Do EM Residencies Usually Take Place at Trauma Centers?

[16846]

The title really says it all, do EM residencies usually take place at trauma centers?

Do some EM residencies take place in hospitals/centers that don't deal with a lot of trauma?

I love most of the aspects of EM, but I am not interested in massive trauma cases. I worked in an emergency department that was cleared for level 2 trauma and we never really got many severe trauma cases with the exception of one gun shot victim and one multiple stab wound victim in two years. We dealt with our fair share of car accidents, suicides etc... but a very limited number of cases involving people with a large number of traumatic injuries and this would be the kind of program that I would be interested in for a residency.

Any information that can be provided is appreciated. Thanks.

Mike

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[tonem]

I think most EM residencies are associated with at least one hospital that is a trauma center. My EM adviser's opinion was that the best programs usually rotate their residents through different kinds of hospitals (ie: busy urban, community, academic etc...) so that they can get a feel for the different environments in which EM is practiced.

 

[DrQuinn]

agree with Tonem...

most EM residencies will be at an either Level 1 or Level 2 Trauma Center. The reason is because these places usually have the patient volume needed to train EM residents. Beware the residencies that only have 10-20k visits a year (believe me, there are some... granted they are usually the DO EM residencies...). EM is best learned in the Emergency Department. If you are only seeing 30 total patients in the ED qd, you're missing out. Ain't nothing like having two DKAs, two CPs, one vag bleeder, and about 10 other fast-trackers at a time, and then get called for a code. You'll need to learn how to handle MULTIPLE MULTIPLE patients at a time, which is why its good to train at a busy ED (i.e. Level 1).

I am not a "trauma junkie" myself, but its a part of the training and will make you a better physician. Hopefully a board certified, Emergency Medicine, physician.

Q, DO

 

[EMRaiden]

Trauma is pretty heavily covered on the boards and without pretty good training you will find it difficult to do well. Also no matter where you work someone can always pull up to the front door with a GSW, or you'll be camping and somebody will fall in a huge crevass and without that experience you'll flounder....

IMHO

 

[PimplePopperMD]

Originally posted by QuinnNSU
its good to train at a busy ED (i.e. Level 1).


Q, DO

Busy does not equal Trauma Level 1. The various levels are indicative of the hospital itself and the level of coverage of other services (ie Ortho, surg, etc)

It would be a mistake to not get any trauma experience. however, you don't need to go to a residency that has a trauma center. Many do rotations outside their primary residency to get trauma experience.

Anyway, be careful not to equate busy with trauma level designation.

 

[ESU_MD]

Most Level 1 trauma centers are regional size hospitals and tend to have more ED volume. More volume = more patients = more diversity = more training.

If you are interested in trauma exposure be careful. Alot of hospitals, mine included, have separate trauma services that are run by surgeons. In fact, the ED residents and attendings have nothing at all to do with the trauma unless they happen to be on the trauma rotation month. I think the only thing they do is answer the phone, talk to the paramedics and then alert the trauma team.

Other programs are more liberal and will have integrated trauma teams where the ED staff is more involved ranging from airway control to running the show.

something to think about when you interview.

However, do not forget that trauma is a surgical disease and should be handled in the long term by surgeons. But it is also vitally important for the EM practioner to become proficient in assessment and initial procedures in the event you wind up working in rural areas with distant surgical backup, or in a hospital where there is no trauma surgeon in house.

 

[alextron]

If you are interested in trauma exposure be careful. Alot of hospitals, mine included, have separate trauma services that are run by surgeons. In fact, the ED residents and attendings have nothing at all to do with the trauma unless they happen to be on the trauma rotation month. I think the only thing they do is answer the phone, talk to the paramedics and then alert the trauma team.

This brings up an interesting question. Does anyone know which programs have a more integrated trauma service i.e ED residents and surgery residents switch running traumas on odd/even days. I haven't noticed that info when researching the various programs.

 

[droliver]

We have a pretty nice relationship here in Louisville I think. Both services respond for the level I trauma's here & it's not unusual to see both teams doing the surveys in a complementary fashion simultaneously as well as the procedural interventions when needed. The ER residents will leave here with extensive experience in emergency IV access, chest tube placement, trauma ultrasound, complex airway management, & initial trauma survey & triage. The secondary triage decisions, interventions, & imaging for the severely injured patients are appropriately surgery directed

 

[Apollyon]

Originally posted by alextron
This brings up an interesting question. Does anyone know which programs have a more integrated trauma service i.e ED residents and surgery residents switch running traumas on odd/even days. I haven't noticed that info when researching the various programs.

The Mt. Sinai program, while the residents are at Elmhurst, has a "red" and "yellow" trauma - one is EM, the other is Surgery. However, I don't know what the criteria is (I don't think it's severity). I asked, but didn't get a straight answer.

 

[DrQuinn]

Here at USF, right now, Surgery is in charge of all the trauma codes. Anesthesia does the airway.

This is mainly because USF/TGH did not have an EM residency. Now that we are just starting, in a few months, EM will being to run the traumas, and in two years, when I will be a third year there (and we have three full years of residents), the EM residents will run the trauma and the trauma team will only come down after the initial EM resident's evaluation of the patient. Also, anesthesia will no longer do the airways. By the time I am a PGY-2, we will have a much stronger role in traumas.

Q, DO

 

[EMRaiden]

However, do not forget that trauma is a surgical disease and should be handled in the long term by surgeons.

I hate to disagree, but trauma is not a surgical disease.

In my experience most traumas never even see the interior of an OR. Thats not to say thay the trauma surgeon does not have a vital role, but the initial frantic resuscitation is a small part of the overall battle, its the daily feeding and watering, vent management, and rehab that marks most trauma care.

 

[EMRaiden]

Originally posted by QuinnNSU
Here at USF, right now, Surgery is in charge of all the trauma codes. Anesthesia does the airway.

Glad to hear that the EM residents will be taking over as time passes, the sooner you can vanquish the anesthesia devils from your department the better. Emergency airways are best handled by Emergency Physicians...

 

[DrQuinn]

I completely agree. I think anesthesia will be out of the traumas in October... once we (the only EM residents in the hospital) get our feet wet.

Q, DO

 

[droliver]

Originally posted by EMRaiden
Emergency airways are best handled by Emergency Physicians...

I disagree with that. While ER physicians need to learn those skills for practical reasons - they're often the only MD in the hospital @ certain hours or present in the ER in non-teaching hospitals- its clearly Anesthesia you want (with prefferably surgeons present for surgical airways if needed) for the hard airway problems when available for the gold standard treatment

 

[Apollyon]

Originally posted by droliver
I disagree with that. While ER physicians need to learn those skills for practical reasons - they're often the only MD in the hospital @ certain hours or present in the ER in non-teaching hospitals- its clearly Anesthesia you want (with prefferably surgeons present for surgical airways if needed) for the hard airway problems when available for the gold standard treatment

I don't have the study, but it was a few years ago that said that paramedics and anesthesiologists were the best at tubing, because they're doing it all day, every day.

The difference I've seen is that, for the vast majority of anesthesia cases, they've been NPO since midnight, have a good sniffing position, and it doesn't become pressing until they (the gas guys) decide it should be. Gas controls the scene, whereas, in the ED, you get mostly pharynxes full of vomit, and no luxury of time to decide.

This needs a study. Plain and simple.

 

[DrQuinn]

This is my personal opinion, but if you put an EP and an Anesthesiologist in a controlled environment with a dummy that could simulate *whatever*, an anesthesiologist would win.

But if you put an anesthesiologist performing IVs or A-lines and all of a sudden put him in front of a crashing patient with 15 people by their side and equipment here or there, he would lose to the EP.

Q, DO

 

[ERMudPhud]

As for "running" traumas try to get beyond the idea of who gets to wear the big cowboy hat on odd or even days. At Denver General we supposedly had an odd/even system but the truth was much more integrative. A great example was a six year old girl with a longitudinal slash in her femoral artery who lost vitals less than one minute from the hospital. She got intubated (by ER resident), central line (surgery resident), large bore saphenous cutdown (2nd ER resident) and somewhere between 2 and 4 units of O neg before going to the OR. Total ER time less than 10 minutes and she walked out of the hospital less than a month later. If your traumas are really running right they will almost run themselves with multiple procedures/decisions occurring at once. ABC becomes a parallel rather than a serial process. Its a bit of shock when you leave to a single coverage hospital where things have to be done sequentially.

The great airway debate: It is meaningless to generalize about which of two broadgroups of practitioners with a huge range of experiences and abilities is better at this. Two good examples. A friend of mine sees a patient one day after some sort of oral surgery complaining of throat swelling. Looks in the mouth and see the soft palate has changed into some sort of giant PULSATILE blood filled ballon covered by a thin layer of mucous membrane. **** he says and calmly sets out his cric set up while paging oral surgery and anesthesia. Two anesthesiologists arrive and my friend assumes that they will probably take him to the OR with the surgeon and carefully fiberoptically intubate him under propafol. Instead as soon as my friend turns his back they try to RSI him with predictable results. My friend turns around to see the walls, ceiling and two very surprised anesthesiologists covered in blood with a drowning patient. My friend crics the patient in about 30 seconds.
On the other hand a few months ago I saw a patient with a CT that showed diffuse tracheopharyngeal swelling and an airway like a straw but he wasn't stridorous and was what I like to call meta-stable. So, I temporized with decadron, racemic epi, and heliox. ENT and Anesthesia had time to take him to the OR and gently fiberoptically intubate him under propafol. Sure I could have taken a shot at his airway and I would have gotten it one way or another but this way if things don't work well there a multiple providers available and I am sure ENT with anesthesias' support can cric him faster than I could alone in the ER. The key is knowing when you can punt and when you can't.

We don't necessarily have to be the best at anything. We just need to be good enough and we need to be THERE when the need is emergent. Surgery may be better at surgical airways but they are not always there. Therefore, most of my classmates (myself included) have cric'd patients who subsequently walked out of the hospital. Likewise, some anesthesiologists may be better at the ugly airway but we are there when that ugly airway comes in so we better be good at it. Just don't let pride and interservice rivalries blind you to the difference between urgent and emergent. If the patient is metastable take the time to get everyone on board and plan what is best for the patient and not the ED's ego. Remember, even surgeons and anesthesiologist are kind and useful people too.

All this being said, in three years at DG I never saw anesthesia in the ED and we saw some truly horrendous craniofacial trauma. Its not that they probably couldn't have done it but there was no need for them to be there

 

[FoughtFyr]

NOt to step into the 'tube debate too much but...

An EMS system I used to work for put on an intubation "obstacle course" for their paramedic class. The dummies were straped to chairs on the wall (odd positions), placed in c-collars, some rooms were dimly lit, others had noise-makers and flashing strobes - in short - it was tough. ED docs and gas passers were invited to try the course alongside the paramedics. The course was timed until all stations successfully tubed, with a disqualification if you declared a successful intubation that was found to not be in the trachea superior to RMS. (You could make as many attempts as you wanted and verify by ascultation, chest rise, or direct visualization, but when you said "It's in" then it was checked by a judge). Interestingly enough, there were no measured differences between groups, only individuals. Some could perform well in the simulated "stress" others could not. The only difference (which was observed, not directly measured) was that paramedics seemed to be more comfortable with intubations in akward positions (patient seated or hanging upside-down) than were any docs.

Now this is a great story, but it is not science. I agree a "real study" should be done - but this course was FUN!

- H

 

[droliver]

MudPhud,

I completely agree with your sentiments. Quite often its going to be an ED doctor (especially @ non-teaching) hospitals who has to deal with the emergent airway & they need to be comfortable with it. The sentiment that an ER physician would be the "best" @ it is what I was tweaked by. You will never convince me that a surgeon or ER physician will approach the skill that anesthesia develops with the non-surgical airway thru repetition. Now I felt I was pretty good @ it when I was doing surgery & I had my ER friends who were REAL good I thought, but I'm pretty realistic about where I was in the pecking order for those skills. Along similar thinking- I've also been a little dismayed about some people's (surgeon,Anethesia, or ER physician) confidence that that can successfully do emergent surgical airways on everyone- these can be really hard even electively on some people for anatomic reasons. You can kill people real quick trying to crich/trach them if you don't have experience surgically there. I would recommend for ER residents to actively pursue some oppurtunities to assist with surgical trachs from their Surgery & Ent colleagues in the ICU - it will give you much more familiarity this anatomy & the potential problems you get into when things aren't pretty (midline veins, high riding thyroids, thyroid ima vessels)

 

[ERMudPhud]

Originally posted by droliver


I would recommend for ER residents to actively pursue some oppurtunities to assist with surgical trachs from their Surgery & Ent colleagues in the ICU - it will give you much more familiarity this anatomy & the potential problems you get into when things aren't pretty (midline veins, high riding thyroids, thyroid ima vessels)

As a resident we rotated through the SICU and did many of the trachs there with the surgical attending. I prefered the wired guided method that used a big blue rhino horn dialator. Now we have similar perc-cric kits in the ED. Also, many of us as residents did crics on DOA's, a practice that is increasingly frowned upon but certainly gave good experience. Many of my classmates have cric'd live patients who survived either during residency or shortly after. My personal case was the worse lisinopril angioedema I have ever seen after anesthesia said they couldn't see a damn thing through the fiber optic scope. Not something we want to do frequently but a worthwhile skill to have.

 

[droliver]

Those perc. trach kits are deceptively dangerous when not done with a bronchoscope is the conclusion many people are coming to. I would defionately have reservations about doing one emergently. A similar device pitched to the ED several years ago for emergent trachs was pulled from the market. In a pitch I think your surgical crich would be more reliable. It's nice to hear that you did get some exposure to elective trachs, ,but I really think your personal education about it (especially when you have to do the ones you're likely to do) gets limited with the percutaneous technique