Trauma Surgery vs Emergency Medicine

kbrown said:

Hey all,

I just recently got into a discussion with a surgery resident about EM. I told him that I was doing it because I love the rush, the excitement, the schedule, etc...His response was, ER's not that exciting because "99% of trauma centers are ran by trauma surgeons", and then he said "ER physicians don't really do much". Now I realize that surgery always thinks that they do everything and that they are God, but that is not my experience with Trauma Centers. I know that surgeons are obviously there in the event that surgery is necessary, but the statement that they do everything seemed a bit off to me. Since I am a lowly med student I couldn't really argue just because I have only worked in 2 level one trauma centers that had surgery residents. Is he right, is that how it works at other trauma centers? I have a hard time believing that because if that were the case, what would be the point of EM?

Just want some feedback and thoughts on this matter. Thanks 👍 👎 😡 😡 😡

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This has been discussed a lot on this forum in the past as well. just do a search.

In short.....this is extremely variable depending on your practice environment ie. rural, urban, suburban, level 1, 2 or 3 trauma center, academic center etc....

Many ED's don't have much EM physician involvement in trauma activations.....many do. It really just depends on where you train for residency and where you end up practicing. I can assure you that wherever you train in EM that is approved by the RRC you will be adequately trained to handle trauma. Meaning you will be comfortable with assessment and critical interventions such as securing an airway, putting in a chest tube, fast scans, vascular access, interpreting studies, directing care and knowing when to call for help.

If you are in the middle of nowhereville the EP may be the only doc in the hospital and you'll get anything that gets dropped off at the door and have to manage it until a helicopter can get there to fly them to surgery etc....

Or........you could be at a major academic institution without an EM residency (like mine) and the EM doc has virtually ZERO to do with trauma activations as it is entirely handled by anesthesia and surgery.

You'll get everything in between those two extremes depending on where you practice.

As for answering "what's the point of EM if there is no trauma" .........Well, I hate to break it to you, but EM is most definately not all about trauma. that's definately a part of it, but definately NOT the majority of what you'll be spending your time doing at most practices.

Mostly, you'll be working up UTI's, SOB, Chest pain, drug-seekers with back pain, kids with fevers, seizures, poorly controlled diabetics, suturing, splinting and reducing fractures/dislocations, working up GI bleeds, and doing pelvics etc....

My point is don't go into EM solely for trauma as you'll be greatly disappointed.

later

Trauma is a part of EM. It's nowhere near the most important part. I'd probably give that honor to cardiac or airway problems. If you really want to deal with trauma more than the other stuff, go surg and then trauma so you don't have to mess around with the medical complaints.

As noted above, it really depends on the environment. We have an EM residency but the Traumas are run by the Surgery and Anesthesia teams. The EM residents are entirely too busy with the other stuff going on outside the bays; this may change as there is talk of having them do a Trauma rotation but I would be willing to bet that the Surgery residents will be taking most of the procedures in the Bay.

If what you're looking for is the "rush", do as docb suggests and do a Trauma fellowship after a General Surgery residency as most of EM doesn't involve anything near what you would call a "rush".

One thing that I forgot to point out is that trauma surgery is not just dealing with the initial presentation and OR. It's also about managing trauma patients in the hospital and ICU for weeks as they recover (or not) and then seeing them in clinic to follow up on whatever happened. So even though trauma may have more adrenaline than most it has its mundane side too.

Kimberli Cox said:

....If what you're looking for is the "rush", do as docb suggests and do a Trauma fellowship after a General Surgery residency as most of EM doesn't involve anything near what you would call a "rush"...

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Absolutely. As a future EM 'tern, I've come just about full circle on this matter. Part of the allure of being a medic / er doc / adrenaline junky, is that you develop an appreciation of and respect for the chaos. However, the 'real world' of emergency medicine is riddled with distinguishing the truly sick from the plain old routine. When I was first looking at EM programs, I placed a relatively high emphasis on the amount of trauma seen at a particular ED. The "how much trauma does your ER/residency see?" question is a common and important one but misses the mark (I think) with regard to individual program quality and appeal. Trauma is just one aspect of an emergency medicine program.

For example, my trauma surgery rotation was scheduled at a Level II center. I was initially disappointed to be away from the hustle and bustle of my urban, inner city level one ED. My experience at the level II center, to my surprise, turned out to be an exceedingly rewarding experience. I was first and second assist on some rather gruesome surgeries, had first shot at many procedures, and followed many patients through the trauma/surgical ICU. While sheer volume of cases at the level II facility paled in comparison to the 'base hospital,' the increased level of involvement made up for any deficiencies. Also, the actual trauma expereince turns out to be routine. Though far from proficient in effecting a trauma resus, many of the same procedures are done on severely injured patients. There is a lesser degree of challenge, IMHO, to the straightforward trauma/ATLS resus event than their would be in a complex medical code. CHF is multifaceted in its presentation and is not easily cured by a fast-paced checklist of invasive intervention. Many emergency attendings are quite satisfied with "dabbling" in trauma just to keep their skills sharp. There's no need to take the lead on a trauma resus in order to maintain competence in tube thoracostomy and CVC placement.

The ER residents and attendings I came to respect most were those who were well-rounded. Emergency medicine is broad in scope.... it embraces the complex and the common. To compare EM vs. trauma surgery is quite misleading precisely because the role of the emergency physician is diverse. The EP might play lead in a trauma resuscitation for one patient and then be charged with the repair of some complex laceration in the next hour. This patient variety comes with added bonuses as well... prominent among them is the lack of SURGERY! Once a trauma patient is committed to the OR, the trauma surgeon may have to embark on a tedious bowel run. This involves frantic searches for some small perforated intestine, valiant attempts at ligation, and added stress on your back. I mean no disrespect to our trauma surgeon colleagues, but I'd prefer to pass on the long surgery and pick up another patient with an irritable myocardium.

So, my perspective widened considerably after trauma surgery and EM rotations. These two specialities share some things in common but are extremely different with regard to lifestyle, patient encounters, and training. To satisfy the 'adrenaline bug' within you, you can certainly pursue a trauma/cc fellowship at a busy trauma center (after an e-med residency). Conversely, if you'd like to offer DEFINITIVE care to traumatically injured patients and spend 7 years in post-doctoral residency training, then trauma surgery is for you.

People like the surgery resident you mention in the initial post who complain about the lack of excitement that characterizes EM probably do NOT appreciate the specialty's diversity. They may not have had to paralyze a head injured patient to effect intubation or have not managed acutely decompensated congestive heart failure. Codes in the dialysis unit are also guaranteed to produce the necessary amount of chaos and confusion at virtually any hospital. As contained within in the previous messages, there's a lot more to the "rush" than is contained within the walls of the trauma bay.

Just tell your surgery resident friend you'll be proud of him/her when they're a 4th-5th year resident and finally starting to make decisions . . .

Seriously, it varies where you train, but at my place, the trauma surgeons / EM docs do the same thing in the trauma bay. There is no difference in the care. Obviously, the trauma & CRITICAL CARE fellowship usually focuses more on the later part.

Only a small fraction of surgeons working in trauma are fulltime trauma surgeons.

After doing anything for awhile: trauma surgery, EM, CT surgery, it's less likely to be a rush because people adapt to just about anything. EM certainly has variety and most doctors develop some passion or love for what they do. You'll just have to find it for yourself.

EM doctors practice in a fishbowl and we never call with good news; just more work. Whenever I overcall something, I'm a dumb ER resident, whenever I'm correct, there's always some doubletalk or retraction. It's not a field full of gratitute and it takes a certain personality to do it and enjoy it.

In general, I like most of the consultants I deal with.

mike

kbrown said:

Hey all,

I just recently got into a discussion with a surgery resident about EM. I told him that I was doing it because I love the rush, the excitement, the schedule, etc...His response was, ER's not that exciting because "99% of trauma centers are ran by trauma surgeons", and then he said "ER physicians don't really do much". Now I realize that surgery always thinks that they do everything and that they are God, but that is not my experience with Trauma Centers. I know that surgeons are obviously there in the event that surgery is necessary, but the statement that they do everything seemed a bit off to me. Since I am a lowly med student I couldn't really argue just because I have only worked in 2 level one trauma centers that had surgery residents. Is he right, is that how it works at other trauma centers? I have a hard time believing that because if that were the case, what would be the point of EM?

Just want some feedback and thoughts on this matter. Thanks 👍 👎 😡 😡 😡

Click to expand...

Chests are open by ED physicians as well (although it's not smart to do a thoracotomy in a small ED by yourself if you don't have to the ability to place the person in the hands of a surgeon soon (you've relieved the tamponade, clamped the aorta, spun the lung... you can't fix the other injuries).

We do crichs, lateral canthotomies, etc, in the trauma bay. In the bay, we're all the same. I'm not knocking trauma surgery --- all the specialist care comes in the OR + ICU. But the OP was talking about "exciting stuff," not running bowel and managing vents.

It was an ED physician that did the perimortem csection at Metro a month or two ago.

njbmd said:

Hi there,
As Mikecwru said correctly, in the trauma bay, EM docs and trauma surgeons are basically the same. An EM physician can place thoracostomy tubes, ET Tubes, large-bore IVs etc and resuscitate the patient. Most often these two specialties will work together, along with Anesthesiology, to get the patients ABCs under control. If anyone is "cracking chests" is is generally the Trauma Surgeon. In a Trauma, one specialty does not outweigh the next specialty. The difference lies in what happens after the trauma bay. The Trauma surgeon will assume the management of the total care of the Trauma patient and the EM physician will move onto the next patient that happens to come into the department. Sometimes the Trauma patient will be wisked off to the OR (my favorite part of the case) and sometimes the patient will be sent to CT Scan and then the floor. About 80% of Trauma managed today in Blunt Trauma that requires a high level of management skill so as not to miss an potential life-threatening condition that may develop hours after being in the Trauma Bay. The 20% of penetrating trauma is generally managed by the Trauma surgeon in the OR to ICU or General Surgery floor.

The key to Trauma management in today's center is having a solid Trauma team from Emergency Medicine to Trauma Surgery to Neurosurgery to Orthopedics to Anesthesia. Everyone works together for the ultimate managment of the patient. There are plenty of opportunities for the "rush" so you have to figure out where you want to work.

nbjmd 🙂

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mikecwru said:

It was an ED physician that did the perimortem csection at Metro a month or two ago.

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The Holy Grail of EM.

< perimortem csection at Metro a month or two ago >

Is there a link to a news story about this? Google News is not helping me...

Ditto all of the above.

Trauma is glamourous when you are a medical student and an intern. The longer you spend time in the ED, you start to realize that trauma becomes INCREDIBLY routine. yes, the procedures are exciting. But it becomes very routine.

And no, trauma surgeons don't run our traumas and I can't remember the last time I saw an anesthesiologist in the ED. Oh yeah, I remember... 12 months ago, when the clerk accidently called them down and they left after realizing it....

The challenges in EM are not the trauma cases. The challenge is in complicated medical patients...

Febrifuge said:

< perimortem csection at Metro a month or two ago >

Is there a link to a news story about this? Google News is not helping me...

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I'd be interested in a link too, if anyone has one. Thanks!

pushkin said:

I'd be interested in a link too, if anyone has one. Thanks!

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Apparently it didn't get a lot of press. Neither the child or mom made it, which may be a factor. During the same time, there was a man that stabbed his family that I was involved in that got a lot of press. Now the big thing in the news was a large housefire where 9 people died.

mike

kbrown,

As you can see, EDs vary widely. Between med school and residency, I have worked in five different EDs--each one ran their level 1 traumas differently. At my medical school the EPs didnt even step into the trauma bay, except to read an EKG and tell the trauma surgerns the reason this guy had an accident is because he's having an STEMI...At Shands, the ED and Trauma surgeons alternate days so all the residents can get a good training. At Kings County, EPs pretty much did everything. And at UT-Houston, everyone worked together with EPs doing primary & most (or all) of the secondary, while surgery did the majority of procedures. There are plenty variations to these. Best of luck choosing a residency...

pushinepi2 said:

Absolutely. As a future EM 'tern, I've come just about full circle on this matter. Part of the allure of being a medic / er doc / adrenaline junky, is that you develop an appreciation of and respect for the chaos.

(.........)

As contained within in the previous messages, there's a lot more to the "rush" than is contained within the walls of the trauma bay.

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GREAT post!!! 👍 👍 👍 🙂

We get all excited about the adrenaline of the ED, but one of the underappreciated skills of the EP is the bedside manner. The biggest stressor of the EP is lawsuits and malpractice, and the biggest deterrent is a good bedside manner- this is a simple truth that many don't appreciate during residency. Too many people get drawn to EM because of the "adrenaline" and forget that the majority of your work in the "real world" will be seeing the worried well and minor illnesses. If you don't figure out how to please these folks and make them feel like you care about their illness, however insignificant, it will bite you on the A$$. Sometimes this customer service A$$ kissing approach can get tiresome, but the sooner you accept it and integrate it into your practice the easier your career will be. Trauma surgeons deal with a sicker group (and generally less desirable one, consisting on average of more druggies, gangsters, and alcoholics) on the whole, than EP's hence once could argue that this great bedside manner and customer service approach is less pertinent to the trauma surgeon. The two specialties are apples and oranges.

"If anyone is "cracking chests" is is generally the Trauma Surgeon."

LOL, not in my ED. If only I could tell the story...

Yeah, I hear that. The couple of times I (as a tech) witnessed or heard about thoracotomies, it was our EM people.

The trauma team is awesome, and they get there in no time when we call the pager. But our peeps tend to crack chests when there's no time to call the pager...