill all over again.

Our payment system is a giant mess. Bundled payments will just make the mess more unique to each hospital system than have it standardized nationally.

 

[VisionaryTics]

Same thing happens with the ED. The ED spends 2 seconds on the patient, hasn't even put the patient in a gown yet. Belly pain? vomited? Surgery consult! The ED doc bills for a level 4 ED visit, writes an EMR autopopulated note 1 day later with "MDM: Surgery consulted", the hospital also gets a Level 4 ED facility fee ($260+). That's a lot of money the ED doc makes for a phone call to the surgery consult resident. And when surgery sees the patient for a consult, you get to bill all over again.

Our payment system is a giant mess. Bundled payments will just make the mess more unique to each hospital system than have it standardized nationally.

That's absolutely ridiculous.

Because our ED docs don't even write assessments or plans. They just do a "10-point" HPI, ROS, and physical exam, then leave the assessment and plan blank.

 

[womp]

That's absolutely ridiculous.

Because our ED docs don't even write assessments or plans. They just do a "10-point" HPI, ROS, and physical exam, then leave the assessment and plan blank.

This is why ED docs now make more than general surgeons while working less than 40 hours a week and why every hospital is rushing to expand their EDs or advertise their low wait times (facility fees, cha-ching!).

Despite all this, CMS is trying to unbundle the 90 day global surgery payments, and pay you surgeons even less for your surgery. Pretty soon fixing my muffler will cost more than a gallbladder. Surgeons need to stop eating their own and advance their interests more as a group.

 

[Winged Scapula]

This is why ED docs now make more than general surgeons while working less than 40 hours a week

Admittedly it's been awhile, but the last time I checked general surgeons were still making more than emergency medicine physicians albeit working longer hours. Where have you seen that EM makes more ?

 

[womp]

Unbundling is going to hurt ortho more than GS. We actually provide postop care so it will be a wash for most our cases.

May be true for ortho trauma cases, but not applicable for elective orthopedic cases. TKA/THAs are generally under ortho's primary service, and there are more postop follow-up visits to assess bone healing or implant stability in elective orthopedic surgeries than your typical gallbladder and appy. And most of sports and hand are outpatient day surgeries anyway.

 

[MDDoubleD]

Admittedly it's been awhile, but the last time I checked general surgeons were still making more than emergency medicine physicians albeit working longer hours. Where have you seen that EM makes more ?

Maybe he meant more per hour? Which is probably true, obviously GS wins in the end but hey.

 

[Winged Scapula]

Maybe he meant more per hour? Which is probably true, obviously GS wins in the end but hey.

Perhaps. They do earn more per hour but annual compensation is higher for surgery compared to EM.

 

[dr zaius]

I love the comments regarding the callousness of the title. Those people clearly haven't spent any time in the trauma bay.

 

[deleted50541]

Oh boy, June is right around the corner and I'm the trauma chief for another exciting round for geriatric pradaxa head bleeds, drunken ATV rollovers, and good old fashioned urban warfare. It's gonna be a great summer!

 

[neusu]

On of my best friends is a LEO at the county lock-up. I like to joke with him that I keep him employed by fishing the criminals out of the toilet when they come in trying to die.

 

[neusu]

Pradaxa is such a pain for the trauma population. I know the cardiologists love it and all but we really need some of those reversal agents they've supposedly been working on to hit the market.

These newer generation anticoagulants have been an absolute nightmare on the neurosurgery end. Irreversible and, sometimes, long acting. Fighting TBI or hemorrhagic stroke with your hands tied behind your back because of operative bleeding risk while watching patients decline is horrible.