Anyone else not into trauma?

[trkd]

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I am wondering if anyone else prefers more bread and butter EM rather than the fast-paced trauma situations. It's not that I can't handle the situation or get uncomfortable. I just don't care for the adrenaline rush.

I really enjoy being in the ED and feel like I belong there. I like helping people with urgent-ish (and even not so urgent) problems. I also like the fact that I can help the poor, uninsured, marginalized members of society (I prefer it actually). I don't wait for the excitement of trauma though.

I feel as though most people (at least on this forum) seem to like the opposite. It is the only reservation I have about EM, though I know there must be people that feel the same because SOMEONE has to work in all the EDs with less excitement. Anyone feel the same? 😳

 

[southerndoc]

I don't even get the adrenalin rush anymore.

 

[JackBauERfan]

is it wrong to get an adrenaline rush for a UTI? I definitely get one. Can't wait for that levaquin dose to go in.

 

[southerndoc]

is it wrong to get an adrenaline rush for a UTI? I definitely get one. Can't wait for that levaquin dose to go in.

 

[Apollyon]

I don't even get the adrenalin rush anymore.

I have to agree - it looks cool, but that's about where it ends. Not a lot of thinking is involved - stop the bleeding, IV fluids, surgeons, ortho. It loses its luster after a while. The opportunities for procedures are not frequent enough to say "yay, another trauma!".

 

[USCDiver]

As long as you aren't getting an adrenaline rush for pelvic exams in vag bleeders, I think you'll be alright.

 

[roja]

I used to be one of those non-trauma guys.... boring, protocol, blah blah blah.


But I do like it.... I dont' want to just do trauma, but I do think its cool stuff....

 

[DropkickMurphy]

is it wrong to get an adrenaline rush for a UTI? I definitely get one. Can't wait for that levaquin dose to go in.

The sad thing is I don't know if he's joking or not.

 

[southerndoc]

is it wrong to get an adrenaline rush for a UTI? I definitely get one. Can't wait for that levaquin dose to go in.

I spent my entire shift last night in awe as I watched the magics of fluoroquinolones doing their work on that dirty urine. Go quinolone, go! My adrenalin is still pumpin'.

 

[DrQuinn]

Trauma used to be cool, but after a month fo being the only trauma intern at a huge Level 1 center, me and my fellow classmates easily got over it.

I'm at a place now where all the "trauma alerts" (those that meet criteria by EMS) go down the hall to the trauma acceptance area... separate from the ED. So now as an attending I don't get pulled to go see a trauma for a half an hour to an hour. Probably cuts down on billing and critical care time, but it makes my life sooooooooooooo mcuh easier.

I agree with Apollyon, it looks cool, but once you get to learn how to handle the traumas, its relatively straightforward.

Q

 

[trkd]

Trauma used to be cool, but after a month fo being the only trauma intern at a huge Level 1 center, me and my fellow classmates easily got over it.

I'm at a place now where all the "trauma alerts" (those that meet criteria by EMS) go down the hall to the trauma acceptance area... separate from the ED. So now as an attending I don't get pulled to go see a trauma for a half an hour to an hour. Probably cuts down on billing and critical care time, but it makes my life sooooooooooooo mcuh easier.

I agree with Apollyon, it looks cool, but once you get to learn how to handle the traumas, its relatively straightforward.

Q

Trauma acceptance area? Out of curiousity, are you at WHC most of the time or are you also taking shifts at GU hospital?

 

[DropkickMurphy]

Oh Christ.....I may have to deal with Quinn if I get either of the two jobs I'll be applying for because of my move. (j/k)

 

[DrQuinn]

Trauma acceptance area? Out of curiousity, are you at WHC most of the time or are you also taking shifts at GU hospital?

3 months out of the year i'll be working at GUH, most of my time is here at WHC, though.

Q

 

[DrQuinn]

Oh Christ.....I may have to deal with Quinn if I get either of the two jobs I'll be applying for because of my move. (j/k)

Where're you looking to go?

It could be worse. I could sign out my recto-vaginal exams to you.

Q

 

[corpsmanUP]

I ended up keeping most of the trauma heavy programs further down on my rank list because I felt like as an EM doc it would not serve me all that well to do "too much" of it. I worked a lot of traumas in the military and throughout my schooling where we had a large trauma center. I think if you had to list in order of frequency the most overasked question on the EM interview trail it would be the one about "who does what in trauma". So many applicants are hung up on it.

I saw some programs where they were so involved in the traumas that the ED was constantly backed up and the board came to a halt every time a major alert came in. Here at my institution the EM residents do not run the traumas. We simply run the head of the bed. But after you have seen 50 of them I think it gives a good perspective on what you need to do in a trauma. I like it because you can come in, take care of the airway, maybe get a procedure or two if surgery needs help, and then get RIGHT back to your grease board.

 

[bulgethetwine]

I ended up keeping most of the trauma heavy programs further down on my rank list because I felt like as an EM doc it would not serve me all that well to do "too much" of it. I worked a lot of traumas in the military and throughout my schooling where we had a large trauma center. I think if you had to list in order of frequency the most overasked question on the EM interview trail it would be the one about "who does what in trauma". So many applicants are hung up on it.

I saw some programs where they were so involved in the traumas that the ED was constantly backed up and the board came to a halt every time a major alert came in. Here at my institution the EM residents do not run the traumas. We simply run the head of the bed. But after you have seen 50 of them I think it gives a good perspective on what you need to do in a trauma. I like it because you can come in, take care of the airway, maybe get a procedure or two if surgery needs help, and then get RIGHT back to your grease board.

I would disagree. You need at least some time running traumas yourself -- either if your department does it at least part-time or if you have a dedicated trauma rotation. Being at the head of the bed is important (something about A is for airway? But to do a succinct, accurate primary survey in front of a room full of people +/- a surly, senior trauma surgeon takes practice.

Also, to take the attitude that "you can come in, take care of the airway, maybe get a procedure if surgery needs help..." is COMPLETELY the wrong attitude; In fact, many programs have fought to establish the EM doc as capable of taking a leadership, management role during traumas.

You certainly don't need to go to a trauma heavy place to get good at it; It is merely one component of your training. But to state that it is an overasked question on the interview trail is simply not true.

 

[Seaglass]

I think it's an overasked question on the interview trail.

 

[DrQuinn]

I think its an important skill. Shoot, out in the community (where the majority of us end up), let's say EMS dumps a "trauma alert" patient in your dinky ED. Its just YOU, and MAYBE two nurses. A paramedic may stay around to help out start some IVs or get a BP. But its just you. Your surgeon is at home, and might show up in 20 minutes if he hurries. So I do think a solid trauma experience is necessary, as in, being the team leader.

BTW, as an almost two week old attending, things are quite different when you're "running" it. Had my first true MI that was mine and only mine. Things change (and time goes by soooo slowly) when you're the only doc there.

Q

 

[corpsmanUP]

I would disagree. You need at least some time running traumas yourself -- either if your department does it at least part-time or if you have a dedicated trauma rotation. Being at the head of the bed is important (something about A is for airway? But to do a succinct, accurate primary survey in front of a room full of people +/- a surly, senior trauma surgeon takes practice.

Also, to take the attitude that "you can come in, take care of the airway, maybe get a procedure if surgery needs help..." is COMPLETELY the wrong attitude; In fact, many programs have fought to establish the EM doc as capable of taking a leadership, management role during traumas.

You certainly don't need to go to a trauma heavy place to get good at it; It is merely one component of your training. But to state that it is an overasked question on the interview trail is simply not true.

I appreciate your reply and I will admit that it makes sense in many respects. I just think that everyone arrives to residency with their own experiences and my own personal desire was to find a place where I would not get bogged down with trauma. Admittedly I have never run the trauma from the standpoint of "running it" but I feel confident that I will be able to after residency (added to the years I have already spent in this setting). I've been a part of traumas for some 15 years from a medic position to an Army Btn. Surg position as a PA. Everyone has their comfort level.

And on the other side of that coin, you can seriously be the most efficient trauma guru on earth, but if you are placed in a small rural ED where your "team" has never run a real trauma, then you are going to function as the team leader and "the team". That skill is not taught in residency because most of us have a team that does what they are taught to do without you even asking them.

My program is a young program with a strong trauma surg program here already. To get the head of the bed is a fine start and eventually our residents will probably have more involvement. And yes, we do have a dedicated 2 months on trauma as an R-1 and an R-3, but we don't take the lead and run the traumas in that capacity either. That is a good point though and maybe we should pursue the idea of being team leader when we are on trauma. I'll bring up the topic when I am on trauma next month and I'll let you all know if I survive the conversation! 😱

 

[southerndoc]

And on the other side of that coin, you can seriously be the most efficient trauma guru on earth, but if you are placed in a small rural ED where your "team" has never run a real trauma, then you are going to function as the team leader and "the team". That skill is not taught in residency because most of us have a team that does what they are taught to do without you even asking them.

I disagree with this statement. As an emergency physician in a community, it is your responsibility to assign tasks to individual team members before a patient arrives. This is where trauma experience comes in handy. You assign nurse 1 to get the IV on the right, nurse 2 on the left, etc.

I am not a gungho trauma junky like many of my classmates. I think the adrenalin rush wore off when I was a paramedic. Having said that, we get a TON of trauma experience at our Level I trauma center. EM residents manage the airway on all trauma patients. PGY-2's run the modified trauma responses during the night, and senior residents run the full trauma responses during the day. The airway is managed by a critical care resident during the day, and by the senior resident during the night. (Surgery residents run the modifieds during the day and the fulls during the night; all fulls are attended to by trauma surgeons and modifieds by ED attendings, to whom the ED and surgery residents report.)

I've probably overseen many trauma resuscitations, and I'm grateful for the experience. It gets you in practice for a systematic way of assessment, makes you more able to detect less than obvious injuries, and gives you an appreciation for the degree of injury associated with often trivial mechanisms. Likewise, you get so confident with your assessments because where I am, you are required to announce your findings to the team (someone is writing it down while you assess the patient).

Being able to rapidly, thoroughly, and confidently assess a trauma patient from head to toe in less than 90 seconds is a skill to be learned.

Even the best paramedics often cannot do this. However, I do think paramedics or those with prior trauma experience are more able to assess trauma patients quickly than those without such experience. By the end of their training, the playing field is leveled.

I do not support the conclusion that trauma experience is unnecessary. Yes, it does clog down the board, especially during the day when a senior resident is not only responsible for running a full trauma (which is based on physiologic parameters and not mechanism), but also is responsible for overseeing the department and ensuring juniors do their jobs and maintaining flow in the department. The attendings usually delegate this to the seniors since my institution is grooming graduates for academic positions, which these skills are necessary. So yea, you do get bogged down, but the experience is invaluable.

 

[bulgethetwine]

I disagree with this statement. As an emergency physician in a community, it is your responsibility to assign tasks to individual team members before a patient arrives. This is where trauma experience comes in handy. You assign nurse 1 to get the IV on the right, nurse 2 on the left, etc.

I am not a gungho trauma junky like many of my classmates. I think the adrenalin rush wore off when I was a paramedic. Having said that, we get a TON of trauma experience at our Level I trauma center. EM residents manage the airway on all trauma patients. PGY-2's run the modified trauma responses during the night, and senior residents run the full trauma responses during the day. The airway is managed by a critical care resident during the day, and by the senior resident during the night. (Surgery residents run the modifieds during the day and the fulls during the night; all fulls are attended to by trauma surgeons and modifieds by ED attendings, to whom the ED and surgery residents report.)

I've probably overseen many trauma resuscitations, and I'm grateful for the experience. It gets you in practice for a systematic way of assessment, makes you more able to detect less than obvious injuries, and gives you an appreciation for the degree of injury associated with often trivial mechanisms. Likewise, you get so confident with your assessments because where I am, you are required to announce your findings to the team (someone is writing it down while you assess the patient).

Being able to rapidly, thoroughly, and confidently assess a trauma patient from head to toe in less than 90 seconds is a skill to be learned.

Even the best paramedics often cannot do this. However, I do think paramedics or those with prior trauma experience are more able to assess trauma patients quickly than those without such experience. By the end of their training, the playing field is leveled.

I do not support the conclusion that trauma experience is unnecessary. Yes, it does clog down the board, especially during the day when a senior resident is not only responsible for running a full trauma (which is based on physiologic parameters and not mechanism), but also is responsible for overseeing the department and ensuring juniors do their jobs and maintaining flow in the department. The attendings usually delegate this to the seniors since my institution is grooming graduates for academic positions, which these skills are necessary. So yea, you do get bogged down, but the experience is invaluable.

Post of the day.

THIS is why you ask about trauma parameters when you interview.

 

[beyond all hope]

Agree with most posters above. Trauma experience is very helpful just so you get your rhythm down. I've worked in two pretty mean trauma centers, and now I'm happy to be at a tame level 1.

It's not a rush anymore. It's just another patient.

Okay, maybe when they're dropping their pressure, or you're about to do a chest tube/pericardiocentesis/thoracotomy, it's a rush. Otherwise:

Pt phonating/mentating, NCAT
Trachea midline
BS clear BL, normal chest wall
Belly NT
Pelvis stable
Pulses x4
What's the blood pressure? Monitor? Pulse Ox? Where are my two lines?
Roll patient (you're going to feel some pressure in your bottom...), start secondary survey, nurses are usually asking for orders (Tetanus +/- Ancef, IVF, T&S vs T&C), where's my FAST?, yadda yadda

Note I don't put a pupil exam in the primary survey of an awake patient. If they're taking to you, they aren't herniating.

 

[southerndoc]

Do you consider the back part of the primary survey? We only do it as you describe for penetrating injuries. For blunt injuries, the back exam actually comes after extremities.