County style residency programs

[Powdermonkey]

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I've been searching through some of the old posts trying to get a good list going of the county style programs (Here and also here). Not necessarily being literally "in the county", but I'm looking more for high acuity, high volume, truama, etc. I want to get pushed in residency, and I want to see a lot so that when I make it out to practice in the community/county, I'll be set up to do well. All residency programs are required to "teach" the same things by the RRC, but some just do it better than others. There will be some learning curves on some of the more business side of things, but I can deal with that then.

Looking for a LICHSIPER style program (see above links), I've recently found out that I LOVE the zoo aspect of these style of programs. I can't stand the slower pace and different feel and style of the more academic programs. I'm looking for a program that is mostly resident run, though not necessarily where the residents have to do their own blood draws, transports and foleys regularly. I did that as a tech, I don't need to do it again as I'm learning to be a physician.

This list is from what I've been told by attendings, and from searching. Thoughts, corrections and additions are welcome.

Cook County
Emory
UF-Jax
Parkland
Eastern NC - Brody
UCLA Harbor
Christiana Care
Indiana
Kings County/SUNY downstate
Bellevue
Lincoln
Washington Hospital Center (DC)
Charity (NOLA)
Detroit Receiving
Henry Ford
Hennepin County
Maricopa
Alameda
Jacobi
Cleveland Metrohealth
BMC
University of Mississippi

+/-
ORMC
El Paso/Texas Tech
University of Maryland
Hopkins
St. Vincents
MCW
Truman Medical Center (KC, MO)
Maine medical center (ME)
Wishard
U of Chicago
St. Luke's - Manhattan

 

[EM_Rebuilder]

I would put University of Mississippi in here...

Some people may say it does not classify since Jackson is not that 'big'... But, there are about 500K people in the Jackson metro area, its the state captiol, its the ONLY Level 1 Trauma center in the state, and Jackson (most all of Mississippi) is a ROUGH town with lots of poverty and violence...

I would say you see a gunshot victim at least every other shift if not more often than that... I think at least one ICH per shift, multiple MVCs per shift. There is a front (higher acuity, trauma) and a back (lower acuity, abd pains, pelvic palace, etc) that you alternate working on. Rarely do you work in the front where you do not do at least one intubation....

Its a resident run program, by that I mean every patient that presents to the ED is seen by the residents... You work hard enough to stay very busy, but it still is doable...

On the plus sides, there are very safe areas in town to live in and the huge shortage of doctors in the state allow the moonlighting residents to really bank!

 

[Powdermonkey]

See... That is the kind of information I've been looking for over the past year or two and not really gotten many good responses. Thanks, EM_Rebuilder! I've looked at the program at UofMS, but I hadn't heard much about it, so I wasn't sure what to make of it.

 

[Hamhock]

I am very "county".

I am also fairly familiar with at least four or five programs on your list.

I'll try to contribute more in the near future (running out the door now), but will quickly say:

Maine Med is in NO WAY 'county'. None. Zip. Zilch.

And I would certainly add to your list of 'hard-core county': USC-LAC and Denver Health, both of which are much more 'county' (especially USC) than places like Christiana Care (although the secondary hospital in Wilmington is fairly 'county').

HH

 

[deleted109597]

ECU/Brody SOM (at Pitt County Memorial Hospital) is not county. It is community however.

 

[WilcoWorld]

UNM is high-acuity, resident-run and serves a very underserved population. With that said it's also academically rigorous and heavy on Critical Care experience.

 

[KidDr]

I would add Region's/Healthpartners to your list (in St. Paul, across the river from Hennepin in Minneapolis)

 

[canjosh]

Ben Taub (Baylor). New program, but definitely a county zoo with volume, acuity, trauma, etc.

 

[old_boy]

Maine Med is in NO WAY 'county'. None. Zip. Zilch.
And I would certainly add to your list of 'hard-core county': USC-LAC and Denver Health, both of which are much more 'county' (especially USC) than places like Christiana Care (although the secondary hospital in Wilmington is fairly 'county').
HH

I interviewed at many of the programs on the list. I second that Maine Med and Christiana should be taken off. Hopkins should also be taken off. All three are solid programs but for various reasons none have a "county" feel.

 

[Interpolfanclub]

UF Jax
LSU New Orleans

Already listed but I have significant experience with both. Doesn't get much more county.

 

[Venko]

Consider adding George Washington University for a "county" style program. (it should be in the +/- section)

 

[UnderwaterDoc]

You should check out UMDNJ in Newark, NJ. Huge amounts of trauma, both penetrating and blunt, many patients for a small number of residents so you will be busy as hell.

Also, you can live in Hoboken which is a stone throw away from NYC.

 

[KarlPilkington]

The "county" designation is interesting and potentially misleading for medical students.

Places like Christiana/Maine Med may not be "county" and lack some of the "zoo-like" aspects of other places but as far as busy, high acuity shops where residents see and do it all, they more than keep pace with the more traditional "county" programs in terms of being busy and seeing real disease. I know Maine Med well and Christiana decently and would be happy to dispel any myths that may exist about their lack of hustle and bustle.

Working in a place that feels like a zoo every shift doesn't mean you get better training, or that you will somehow be better equipped when it comes to working as an attending. The best docs aren't necessarily the ones who see gunshots every shift, have patients out in the waiting room for 18 hours, or work in an inner city.

 

[J031p]

In NYC, I definitely have to agree with the county feel for Kings County and Bellevue. I would have to add Jacobi into the mix too. And to be honest, I would have to add Columbia NY Presbyterian into that mix. That place has a zoo feeling to that place, which is a huge contrast to its sister campus at Cornell.

 

[jbar]

I suggest keeping an open mind. Going into the application process I totally saw myself as a "county" person. I wanted hard core, busy, trauma etc. But there are a lot of things that go with some of these county programs. The ones I looked at tended to have longer shifts (like working 16 12s your fourth year), fewer ancillary services, no electronic medical record etc. Some of the county people say that those who don't have to deal with all this are spoiled. I would argue that I can see a lot more pathology in a shift if I'm not babysitting people at x-ray, fighting with nurses to give me a machine to do a 12 lead, or writing notes till my hand cramps.

As to the zoo aspect, it's fun, but you have to figure out at what point it isn't safe for you or for the patient's. I've seem places where the patients are stacked three deep by three wide. There is no way the person in the middle is getting the same sort of care or frequent reasessments when the resident has to climb over people to get to them.

So I'm all for making a good list of county programs. But I'd apply to some "academic" ones too, at the least to have something to compare the county programs to. And keep an open mind, you might be suprised.

 

[Powdermonkey]

Just updating the list a little from feedback as well as some PMs. Again, this is a list mostly for me, but I'm glad for it to be around for those that are interested as well. I fully understand that the "zoo" feeling and seeing gunshots and multi organ system traumas repeatedly every shift isn't necessary to create a high functioning, well prepared resident. But I used to work as a tech in that environment, and I just feel more at home in those style programs, so it's what I'm looking for personally. I don't like being bored at work. If I'm bored, I'd rather be at home. That's part of the reason I like EM, you work while you're at work, and you don't care about picking up more patients. And when you're done, you're done. You have the opportunity to go drink a beer and pass out. YMMV.

Again, I greatly appreciate those of you who have imparted some knowledge upon me. I'm at a new school and since we don't have a large teaching institution attached to the school (at least yet), I don't have many people to ask these questions. My faculty advisor at school is our EM chair person, but they are FM boarded and have been practicing EM for a number of years now. I've gotten some awesome advice so far, but unfortunately there just isn't a huge connection to academic EM and residency programs. Having this list or knowledge is helping me better decide which programs I should and possibly shouldn't apply to.



Cook County
Emory
UF-Jax
Denver - work residents very hard, malignant(??) residents/attendings 2/2 work schedule
Parkland
Eastern NC - Brody - More community vs. "county"
UCLA Harbor
USC-LAC
Christiana Care
Indiana
Kings County/SUNY downstate
Bellevue
Lincoln
Washington Hospital Center (DC)
Charity (NOLA)
Detroit Receiving
Henry Ford
Hennepin County
Maricopa
Alameda
Jacobi
Cleveland Metrohealth
BMC
University of Mississippi - I've now heard some great things about this program from a number of different individuals. May be the hidden gem for me
Ben Taub/Baylor
University of New Mexico

+/-
ORMC
El Paso/Texas Tech
University of Maryland
Hopkins
St. Vincents
MCW
Truman Medical Center (KC, MO)
Maine medical center (ME) - More community vs. "county"??
Wishard
U of Chicago - some political battles/issues that may or may not effect the residents
St. Luke's - Manhattan
Jacobi
Columbia Presbyterian
George Washington University
UMDNJ - Newark
Regions/Healthpartners - St. Paul

 

[quicknss]

Consider adding George Washington University for a "county" style program. (it should be in the +/- section)

George Washington only does a few months at a county place so I wouldn't classify this a a "county program"

 

[deleted6669]

didn't see hurley(flint michigan) on the list: http://education.hurleymc.com/gme/residencies-and-fellowships/affiliated/emergency-medicine
hard to get more county than LA/USC. and you also get mel hebert as faculty. doesn't get better than that.
when I was an LA county medic( 20 yrs ago) it was so zoolike there that we would routinely run codes from their waiting room and be calling for orders because they had no rooms or hall beds available. 911 to county with full arrest in 15 min then spend 40 min in the WR running the code waiting on a bed.....that's a zoo.

 

[old_boy]

didn't see hurley(flint michigan) on the list: http://education.hurleymc.com/gme/residencies-and-fellowships/affiliated/emergency-medicine
hard to get more county than LA/USC. and you also get mel hebert as faculty. doesn't get better than that.
when I was an LA county medic( 20 yrs ago) it was so zoolike there that we would routinely run codes from their waiting room and be calling for orders because they had no rooms or hall beds available. 911 to county with full arrest in 15 min then spend 40 min in the WR running the code waiting on a bed.....that's a zoo.

Things at LAC/USC have changed. They now have one of the (the?) biggest ED's in the country (no more codes in the waiting room) and actually have 24 hour attending coverage. ...still badass though.

 

[Venko]

George Washington only does a few months at a county place so I wouldn't classify this a a "county program"

Thanks for your thoughts.

Interesting, that I would suggest to put it in the +/- section...do you have any experience other than an interview at GW?

Since Quick, it is your opinion that is important, let me offer that Washington Hospital Center is not a county hospital but is considered a county style experience. The Emory system consists of more than Grady but also is considered a county style experience. GW system includes includes a county hospital (in fact the only real county hospital in the DC area) and having staffed it along side the GW residents, they certainly get the "county" experience.

Again, just my thoughts, clearly you have a different opinion; from what experience do you suggest that GW should not be considered to offer a county type experience?

 

[xaelia]

What is the perceived awesomeness of a "county-style" residency again? Just because a few county programs have outstanding faculty and reputations does not mean there's a causative association between county and excellent training. One of our two hospitals faculty cover is a county box - and there's nothing special about requiring a translator for every patient, sitting on boarders for >24 hours, and having 60+ in the waiting room for 40-odd hours. It's probably harder for me to generate an applicable resident training experience/opportunity there than at the university shop. It's a unique and challenging change of pace, but it's only part of the equation.

 

[docB]

What is the perceived awesomeness of a "county-style" residency again? Just because a few county programs have outstanding faculty and reputations does not mean there's a causative association between county and excellent training. One of our two hospitals faculty cover is a county box - and there's nothing special about requiring a translator for every patient, sitting on boarders for >24 hours, and having 60+ in the waiting room for 40-odd hours. It's probably harder for me to generate an applicable resident training experience/opportunity there than at the university shop. It's a unique and challenging change of pace, but it's only part of the equation.

I think it has to do with the pervasive med student belief that trauma is really cool. That and the fact that the the sheer wackiness of stuff you run into down town is exciting until you get your fill of it. The usual life cycle for EPs is to train in county settings, get pretty burnt out on it by the end of residency and then shuffle off to less county settings.

 

[Hamhock]

I think it has to do with the pervasive med student belief that trauma is really cool. That and the fact that the the sheer wackiness of stuff you run into down town is exciting until you get your fill of it. The usual life cycle for EPs is to train in county settings, get pretty burnt out on it by the end of residency and then shuffle off to less county settings.

I think it's more than just trauma.

County often means trauma, but it also often means poor...and with this comes increased autonomy in the ED (no PCP to call; no specialist to run proposed treatments by; often "weaker' other services; more of a sense of being on your own in the ED)...of course, with this also comes more primary care, social work, etc...

I think a lot of the places that EM developed/matured - some of the oldest programs - are county programs. Powerful Depts of EM in the ivory towers of medicine and 'posh' community hospitals are a relatively new thing and still rare.

HH

 

[Powdermonkey]

I think it has to do with the pervasive med student belief that trauma is really cool. That and the fact that the the sheer wackiness of stuff you run into down town is exciting until you get your fill of it. The usual life cycle for EPs is to train in county settings, get pretty burnt out on it by the end of residency and then shuffle off to less county settings.

Yes, trauma is cool, but its not everything. I'm more in to the wacky stuff, and I've not yet gotten my fill of it yet. Thats what I'm looking for in residency. I'm at a much more academic program this month and I find myself getting bored. The pace is just much slower. Not that its necessarily a bad thing, but I just don't like it. We are still busy I suppose, and I've gotten to see some amazing cases this month so far. I don't like the way the traumas are handled here. EM only gets airways, they don't switch with the trauma team and get to run the code because the trauma guys can't do airways. They tried that and stopped after a few weeks. I don't necessarily see myself at a level 1 trauma center constantly dealing with traumas on every shift after residency, but I'd still like to get my fill of it during residency and know how to properly run one.

I think it's more than just trauma.

County often means trauma, but it also often means poor...and with this comes increased autonomy in the ED (no PCP to call; no specialist to run proposed treatments by; often "weaker' other services; more of a sense of being on your own in the ED)...of course, with this also comes more primary care, social work, etc...

I think a lot of the places that EM developed/matured - some of the oldest programs - are county programs. Powerful Depts of EM in the ivory towers of medicine and 'posh' community hospitals are a relatively new thing and still rare.

HH

Exactly. I like the thought of autonomy in residency. I know there are other ways of learning, but I feel like this suits me better. I also have found that the type of resident at a county or community type residency is different than academic. It's the nature of the beast, and its just the type of students that want to work vs. wanting to stay in academics and research. I despise doing research. I would rather work my shifts and then go play. Outside the hospital.

 

[Venko]

Yes, trauma is cool, but its not everything. I'm more in to the wacky stuff, and I've not yet gotten my fill of it yet. Thats what I'm looking for in residency. I'm at a much more academic program this month and I find myself getting bored. The pace is just much slower. Not that its necessarily a bad thing, but I just don't like it. We are still busy I suppose, and I've gotten to see some amazing cases this month so far. I don't like the way the traumas are handled here. EM only gets airways, they don't switch with the trauma team and get to run the code because the trauma guys can't do airways. They tried that and stopped after a few weeks. I don't necessarily see myself at a level 1 trauma center constantly dealing with traumas on every shift after residency, but I'd still like to get my fill of it during residency and know how to properly run one.



Exactly. I like the thought of autonomy in residency. I know there are other ways of learning, but I feel like this suits me better. I also have found that the type of resident at a county or community type residency is different than academic. It's the nature of the beast, and its just the type of students that want to work vs. wanting to stay in academics and research. I despise doing research. I would rather work my shifts and then go play. Outside the hospital.

What specifically do you think you get to do in the county program that you wont other places? What autonomous action do you think your staff will restrict you from doing elsewhere? I guess I never understood this...

In fact, I found I made fewer MD level decisions in the county settings I have worked because of fewer resources, usually a single problem with a textbook management, I spend so much time fighting for things that are routine elsewhere....some county programs you'll be wheeling the patients to their tests....that isnt necessarily the "autonomy" I would want, so I presume there is something else that students anticipate getting to experience or do when they push for "county" programs.

 

[erin682]

What you're describing doesn't happen just in county type programs. I trained at a hospital in an inner-city, that was also a major academic center. I was always overwhelmingly busy seeing every imaginable type of pathology, but I never once rolled a patient to CT and had great support from ancillary staff and a great physical plant. I spent my time learning how to be an er doc, not a tech. Autonomy is great, but you also need to be taught in residency and should be a gradual process. I had plenty of autonomy as a senior with the opportunity for more moonlighting. Also, just because a program is affiliated with a major research center doesn't mean the em residency is as well. I had the opportunity to do any research project I wanted, but I hate research and got away with a basic project that didn't involve a ton of time.



[/QUOTE]Exactly. I like the thought of autonomy in residency. I know there are other ways of learning, but I feel like this suits me better. I also have found that the type of resident at a county or community type residency is different than academic. It's the nature of the beast, and its just the type of students that want to work vs. wanting to stay in academics and research. I despise doing research. I would rather work my shifts and then go play. Outside the hospital.[/QUOTE]

 

[tkim]

Things at LAC/USC have changed. They now have one of the (the?) biggest ED's in the country (no more codes in the waiting room) and actually have 24 hour attending coverage. ...still badass though.

No more C-booth.

 

[TysonCook]

...at least from my experience...

County is good for trauma, but not great for the private world. Some have a mixed shop (county that also covers the well insured), it seems to help in that you get used to working with private attending from all specialties, get the K+G club, and the high rollers who come in with their own private MD meeting them there.

In private you don't see too much trauma, but you do see a lot of bread/butter with usually NO sub specialists "in house", as opposed to county/residency/big programs where you have a vascular fellow/cath lab/optho all in house.

Learning to manage those types of patients and knowing what to do WITHOUT a sub-specialist immediately on call is a good thing to have coming out of residency.

Clinically as well as "ancillary support" is vastly different between the two. In retrospect (med school at Cincy, residency at Carolinas, split work 30hr/mo private group, and 130hr/mo with Carolinas) I don't see much appeal in a pure "county" setting.

 

[Cerberus]

What specifically do you think you get to do in the county program that you wont other places? What autonomous action do you think your staff will restrict you from doing elsewhere? I guess I never understood this...

In fact, I found I made fewer MD level decisions in the county settings I have worked because of fewer resources, usually a single problem with a textbook management, I spend so much time fighting for things that are routine elsewhere....some county programs you'll be wheeling the patients to their tests....that isnt necessarily the "autonomy" I would want, so I presume there is something else that students anticipate getting to experience or do when they push for "county" programs.

This is an excellent point. Your resources really affect what treatments are actually feasible in the ED. Got a bad beta blocker overdose and want to use hyperinsulinemic euglycemia therapy? Well, I hope you only have one patient so you can be drawing those frequent blood gases and doing fingersticks.
In my ED you can really rely on the nurses to be on their A-game, drawing labs, monitoring drips etc. I can see a hell of a lot more patients in a shift than I could a lot of other places because I have nurses and ancillary services I know I can count (usually) on.

 

[quicknss]

Thanks for your thoughts.

Interesting, that I would suggest to put it in the +/- section...do you have any experience other than an interview at GW?

Since Quick, it is your opinion that is important, let me offer that Washington Hospital Center is not a county hospital but is considered a county style experience. The Emory system consists of more than Grady but also is considered a county style experience. GW system includes includes a county hospital (in fact the only real county hospital in the DC area) and having staffed it along side the GW residents, they certainly get the "county" experience.

Again, just my thoughts, clearly you have a different opinion; from what experience do you suggest that GW should not be considered to offer a county type experience?

People that want county want high intensity, craziness, and often intense trauma. All the bread and butter stuff is available anywhere. GW is mainly an ivory tower academic program. You do work a few months as a first year at Prince George which is a county hospital but the ED residents do not participate in any of the Trauma. Trauma is run by a private surgery group. So what you get is a lot of drug seekers and alcohols with some bizarre pathology but at a more relaxed pace because there is not trauma. I believe only 3-4 months of the entire 4 years is at prince george. Soo....if you like county you will wish you went somewhere else.

 

[Venko]

People that want county want high intensity, craziness, and often intense trauma. All the bread and butter stuff is available anywhere. GW is mainly an ivory tower academic program. You do work a few months as a first year at Prince George which is a county hospital but the ED residents do not participate in any of the Trauma. Trauma is run by a private surgery group. So what you get is a lot of drug seekers and alcohols with some bizarre pathology but at a more relaxed pace because there is not trauma. I believe only 3-4 months of the entire 4 years is at prince george. Soo....if you like county you will wish you went somewhere else.

Quickness, again thank you for your thoughts. There are residents of all years staffing PG, its roughly two months per year is my understanding and so 8 months total. If "drug seekers" and alcohol related emergencies are not county staples, I am clearly out of touch with what it means to be "county".

As for GW being the "ivory tower" I'm not sure you have seen it....I currently work in the ivory tower of medicine, and GW is far from it. The attendings at GW literally staff an average of 60 pts per shift and the residents are responsible for the bulk of them. There are patients in hallway beds throughout and the physician staff are pushed to the limits at GW to see them (oh by the way it is a trauma center too)...I dont work there now, and I will say my current job is as perfect a setting to practice as I have seen...GW is not an ivory tower (this is actually quite funny)

As for trauma....tube, needle/Chest tube, line, blood, T-pod, FAST....your training is over as far as EM goes. If you decide you are going to take out the spleen or explore the chest in the OR things get more interesting....please forgive the condescending tone this will come off as but you will find as you finish more than July of your intern year that trauma is easily one of the least important things to evaluate an EM residency by.

In any case, thanks for your opinion of GW, whether it is on the list or not is only to help medical students and does nothing for either of our careers. Whenever you have time, if you want to see what a true "ivory tower" academic program looks like, let me know....

 

[MSmentor018]

you will find as you finish more than July of your intern year that trauma is easily one of the least important things to evaluate an EM residency by.

yep trauma's a very small and automated part. once that trauma alert goes off and the surgeons arrive....it's cookbook medicine

 

[Calahin]

Have to agree that GW is not really "county" having rotated at GW as a student. Currently in residency in NYC at one of the county shops on your list. The main GW hospital is amazingly well equipped, nice ancillary services, a good computer tracking system. All those great things that we lack at our county shop.

Yes the residents do rotate through a little hospital in Maryland that's pretty poor but that's only a few blocks out of the whole curriculum and it doesn't nearly have the volume as some of the big programs. To be a county program it means you gotta have it 24/7 and you live and breathe it.

Just to give you perspective as a student I also rotated at Cook County (my home institution). GW and Cook were worlds apart. At my current shop it's almost always a zoo and crap hits the fan all the time in some way or another.

 

[Venko]

Have to agree that GW is not really "county" having rotated at GW as a student. Currently in residency in NYC at one of the county shops on your list. The main GW hospital is amazingly well equipped, nice ancillary services, a good computer tracking system. All those great things that we lack at our county shop.

Yes the residents do rotate through a little hospital in Maryland that's pretty poor but that's only a few blocks out of the whole curriculum and it doesn't nearly have the volume as some of the big programs. To be a county program it means you gotta have it 24/7 and you live and breathe it.

Just to give you perspective as a student I also rotated at Cook County (my home institution). GW and Cook were worlds apart. At my current shop it's almost always a zoo and crap hits the fan all the time in some way or another.

No problem. I agree cook and GW are not the same at all. If people feel strongly that GW is not to be included on the +/- list, no problem, take it off. I dont think its the weakest member, but I am biased as I have been an attending there. I also have brief periods of experience with Shands and Cook to compare it to, but am not an expert in categorizing departments. Its possible I am way off and GW is truly an academic powerhouse. Its just not my impression of the system....

 

[quicknss]

I'm sure trauma is overrated but as a resident of emergency medicine I would much rather go to a place with a lot of trauma, since they are common cause of emergencies, so I get good with repetition and am around attending that live and breath trauma rather than only have a few months a year or learn a lot through simulation.

You will have the required RRC approved experiences wherever you go but not all residencies are created equal.

 

[deleted109597]

You get enough trauma everywhere you go.
I would rather go somewhere without a lot of trauma as I don't want to live or work somewhere I'm likely to get shot or assaulted walking to the parking lot.

Not all residencies are equal, but just because you can handle trauma doesn't mean you can handle everything. There is no thought process to ATLS, it is completely algorithm driven.

 

[docB]

Have to agree that GW is not really "county" having rotated at GW as a student. Currently in residency in NYC at one of the county shops on your list. The main GW hospital is amazingly well equipped, nice ancillary services, a good computer tracking system. All those great things that we lack at our county shop.

This raises and interesting question. What makes a county shop a county shop?

Calahin is defining a county shop by the lack of services, equipment, etc. Others might define county by the population or the pathology. For others it might be geography. For administrators it's all about financial structure (i.e. only a publicly funded hospital is county).

 

[Hamhock]

. There is no thought process to ATLS, it is completely algorithm driven.

I completely agree that most critical medical is more difficult and more cerebral than 'most' trauma.

...but trauma is not as cookbook as people on this board imply. I propose (ready to be attacked) that is mostly folks trained in places that are not 'county' who believe trauma is just ATLS.

First, ATLS is not the way to handle trauma. You don't follow ACLS/AHA guidelines for medical codes, do you?

Remember, ATLS used to cric at the drop of a hat..say there should be no RSI!...be surgeon +/- anesthesiology only...

No RSI or cutting the neck of c-collared patient with possible fractures may seem crazy now, but I bet some of the older docs remember this. And there are certainly things in ATLS (although not as glaringly wrong as in ACLS/AHA publications) currently that we will soon consider nuts.

ATLS is written for a "general" population to follow.

As EM-trained docs, we should be well beyond ATLS in trauma. I would argue that trauma is more difficult that people propose because it is not just ETT, chest tube, hand off to the surgeons for OR or admission.

It is these obvious interventions, but it is also coagulopathy/bleeding management (acidosis, temperature control), hemodynamic monitoring and stabilization ("permissive" hypotension vs. IVF or colloid SBP>120; appropriate pain control and sedation), transfusion (1:1:1 vs. PCC and pRBC in coumadin-toxic patients vs. factor 7), etc...

This is trauma and it is not cookbook...and it is not in ATLS...and you will not get that experience "wherever you go" for EM residency.

And, this is the kind of trauma experience I think all EM residents should be searching for...not for a place that you alternate "airway" (kills me!) and "running the trauma"...that mentality is not consistent with the EM mentality and is not really a trauma experience.

I think it is minimizing our specialty whenever we say trauma is not important and is easy. Trauma defines EM in many ways...we are the specialists in emergent care who cover surgery, anesthesiology (EM docs are the anesthesiologists in early trauma care and I don't mean airway only), medicine, and some radiology in trauma.

HUMBLY opinionated,

HH

 

[quicknss]

I completely agree that most critical medical is more difficult and more cerebral than 'most' trauma.

...but trauma is not as cookbook as people on this board imply. I propose (ready to be attacked) that is mostly folks trained in places that are not 'county' who believe trauma is just ATLS.

First, ATLS is not the way to handle trauma. You don't follow ACLS/AHA guidelines for medical codes, do you?

Remember, ATLS used to cric at the drop of a hat..say there should be no RSI!...be surgeon +/- anesthesiology only...

No RSI or cutting the neck of c-collared patient with possible fractures may seem crazy now, but I bet some of the older docs remember this. And there are certainly things in ATLS (although not as glaringly wrong as in ACLS/AHA publications) currently that we will soon consider nuts.

ATLS is written for a "general" population to follow.

As EM-trained docs, we should be well beyond ATLS in trauma. I would argue that trauma is more difficult that people propose because it is not just ETT, chest tube, hand off to the surgeons for OR or admission.

It is these obvious interventions, but it is also coagulopathy/bleeding management (acidosis, temperature control), hemodynamic monitoring and stabilization ("permissive" hypotension vs. IVF or colloid SBP>120; appropriate pain control and sedation), transfusion (1:1:1 vs. PCC and pRBC in coumadin-toxic patients vs. factor 7), etc...

This is trauma and it is not cookbook...and it is not in ATLS...and you will not get that experience "wherever you go" for EM residency.

And, this is the kind of trauma experience I think all EM residents should be searching for...not for a place that you alternate "airway" (kills me!) and "running the trauma"...that mentality is not consistent with the EM mentality and is not really a trauma experience.

I think it is minimizing our specialty whenever we say trauma is not important and is easy. Trauma defines EM in many ways...we are the specialists in emergent care who cover surgery, anesthesiology (EM docs are the anesthesiologists in early trauma care and I don't mean airway only), medicine, and some radiology in trauma.

HUMBLY opinionated,

HH

Right on brother! EM is about sick critical patients. These are trauma a pre-ICU admissions and a county shop is a place that is full of tons of sick patients, who just so happen to be poor.

 

[SepulvedaMD]

I completely agree that most critical medical is more difficult and more cerebral than 'most' trauma.

...but trauma is not as cookbook as people on this board imply. I propose (ready to be attacked) that is mostly folks trained in places that are not 'county' who believe trauma is just ATLS.

First, ATLS is not the way to handle trauma. You don't follow ACLS/AHA guidelines for medical codes, do you?

Remember, ATLS used to cric at the drop of a hat..say there should be no RSI!...be surgeon +/- anesthesiology only...

No RSI or cutting the neck of c-collared patient with possible fractures may seem crazy now, but I bet some of the older docs remember this. And there are certainly things in ATLS (although not as glaringly wrong as in ACLS/AHA publications) currently that we will soon consider nuts.

ATLS is written for a "general" population to follow.

As EM-trained docs, we should be well beyond ATLS in trauma. I would argue that trauma is more difficult that people propose because it is not just ETT, chest tube, hand off to the surgeons for OR or admission.

It is these obvious interventions, but it is also coagulopathy/bleeding management (acidosis, temperature control), hemodynamic monitoring and stabilization ("permissive" hypotension vs. IVF or colloid SBP>120; appropriate pain control and sedation), transfusion (1:1:1 vs. PCC and pRBC in coumadin-toxic patients vs. factor 7), etc...

This is trauma and it is not cookbook...and it is not in ATLS...and you will not get that experience "wherever you go" for EM residency.

And, this is the kind of trauma experience I think all EM residents should be searching for...not for a place that you alternate "airway" (kills me!) and "running the trauma"...that mentality is not consistent with the EM mentality and is not really a trauma experience.

I think it is minimizing our specialty whenever we say trauma is not important and is easy. Trauma defines EM in many ways...we are the specialists in emergent care who cover surgery, anesthesiology (EM docs are the anesthesiologists in early trauma care and I don't mean airway only), medicine, and some radiology in trauma.

HUMBLY opinionated,

HH

Amen

 

[Cerberus]

This argument almost always plays out the same. EM residents and attendings say trauma is largely overrated and not as exciting as one thinks when they are a med student - med students argue "nuh uh!". Not to minimize the importance of trauma to our specialty, as Hamhock points out, trauma is more than just ATLS. However, I think people focusing on trauma as their criteria of what makes a good residency experience experience are just wrong. While trauma is not strictly protocol, it does not have as much nuance as a sick medical patient. With trauma, you are usually given a known quantity (i.e. 57yo M s/p MVC rollover, GCS of 7, intubated in field with decreased BS on left), with the critically ill medical patient it is often far less straight forward and tends to require a lot more detective work. An example is a nursing home pt I had recently who came in with "altered mental status" and little else for history aside from pmhx and med list. She was slightly febrile (100.6 rectally) in the ED and had a LLL infiltrate vs atelectasis on CXR. She also had a BGM of 500 (w/o anion gap), a lactate of 6, and was brady into the 30s/40s. Due to the bradycardia and her medlist I sent off a digoxin which came back at an astronomically high level. After digibind she improved significantly and after a few days in the ICU she was discharged back home in her baseline gomerific state. Did I alter the course of mankind by bringing back a gomer from the brink? Probably not. Was it a more interesting case than a "25 yo M s/p assault", definitely.

 

[Venko]

I completely agree that most critical medical is more difficult and more cerebral than 'most' trauma.

...but trauma is not as cookbook as people on this board imply. I propose (ready to be attacked) that is mostly folks trained in places that are not 'county' who believe trauma is just ATLS.

First, ATLS is not the way to handle trauma. You don't follow ACLS/AHA guidelines for medical codes, do you?

Remember, ATLS used to cric at the drop of a hat..say there should be no RSI!...be surgeon +/- anesthesiology only...

No RSI or cutting the neck of c-collared patient with possible fractures may seem crazy now, but I bet some of the older docs remember this. And there are certainly things in ATLS (although not as glaringly wrong as in ACLS/AHA publications) currently that we will soon consider nuts.

ATLS is written for a "general" population to follow.

As EM-trained docs, we should be well beyond ATLS in trauma. I would argue that trauma is more difficult that people propose because it is not just ETT, chest tube, hand off to the surgeons for OR or admission.

It is these obvious interventions, but it is also coagulopathy/bleeding management (acidosis, temperature control), hemodynamic monitoring and stabilization ("permissive" hypotension vs. IVF or colloid SBP>120; appropriate pain control and sedation), transfusion (1:1:1 vs. PCC and pRBC in coumadin-toxic patients vs. factor 7), etc...

This is trauma and it is not cookbook...and it is not in ATLS...and you will not get that experience "wherever you go" for EM residency.

And, this is the kind of trauma experience I think all EM residents should be searching for...not for a place that you alternate "airway" (kills me!) and "running the trauma"...that mentality is not consistent with the EM mentality and is not really a trauma experience.

I think it is minimizing our specialty whenever we say trauma is not important and is easy. Trauma defines EM in many ways...we are the specialists in emergent care who cover surgery, anesthesiology (EM docs are the anesthesiologists in early trauma care and I don't mean airway only), medicine, and some radiology in trauma.

HUMBLY opinionated,

HH

Certainly we are experts in emergent care of critically ill patients of all kinds. With that said, the emergent care doesnt necessarily mean that it is difficult care. In the case of trauma, everything you mentioned above falls into ATLS (i.e. replacing whole blood lost with 1:1:1 is now a standard part of circulation). Maybe people like me should be more detailed so as to not cause confusion...when I said ETT I meant also it is hooked to a Bag or ventilator, when I said line I also meant we would give blood through it, etc.

When it comes to medical decision making, the trauma care(including rewarming, giving blood, etc) is still very easy in the ED. It certainly is more difficult in the operating room.

Its funny, because your first line is the key HH as you agree that trauma is easier than medical which is the point that all the attendings are trying to convey. Medical students such as the one who decided to champion your comments, are tremendously fixated on trauma almost to the expense of medical patients. They believe that taking care of medically ill patients is something they will get everywhere in equal amounts...and I believe there is a much wider range of medically ill patients and wider range of evidence based practices in the country for this.

In the end, if there is an EM doc who is only average at medical or trauma and stellar at the other...chances are the hospital needs them to be stellar in medically critical patients. There is a team or a system in place to care for the trauma patient for that MD who is only average in trauma, but there is no abdominal pain team to come by and make sure that you did everything for them.

 

[Venko]

Right on brother! EM is about sick critical patients. These are trauma a pre-ICU admissions and a county shop is a place that is full of tons of sick patients, who just so happen to be poor.

BTW, most county places I have been to the patient is sick with DKA and very little else, or COPD exacerbation and little else...occasionally the patient has some hx of drug abuse, sickle cell, asthma, etc....but thats actually not that sick compared to some other shops....

how about this:

55 yo W 6 wks s/p hemipelvectomy for cancer undergoing chemotherapy and whose post op course is complicated by intraabdominal abscess, PMHx includes liver mets, CKD, CAD with 2 prior stents, who comes in with increasing abdominal pain over the past four days, mild fever, and sweats. She was hypotensive, and tachypneic. Lactate of 6. Potassium 6.5. She gets dx with complete IVC thrombus with extension into the iliacs bilaterally.

I dont present the case to you Quicknss because I want a back and forth about who has the most ill patients, but rather to offer that county doesnt necessarily mean sick. DKA is a management guideline that is rather easy to follow when you have done it for some time, but imagine that it is in the setting of multiple other complicating factors....

I am sure there are county hospitals out there that have patients who are intricate like the one I described, but it is not in my experience. My experience is that more of the non-county hospitals would have these types of patients frequenting their EDs....but I could be wrong.

DISCLAIMER: The case I gave is not an actual patient case because of privacy rules, but is an equivalent to the type of sick patients I have seen at least twice per shift.

 

[WilcoWorld]

This argument almost always plays out the same. EM residents and attendings say trauma is largely overrated and not as exciting as one thinks when they are a med student - med students argue "nuh uh!". Not to minimize the importance of trauma to our specialty, as Hamhock points out, trauma is more than just ATLS. However, I think people focusing on trauma as their criteria of what makes a good residency experience experience are just wrong. While trauma is not strictly protocol, it does not have as much nuance as a sick medical patient. With trauma, you are usually given a known quantity (i.e. 57yo M s/p MVC rollover, GCS of 7, intubated in field with decreased BS on left), with the critically ill medical patient it is often far less straight forward and tends to require a lot more detective work. An example is a nursing home pt I had recently who came in with "altered mental status" and little else for history aside from pmhx and med list. She was slightly febrile (100.6 rectally) in the ED and had a LLL infiltrate vs atelectasis on CXR. She also had a BGM of 500 (w/o anion gap), a lactate of 6, and was brady into the 30s/40s. Due to the bradycardia and her medlist I sent off a digoxin which came back at an astronomically high level. After digibind she improved significantly and after a few days in the ICU she was discharged back home in her baseline gomerific state. Did I alter the course of mankind by bringing back a gomer from the brink? Probably not. Was it a more interesting case than a "25 yo M s/p assault", definitely.

Alternatively:

57 yo m s/p rollover MVC with a GCS of 8 or 9 (depending on how you score the verbal) who has poor inspiratory effort (so while there seems to be diminished BS on the L you're not entirely sure) & tachycardia but is normotensive and moving all 4 extremities in response to noxious stimuli. Odds are he's just drunk, but he could have a massive subdural and a splenic lac. You have no Trauma ICU beds, so if you tube him for a work up, you very likely will have a ventilated drunk in your ED all night and he will go into withdrawal before you're able to extubate and you'll be down a nurse all night.

vs.

A nursing home resident with a chief complaint of "fever" who can't give a history, so all you have to do is review a med list, check applicable drug levels (salicylate, digoxin, valproate, etc), order a CXR, perform a particularly easy intubation and follow it with a CVL on someone with easily identifiable landmarks, start the standard antibiotics, follow up on said labs, and admit to the MICU.

Now which one sounds like the more difficult patient?

I'm not saying that the answer is clearly that trauma is harder than medical - I'm saying that it's absolutely not clear.

 

[Hamhock]

Alternatively:

57 yo m s/p rollover MVC with a GCS of 8 or 9 (depending on how you score the verbal) who has poor inspiratory effort (so while there seems to be diminished BS on the L you're not entirely sure) & tachycardia but is normotensive and moving all 4 extremities in response to noxious stimuli. Odds are he's just drunk, but he could have a massive subdural and a splenic lac. You have no Trauma ICU beds, so if you tube him for a work up, you very likely will have a ventilated drunk in your ED all night and he will go into withdrawal before you're able to extubate and you'll be down a nurse all night.

vs.

A nursing home resident with a chief complaint of "fever" who can't give a history, so all you have to do is review a med list, check applicable drug levels (salicylate, digoxin, valproate, etc), order a CXR, perform a particularly easy intubation and follow it with a CVL on someone with easily identifiable landmarks, start the standard antibiotics, follow up on said labs, and admit to the MICU.

Now which one sounds like the more difficult patient?

I'm not saying that the answer is clearly that trauma is harder than medical - I'm saying that it's absolutely not clear.

Agreed. 👍

Furthermore, I am not sure the work-up of the soon-to-be-dead-no-matter-what-is-done patient described by Thyme is all that complicated. (of course a few other acute issues might make it so; add myxedema or thyroid storm; add Afib RVR; add UGIB; etc)

I would argue most GOMER sepsis is more straightforward than a lot of trauma....it's just that in many centers, the eval, diagnosis, and intial therapy is left up to the ED alone while trauma in many of these same centers, the initial eval involves EM in consult with trauma (at best) and the diagnosis and initial therapy is mostly trauma surgery determined.

PLEASE NOTE: (1) I still stand by the belief that most critical medical is more complicated and cerebral than most trauma. (2) I do not think med students should pick a residency based on trauma alone or even in the top 3 reasons; INDEED, I don't think my first post here even belongs in this thread, as I was not making any points about picking a residency or county vs. community. Instead, I just happened to be reading this thread when I reached my boiling point regarding the continuous mis-representation of the importance of trauma for our specialty and the continuous minimization of trauma's complexity by folks who - it seems - do not manage major trauma for more than the first 30-60 minutes.

One last point, this time regarding picking a residency: Choose based on what kind of EM you want to practice when you are finished. If you are going to be hard-core research, pick a place that will support that. If you are going to be an urban, county doc, train at county. If you are going to be a small community doc pick a community program (or - IN MY OPINION ONLY - hard core county - as a lot of those community docs are left all on their own with little support and have to be able to do everything, like EM docs at county do).

When in doubt, try to see it all and do it all...where that best experience is, no one knows.

HH

 

[Hamhock]

Alternatively:

57 yo m s/p rollover MVC with a GCS of 8 or 9 (depending on how you score the verbal) who has poor inspiratory effort (so while there seems to be diminished BS on the L you're not entirely sure) & tachycardia but is normotensive and moving all 4 extremities in response to noxious stimuli. Odds are he's just drunk, but he could have a massive subdural and a splenic lac. You have no Trauma ICU beds, so if you tube him for a work up, you very likely will have a ventilated drunk in your ED all night and he will go into withdrawal before you're able to extubate and you'll be down a nurse all night.

I'm not saying that the answer is clearly that trauma is harder than medical - I'm saying that it's absolutely not clear.

I would add to this case that Wilco gave: Pradaxa and an open pelvis...60 minutes until angio is ready (not sure angio is the best place for this patient anyway)...hypotension.

Quote from Wilco: "I'm not saying that the answer is clearly that trauma is harder than medical - I'm saying it's absolutely not clear."

👍👍

I guess I am saying that too but I can't seem to do it so succinctly. Damn.

HH

 

[xaelia]

I got pushback at County from admin last night regarding my proposed admission of a nice young lady who had recurrent RLE DVT and bilateral subsegmental PE while already anticoagulated (INR 3.3) for her prior DVT.

Huh.

 

[gro2001]

I think trauma and 'major med' are both important (not going to get into the argument of which one is more important), but I think deficiencies in trauma are easier to make up than deficiencies in major med. If towards the end of your residency you feel like you are not as comfortable with trauma as you'd like, you can spend a month or two of elective time doing trauma surg or trauma anesthesia at a place like Shock Trauma and become supremely comfortable with trauma. Deficiencies in thinking through and managing medically SICK SICK folks are not going to be fixed with an elective or two.

 

[MSmentor018]

Deficiencies in thinking through and managing medically SICK SICK folks are not going to be fixed with an elective or two.

very true, the "M" in EM is "medicine"

 

[Hamhock]

the "M" in EM is "medicine"

really?

I hope you are joking with this...maybe I am in too serious of a mood, but...

HH