Difference between EMS and Emergency medicine and Critical Care?

[MoGhazidoc1990]

Hi there,

I am an final year med student and have a great interest in going into emergency medicine most particularly on the trauma side of things.

I have a few questions however about some fellowship programs pertaining to ER medicine.

What exactly is an EMS fellowship or the EMS career? By what I have read I haven't really got a solid idea, it seems to be more of an administrative position. Can you have a career in field work and what kind of field work will you be doing and what kind of things can you do in Pre hospital care?

Also I found this on the Shock trauma center websitehttp://umm.edu/programs/shock-trauma/professionals/original-division-of-critical-care-and-trauma-education/education/emergency-medicine-and-critical-care-fellowship

Now a member of this site in a post that I had said this would not turn you into a surgeon but allow you to handle or manage surgical trauma patients. My question here is can this also lead to a career in prehospital care or is it more based in an established OR or ER?

Now most people on this site know that I want to also have a medical career in the military and also have an interest in prehospital care. Out of these two fellowships what would suit me more for Battlefield medicine if I wanted to be trained in, how to receive a trauma patient, how to resuscitate that patient and stabilize him/her and how to treat wounds and trauma to the point where I could stabilize enough to send him to the next higher level of care, all while have very spartan like or in other words only the minimalist equipment, like at a small FOB or COP? Again trauma being my main focus in EM

Thanks
Mo

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[deleted547339]

Hi there,

I am an final year med student and have a great interest in going into emergency medicine most particularly on the trauma side of things.

I have a few questions however about some fellowship programs pertaining to ER medicine.

What exactly is an EMS fellowship or the EMS career? By what I have read I haven't really got a solid idea, it seems to be more of an administrative position. Can you have a career in field work and what kind of field work will you be doing and what kind of things can you do in Pre hospital care?

Also I found this on the Shock trauma center websitehttp://umm.edu/programs/shock-trauma/professionals/original-division-of-critical-care-and-trauma-education/education/emergency-medicine-and-critical-care-fellowship

Now a member of this site in a post that I had said this would not turn you into a surgeon but allow you to handle or manage surgical trauma patients. My question here is can this also lead to a career in prehospital care or is it more based in an established OR or ER?

Now most people on this site know that I want to also have a medical career in the military and also have an interest in prehospital care. Out of these two fellowships what would suit me more for Battlefield medicine if I wanted to be trained in, how to receive a trauma patient, how to resuscitate that patient and stabilize him/her and how to treat wounds and trauma to the point where I could stabilize enough to send him to the next higher level of care, all while have very spartan like or in other words only the minimalist equipment, like at a small FOB or COP? Again trauma being my main focus in EM

Thanks
Mo

You need to sit down with a good mentor.

First of all, trauma gets pretty old, quick. Most med students love it, residents become apathetic, then attendings hate it. Truth be told, it sounds like you want to be a good ER doc at a shop with a lot of trauma, but that will likely change. Trauma patients always have sticky social situations, take up a lot of time, have overwhelmingly unimpressive workups, are usually drunk/high, etc. It's great for TV, bad for being a professional with a family.

As far as EMS goes - I can't entirely speak to it because I haven't done the fellowship, but I did residency at program that had one. The people who do these fellowships tend to be people who were EMTs/paramedics in a prior life. It is almost entirely administrative and educational. You provide medical direction for EMS agencies, helping establish protocols and educating for medics. You also do a lot of education for EMTs/paramedics. It is necessary only if you want to run a big EMS system or work in academics. If you want to live in a smallish town and run the EMS group, you just need to be a good EM physician with an interest. These jobs pay less than if you were just working in the ED, so people aren't really fighting over it. Also, this stuff seems to get old (to me). As a physician, you will be spending very little time in the field outside of true catastrophes.

As far as critical care goes, it's entirely different from EMS and EM. I'm doing a CCM fellowship right now. It teaches you to be an attending in an ICU, be it a medical, surgical, trauma, cardiothoracic, whatever (except neuro, that's it's on deal - kind of) and has almost nothing to do with EMS. Here's the difference between "doing trauma" and being an intensivist, at most big hospitals, there is a surgical service following a patient and an intensivist (read: ICU doctor) following the patient. Sometimes, the surgeon will be the admitting physician, sometimes the intensivist. A lot of this has to do with hospital politics, and even the name on paper or a "closed ICU" doesn't always mean what it sounds like. It's all about hospital culture. There are even times where you'll have a surgeon who is the intensivist but not the surgeon of record, but then also a consulting (or primary) surgeon who is managing his surgical issues. As an example, you can have a trauma patient brought in for a gunshot wound to the chest. He gets transported by EMS who hands them off to the trauma team (usually ER doc, trauma surgeon +/- anesthesiologist). They acutely manage the patient's emergent issues with or without a trip to the OR with the trauma surgeon. The patient is subsequently admitted to the ICU. The intensivist manages the patients fluid status, ventilator, antibiotics, feeding, electrolytes, etc. The surgeon manages the chest tube, surgical wound etc. Who gets the final say on areas of debate it again a matter of institutional culture.

If you want to manage trauma patients exclusively, you'd probably be better served doing a gen surg residency followed by a trauma and critical care fellowship. That would allow you to go to the OR and be an attending in the ICU. But trauma gets very old. And truth be told, EM is often overshadowed by the trauma service at a lot of big trauma centers. It's an all around odd arrangement. It sounds like you want to work at a busy level 2 trauma center with little surgical involvement.

Regardless, look at the people who are 10-20 years ahead of you in their career and see if that's what you want your career and life to look like. If that is running an EMS agency while working 10 shifts a month in the ED, do EMS. If you want to be the one taking care of all the trauma patients and operating, be a trauma surgeon. If you want to think about your sick patients and round, do CCM. If you're smart, then do derm or ophtho or something else entirely.

 

[MoGhazidoc1990]

Thanks for the input I appreciate it

 

[TheComebacKid]

Doing an EMS fellowship essentially prepares you to become an EMS medical director. The above poster gave a good description of what the EMS medical director does.

What I'd like to add is that several EMS agencies have a physician response vehicle where you, as the EMS medical director, can respond to calls. You can also do ride alongs with the medics. But by and large, this is probably more of the exception than the norm. At this time, there is no definitive role for the physician in the field with regards to pre-hospital care in the United States. Certain places, for instance, AirCare (helicopter EMS service out of University of Cincinnati) has a physician/nurse staffing model on every flight. There are a few set ups like this around the country, but again, not the norm. Overseas (i.e. Europe, Australia) routinely have physicians respond in the field.

While pre-hospital care plays a vital role in the management of trauma patients, EMS brings anyone and everyone to an emergency department. That includes the renal failure patient who syncopized in dialysis clinic, the drunk passed out at the bar, and the schizophrenic patient found wandering the streets off his/her medications.

Given your interest in military medicine, you may want to consider tactical EMS. This is where you learn about providing care to law enforcement in the field (i.e. SWAT team during a raid). This is a new specialty and honestly I'm not sure regarding it's future (Google John's Hopkins tactical EMS fellowship, I believe it's currently the only fellowship program in the country).

The Shock Trauma fellowship in Baltimore will prepare you for the life of an ED intensivist (i.e. critical care physician). Most of these fellowship trained docs will work in a surgical/trauma ICU (in addition to others). You will likely get the patient AFTER the ED doc, trauma surgeon etc have resuscitated and stabilized the patient. These patients can still be very sick and require very complex care in the monitored setting of the ICU.

If you want my personal opinion, you don't need an EMS fellowship to provide emergency care in a combat setting. Do an EMS fellowship if you like working with politicians, government officials, fire departments, medics/EMTs to create a well functioning EMS system that meets the needs of your community.

A critical care fellowship is definitely not needed to provide care in the field. In fact, I would argue, that most residency trained emergency physicians (not fellowship trained) could provide combat casualty care. What I mean by that is that most of emergency medicine will prepare you for routine medical care of these patients. Preparing for the emotional and physical stressors of being in combat is a whole different issue.

 

[MoGhazidoc1990]

Doing an EMS fellowship essentially prepares you to become an EMS medical director. The above poster gave a good description of what the EMS medical director does.

What I'd like to add is that several EMS agencies have a physician response vehicle where you, as the EMS medical director, can respond to calls. You can also do ride alongs with the medics. But by and large, this is probably more of the exception than the norm. At this time, there is no definitive role for the physician in the field with regards to pre-hospital care in the United States. Certain places, for instance, AirCare (helicopter EMS service out of University of Cincinnati) has a physician/nurse staffing model on every flight. There are a few set ups like this around the country, but again, not the norm. Overseas (i.e. Europe, Australia) routinely have physicians respond in the field.

While pre-hospital care plays a vital role in the management of trauma patients, EMS brings anyone and everyone to an emergency department. That includes the renal failure patient who syncopized in dialysis clinic, the drunk passed out at the bar, and the schizophrenic patient found wandering the streets off his/her medications.

Given your interest in military medicine, you may want to consider tactical EMS. This is where you learn about providing care to law enforcement in the field (i.e. SWAT team during a raid). This is a new specialty and honestly I'm not sure regarding it's future (Google John's Hopkins tactical EMS fellowship, I believe it's currently the only fellowship program in the country).

The Shock Trauma fellowship in Baltimore will prepare you for the life of an ED intensivist (i.e. critical care physician). Most of these fellowship trained docs will work in a surgical/trauma ICU (in addition to others). You will likely get the patient AFTER the ED doc, trauma surgeon etc have resuscitated and stabilized the patient. These patients can still be very sick and require very complex care in the monitored setting of the ICU.

If you want my personal opinion, you don't need an EMS fellowship to provide emergency care in a combat setting. Do an EMS fellowship if you like working with politicians, government officials, fire departments, medics/EMTs to create a well functioning EMS system that meets the needs of your community.

A critical care fellowship is definitely not needed to provide care in the field. In fact, I would argue, that most residency trained emergency physicians (not fellowship trained) could provide combat casualty care. What I mean by that is that most of emergency medicine will prepare you for routine medical care of these patients. Preparing for the emotional and physical stressors of being in combat is a whole different issue.

Doing an EMS fellowship essentially prepares you to become an EMS medical director. The above poster gave a good description of what the EMS medical director does.

What I'd like to add is that several EMS agencies have a physician response vehicle where you, as the EMS medical director, can respond to calls. You can also do ride alongs with the medics. But by and large, this is probably more of the exception than the norm. At this time, there is no definitive role for the physician in the field with regards to pre-hospital care in the United States. Certain places, for instance, AirCare (helicopter EMS service out of University of Cincinnati) has a physician/nurse staffing model on every flight. There are a few set ups like this around the country, but again, not the norm. Overseas (i.e. Europe, Australia) routinely have physicians respond in the field.

While pre-hospital care plays a vital role in the management of trauma patients, EMS brings anyone and everyone to an emergency department. That includes the renal failure patient who syncopized in dialysis clinic, the drunk passed out at the bar, and the schizophrenic patient found wandering the streets off his/her medications.

Given your interest in military medicine, you may want to consider tactical EMS. This is where you learn about providing care to law enforcement in the field (i.e. SWAT team during a raid). This is a new specialty and honestly I'm not sure regarding it's future (Google John's Hopkins tactical EMS fellowship, I believe it's currently the only fellowship program in the country).

The Shock Trauma fellowship in Baltimore will prepare you for the life of an ED intensivist (i.e. critical care physician). Most of these fellowship trained docs will work in a surgical/trauma ICU (in addition to others). You will likely get the patient AFTER the ED doc, trauma surgeon etc have resuscitated and stabilized the patient. These patients can still be very sick and require very complex care in the monitored setting of the ICU.

If you want my personal opinion, you don't need an EMS fellowship to provide emergency care in a combat setting. Do an EMS fellowship if you like working with politicians, government officials, fire departments, medics/EMTs to create a well functioning EMS system that meets the needs of your community.

A critical care fellowship is definitely not needed to provide care in the field. In fact, I would argue, that most residency trained emergency physicians (not fellowship trained) could provide combat casualty care. What I mean by that is that most of emergency medicine will prepare you for routine medical care of these patients. Preparing for the emotional and physical stressors of being in combat is a whole different issue.

Hey thank you very much sir.
So what your saying is that I don't need to do a fellowship to be a good combat trauma doc?

If so what fellowship and what er programs focus on trauma? since that is what I really want.

 

[shookwell]

Any good EM residency will teach you ED management of trauma patients. Some have more exposure and you can try to do residency in a major trauma center if that's what you want. Trauma is very formulaic and really not very complicated; it gets boring after a while.

EMS fellowships don't have much to do with managing trauma, it's more about running EMS systems. EMS physicians do respond to major incidents in some big systems but this is atypical and not really what you will be learning.

If you are more interested in longer-term management of trauma patients you can try to do EM and then do a surgical critical care fellowship, this may allow you to work in a SICU although you should talk to the trauma surgery people about that. I'm aware of a few people who do this but I'm not sure if most hospitals will hire a SICU attending who doesn't do surgery.

 

[Apollyon]

Not to ding on the OP, but this guy posted around 5 threads on the MilMed forum asking about the same thing - how to be a doc that is a door-kicker, or to be a doc AND a Spec Forces operator. He seems to have a real thing about the action.

 

[MoGhazidoc1990]

Not to ding on the OP, but this guy posted around 5 threads on the MilMed forum asking about the same thing - how to be a doc that is a door-kicker, or to be a doc AND a Spec Forces operator. He seems to have a real thing about the action.

I assure you have shifted my focus from that mindset to being more a Battalion aid station or simply being at a shock trauma platoon or FRSS

 

[deleted109597]

Don't worry, if that's what you want to do, the army will have no problem putting you there after an internship. And basically you'll learn on the job.
If you want to do trauma, become a trauma surgeon. If you want to do EM, do EM.
EMS does not make you a prehospital doctor. You can train in prehospital in other countries though.

 

[TheComebacKid]

If so what fellowship and what er programs focus on trauma? since that is what I really want.

There are no ER programs or fellowships that "focus" on trauma. Some programs have a higher proportion of trauma patients than others. But at the end of the day, if you are going into EM, you can be damn sure that your program will also focus on your ability to manage syncope and low risk chest pain just as much as trauma.

If trauma is literally the only thing you want, you need to be highly considering a general surgery residency followed by a trauma/surgical critical care fellowship.

I've noticed people in EM can sometimes be a bit off putting and discouraging by saying things like "trauma is a pain" and "trauma is cook book." I wouldn't let that discourage you. Trauma is amazing in many aspects and I for one really enjoy it. however, you have to make the best decision for yourself, and if you are looking for exclusively trauma, then a trauma surgery fellowship may give you more.

That being said, trauma surgeons spend a lot of time doing elective cholecystectomies, bowel resections, appendectomies etc. So it's not blood, guts and glory all the time. Trauma surgeons have virtually no role in pre-hospital care (in fact, I would argue that EM physicians probably could have a bigger role than trauma surgeons when it comes to prehospital care). Despite what people on the far left will tell you about the state of gun violence in this country, the reality is that at most places, there isn't enough penetrating inner city trauma to keep you doing just trauma all the time. You will likely have to supplement your practice with bread and butter general surgery.

Good luck

 

[shookwell]

trauma is boring and you don't have to actually be awake to do trauma

 

[wook]

EMS fellowships don't have much to do with managing trauma, it's more about running EMS systems. EMS physicians do respond to major incidents in some big systems but this is atypical and not really what you will be learning.

Agreed it is about providing medical direction for an EMS system. However, EMS clinical care is different than working in the ED. That's why it is a sub-specialty board.

I would suggest reaching out to an EMS board certified physician for guidance about what is EMS.


Thanks.


Wook