Does high liver volume make up for lack of trauma?

[OrgoCoop]

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Hi all,
Hoping this message reaches mostly practicing attending anesthesiologists (or even CRNAs). I am on the interview trail and a number of very good programs cite their lack of trauma experience as a potential weakness. They tend to cite their strengths in liver transplantation and surgery as a reasonable alternative to the resuscitation needed in trauma. Do you feel like this is an accurate statement, and if so would you be willing or able to work in a level one trauma center despite not having robust trauma experience in residency?

I come from a home institution that is very heavy in trauma, and I’ve been involved with liver transplantation cases as a medical student. While I see the similarities, there seems to be a significant difference in the acuity of the situation and the ability to handle whatever comes to the door in trauma . Do you feel like you would be able to “figure out” trauma situations as a new attending if you were well versed in livers? I plan on pursuing fellowship at this time, but I also want to feel like I have a very strong General anesthesia experience so I can deliver a safe anesthetic to all comers.
Thanks in advance.

 

[OrgoCoop]

I should clarify, lack of trauma doesn’t mean zero trauma (although there are some top programs that get zero trauma). The ones I am more interested in are just weaker in trauma (very little penetrating trauma, low to moderate amount of blunt).

 

[Ronin786]

Somebody else will give you advice about liver vs trauma, but let me give you another piece of advice.

You are going to be a physician. No CRNA, NP, nurse or PA has any say in what your training should be or what your qualifications are. Their opinions do not matter in your training. Your standard is different, higher and more arduous.

 

[Lecithin5]

Somebody else will give you advice about liver vs trauma, but let me give you another piece of advice.

You are going to be a physician. No CRNA, NP, nurse or PA has any say in what your training should be or what your qualifications are. Their opinions do not matter in your training. Your standard is different, higher and more arduous.

Good advice- not sure why you want the advice of a non-physician on a physician board. In any case, there are similarities between liver and trauma (however still not quite the same), and my program had a little trauma with lots of liver. But I feel well trained and currently do lots of trauma with no issues. I think you’ll be fine. It’s all about the ABCs (or CABs).

 

[OrgoCoop]

Somebody else will give you advice about liver vs trauma, but let me give you another piece of advice.

You are going to be a physician. No CRNA, NP, nurse or PA has any say in what your training should be or what your qualifications are. Their opinions do not matter in your training. Your standard is different, higher and more arduous.

Gotcha. Would definitely prefer an MD/DO perspective on this subject, wasn’t sure how active this sub-forum was. There may be “some” value in hearing from a CRNA that trained at a place with high liver low trauma and went on to practice in a higher trauma setting. Regardless, I understand your point.

 

[OrgoCoop]

Good advice- not sure why you want the advice of a non-physician on a physician board. In any case, there are similarities between liver and trauma (however still not quite the same), and my program had a little trauma with lots of liver. But I feel well trained and currently do lots of trauma with no issues. I think you’ll be fine. It’s all about the ABCs (or CABs).

Thank you.

 

[Mikkel]

"Trauma" can mean a lot of things. Make sure you have enough experience doing everything, craniotomies, aneurysms, CVAs, AAAs, DLTs, jacked up cervical spines, etc.

When it comes to putting lines and tubes and blood in a 20 year old blunt/stabbing/GSW victim, it's self explanatory.

 

[blockstar]

I have a pretty good perspective on this as a resident. I transferred from an extremely busy and trauma heavy program to an extremely intense and transplant heavy program.

The similarities between big traumas and sick livers in regards to anesthetics are undeniable. Lots of ABG analysis, lots of blood products (nearly continuous for both) and usage of a rapid infuser.

The big difference between the two I would argue come down to brains for livers and brawn for traumas. Traumas can come in minutes from death. You have to secure what could be a horrible airway very quickly. You have to get large bore iv access, central line access for pressors and an arterial line very quickly or your patient may die if the patient cannot be resuscitated. The surgeons have to get to work quickly and get hemostatic control. Even someone sawed down by an AK47 can live but will usually get brought to the OR immediately, hemostasis achieved and belly is left open. The real work by the surgeons is done for days after the inciting trauma.

Livers are planned more in advance than a trauma. The patients are typically older,sicker and have the sequelae of liver disease. That is to say they are a coagulopathic nightmare. Its a more controlled chaos than a trauma. Securing the airway is more thought out. Intravenous access is done more thoughtfully. You can usually tune your patient up prior to reperfusion but there is nothing more dangerous in anesthesia imho than reperfusion. Massive release of cytokines and ph altering substances can kill a patient if you do not adequately resuscitate a patient with a good mix of products and medications. You may be breaking out the defibrillator more often in a liver than a trauma. Youre watching abgs TEGs cbcs and coags throughout the case which is usually 6 hours plus.

So basically I believe if you can master livers AND be good with speed you can do traumas no problem.

 

[pgg]

Trauma anesthesia is not complicated. It's the same thing every time. Tube, blood, not necessarily in that order, pack them off to the ICU.

If a trauma case is complex in any way, it's because of the patient's pre-existing comborbidities, not the trauma. You're better off doing cases in residency where the patients are sick and old, than doing more 2 AM traumas on mostly young people who were healthy an hour ago.

I wouldn't lose a second of worry about a residency program that didn't see a lot of trauma.

 

[Iso4ane]

Liver Transplants are the Gentlemen Trauma, you know when it’s gonna start and you have some time to prepare.

 

[OrgoCoop]

Cheers all - I just wanted to confirm with some unbiased folk that the claims these programs were making were genuine.

 

[deleted171991]

Traumas are all about prioritizing. If they are really big, they get into the realm of critical care, but the average liver transplant is much sicker than the average trauma.

A place that does a ton of liver transplants has waaay more educational value than a place that does a lot of traumas.

 

[Ronin786]

Traumas are all about prioritizing. If they are really big, they get into the realm of critical care, but the average liver transplant is much sicker than the average trauma.

A place that does a ton of liver transplants has waaay more educational value than a place that does a lot of traumas.

Trauma center: inner-city hospital with poor resources

Large transplant center: usually the premier academic institution in town

 

[Monterosso]

I trained at a program with both a heavy liver transplant program and busy Level 1 trauma program. The two are similar in that they require multiple lines, resuscitation, and blood loss/coagulopathy. However, as some of the other posters mentioned, they are distinct entities. Blockstar gives a nice overview of the differences. I do not believe liver transplant replaces a trauma experience.

As a trainee, I feel experiencing both is important if you can. A liver is a big, but anticipated, case with some time for preparation and at times (not always) algorithmic. I felt a lot of the learning for trauma came in how you deal with a case suddenly thrust at you with little warning. How quickly (and safely!) can you put in that central line after being jarringly woken up at 3am, with the adrenaline of rushing the bleeding-out GSW patient to the OR? I feel experiencing that stress is educational for a resident. I and many of my co-residents - after doing several months of trauma - felt much more comfortable with scheduled cases, however big, where there is time to prepare.

 

[dchz]

Trauma center: inner-city hospital with poor resources

Large transplant center: usually the premier academic institution in town

what about a place that has both? XD

I feel trauma experience is overrated. But my first day in the OR is a guy who got shot with 9 hollow points and we gave him all the blood in the county. So the chances that i take the trauma experience for granted is very high as well. Therefore, I would count having no trauma as a negative. How much of a negative? not very much.

All other things equal I would rank: Liver + Trauma >>> Liver only >>Trauma only >>>> no liver no trauma.

But would I put with no liver or no trauma to live in the city I want? yes. I would. hope that gave you some perspective on things.

 

[vector2]

I trained at a program with both a heavy liver transplant program and busy Level 1 trauma program. The two are similar in that they require multiple lines, resuscitation, and blood loss/coagulopathy. However, as some of the other posters mentioned, they are distinct entities. Blockstar gives a nice overview of the differences. I do not believe liver transplant replaces a trauma experience.

As a trainee, I feel experiencing both is important if you can. A liver is a big, but anticipated, case with some time for preparation and at times (not always) algorithmic. I felt a lot of the learning for trauma came in how you deal with a case suddenly thrust at you with little warning. How quickly (and safely!) can you put in that central line after being jarringly woken up at 3am, with the adrenaline of rushing the bleeding-out GSW patient to the OR? I feel experiencing that stress is educational for a resident. I and many of my co-residents - after doing several months of trauma - felt much more comfortable with scheduled cases, however big, where there is time to prepare.

The anticipation is also important in another respect. Many will say something like “oh, they’re both just big access, TEG, and MTP etc.” The difference is that cirrhosis patients usually come in with huge, juicy central/peripheral veins and bounding pulses whereas I’ve had more than a few exsanguinating traumas where the pt was cold and clamped down, no peripheral veins, IJ cycled between 1cm or totally collapsed depending on the vent and the artery was tiny and essentially non pulsatile on U/S because the BP was 60/35. IMO, high acuity trauma certainly places a premium on working under pressure and having good hand-eye skills.

 

[blockstar]

The anticipation is also important in another respect. Many will say something like “oh, they’re both just big access, TEG, and MTP etc.” The difference is that cirrhosis patients usually come in with huge, juicy central/peripheral veins and bounding pulses whereas I’ve had more than a few exsanguinating traumas where the pt was cold and clamped down, no peripheral veins, IJ cycled between 1cm or totally collapsed depending on the vent and the artery was tiny and essentially non pulsatile on U/S because the BP was 60/35. IMO, high acuity trauma certainly places a premium on working under pressure and having good hand-eye skills.

Could also argue a cirrhotic has had his right ij manipulated a few times altering the anatomy forcing you to change your game plan

 

[vector2]

Could also argue a cirrhotic has had his right ij manipulated a few times altering the anatomy forcing you to change your game plan

Certainly a possibility, but having trained at a very high volume center (top 5) where R IJ double sticks were common, I maybe heard of a handful of difficult accesses over the course of 3 years

 

[MoMoGesiologist]

The anticipation is also important in another respect. Many will say something like “oh, they’re both just big access, TEG, and MTP etc.” The difference is that cirrhosis patients usually come in with huge, juicy central/peripheral veins and bounding pulses whereas I’ve had more than a few exsanguinating traumas where the pt was cold and clamped down, no peripheral veins, IJ cycled between 1cm or totally collapsed depending on the vent and the artery was tiny and essentially non pulsatile on U/S because the BP was 60/35. IMO, high acuity trauma certainly places a premium on working under pressure and having good hand-eye skills.

How do u get access in the situation u described? What’s your go to?

 

[Ronin786]

In my experience, academic liver staff are usually the fellowship-trained faculty who are generally more knowledgeable than the general call pool anesthesiologist thrust into taking in-house call and being stuck in a middle of the night GSW.

There's a lot of bad medicine that happens when your 2-year from retirement generalist has to staff a midnight trauma. Of course the mortality is expected to be so high that nobody pays attention anyways.

 

[vector2]

How do u get access in the situation u described? What’s your go to?

I open a 7cm micropuncture kit into my MAC kit. Volume going in through whatever IV I have, steep tburg, push a bunch of pressor and then tell crna to hold a valsalva while I stick tiny vessel and thread the micropuncture wire. These are frequently lines where I have to confirm using short and then long axis that the needle is dead center in the tiny vessel before attempting to thread. Continue seldinger until big line in.

For the a-line, I'll get out a 12cm 20g catheter and go straight to brachial or axillary. More proximal arteries have enough muscular structure where they'll usually be stickable even in the shockiest pts. Not to mention, in extremes of volume status, pt temperatures and pressors, a radial art line rarely accurately reflects the central aortic pressure (similar to radial vs fem arterial pressure after a circ arrest and long bypass run etc).

 

[OrgoCoop]

what about a place that has both? XD

I feel trauma experience is overrated. But my first day in the OR is a guy who got shot with 9 hollow points and we gave him all the blood in the county. So the chances that i take the trauma experience for granted is very high as well. Therefore, I would count having no trauma as a negative. How much of a negative? not very much.

All other things equal I would rank: Liver + Trauma >>> Liver only >>Trauma only >>>> no liver no trauma.

But would I put with no liver or no trauma to live in the city I want? yes. I would. hope that gave you some perspective on things.

So far on my interview trail a lot of the big namers in the top 20 seem to sacrifice trauma for their other big time academic stuff. I still have a few “top 10” programs to go so maybe they will be able to offer both.

 

[blockstar]

How do u get access in the situation u described? What’s your go to?

Femoral!

 

[coffeebythelake]

liver definitely more challenging

 

[ShockIndex]

Femoral!

Yep. I’m a femoral guy too unless there is a possibility of an IVC injury. That is not an uncommon injury from GSWs that traverse the thorax and arrive in shock. Then, it’s a subclavian (traditional or supraclavicular approach) with a preference for the side that might already have a chest tube...or the right so that I’m not in the way of the inevitable thoracotomy 😉.

 

[ShockIndex]

I should clarify, lack of trauma doesn’t mean zero trauma (although there are some top programs that get zero trauma). The ones I am more interested in are just weaker in trauma (very little penetrating trauma, low to moderate amount of blunt).

This sounds like a program at a big university that rhymes with Fishigan and has a football team that won yesterday but will likely get clobbered by OSU next week...

If so, I bet you will get great training there. They are solid. 😉

 

[OrgoCoop]

This sounds like a program at a big university that rhymes with Fishigan and has a football team that won yesterday but will likely get clobbered by OSU next week...

If so, I bet you will get great training there. They are solid. 😉

;-P

 

[HalO'Thane]

This sounds like a program at a big university that rhymes with Fishigan and has a football team that won yesterday but will likely get clobbered by OSU next week...

If so, I bet you will get great training there. They are solid. 😉

That was my first thought as well. If you come out of there or a program like it you will be very well trained.

I agree that exposure to complex cases; including transplant, neuro, cardiac, thoracic, and vascular is more important than being at a busy trauma center.

I am doing way more trauma at my current gig than I ever did in training. After a while it is usually fairly formulaic: airway, vascular access, and transfusions. Keeping a cool head and managing resources (including people) are probably most important.

And yes, if Justin Fields is healthy then OSU is going to stomp Michigan.

 

[Iso4ane]

And yes, if Justin Fields is healthy then OSU is going to stomp Michigan.

And if he’s not, OSU will just walk over Michigan.

 

[DM27]

Beyond the concept of "lots of lines" and "lots of blood" I do not think livers are an appropriate surrogate for traumas. What makes traumas challenging is the general lack of significant advanced notice, often suboptimal conditions for placing lines and securing an airway, variables relating to trauma that add additional challenges and considerations to airways (unstable c-spines, hardware in place, facial trauma) and lines (severely hypovolemic, unstable and rapid access needed) which are generally not present in your typical liver transplant patient. Where I did residency we also had a lesser trauma exposure and the liver volume was felt to be an adequate surrogate, that is honestly a cop out.

 

[Mikkel]

What makes traumas challenging is the general lack of significant advanced notice

You should be comfortable with this if you have done any major OB, emergency craniotomies, emergency aneurysms, stroke embolization.

often suboptimal conditions for placing lines and securing an airway

Crashing ortho and OB should have taught you this

variables relating to trauma that add additional challenges and considerations to airways (unstable c-spines, hardware in place, facial trauma)

Everything except facial trauma is taught with any reasonable neuro spine training

and lines (severely hypovolemic, unstable and rapid access needed) which are generally not present in your typical liver transplant patient.

You should have this experience with major general surgery cases, crashing ortho and OB.

Where I did residency we also had a lesser trauma exposure and the liver volume was felt to be an adequate surrogate, that is honestly a cop out.

Your other experiences in residency should have prepared you for trauma.

 

[deleted162650]

You should be comfortable with this if you have done any major OB, emergency craniotomies, emergency aneurysms, stroke embolization.





Crashing ortho and OB should have taught you this



Everything except facial trauma is taught with any reasonable neuro spine training




You should have this experience with major general surgery cases, crashing ortho and OB.



Your other experiences in residency should have prepared you for trauma.

Crashing ortho???

 

[Mikkel]

Crashing ortho???

Fat emboli, PE, major vascular injury, terrible surgeons, 3-5L blood loss on revision THAs on super morbid obese patients, sick 105 year olds, etc.

 

[deleted162650]

Fat emboli, PE, major vascular injury

If any of these things happen to you more than once every couple years, you are the unluckiest person alive.

 

[Mikkel]

If any of these things happen to you more than once every couple years, you are the unluckiest person alive.

Terrible surgeons in high acuity academic medical center with high production pressure.

You might ask why terrible surgeons would be teaching fellows and residents.

EXCELLENT QUESTION!!!

 

[deleted162650]

Terrible surgeons in high acuity academic medical center with high production pressure.

A) you need a new job

B) I've always said that having terrible surgeons makes for excellent anesthesia training

 

[Mikkel]

A) you need a new job

B) I've always said that having terrible surgeons makes for excellent anesthesia training

We're talking about training. I trained at a place with terrible surgeons and I value everything I learned. I also appreciate how my current job is infinitely better residency.

 

[deleted162650]

Fat emboli, PE, major vascular injury, terrible surgeons, 3-5L blood loss on revision THAs on super morbid obese patients, sick 105 year olds, etc.

When you said "crashing ortho" I envisioned some yoked out ortho dude running into the OR pushing a stretcher all hair on fire OB nurse mode yelling "We've gotta fix this femur NOWWWWWWW!!!!!!!"

 

[pgg]

Crashing ortho???

The patient has a condition I have not seen before. There is a fracture. I need to fix it.

 

[T-burglar]

Trauma anesthesia is not complicated. It's the same thing every time. Tube, blood, not necessarily in that order, pack them off to the ICU.

If a trauma case is complex in any way, it's because of the patient's pre-existing comborbidities, not the trauma. You're better off doing cases in residency where the patients are sick and old, than doing more 2 AM traumas on mostly young people who were healthy an hour ago.

I wouldn't lose a second of worry about a residency program that didn't see a lot of trauma.

PGG I think you're a sharp doc, but I hate this sentiment.

Trauma is only "not complicated" if you leave all the diagnosis to the surgeon and emergency doctors. Or in other words, if you just take responsibility for the nursing tasks (basic transfusion and airway), then sure it's not complicated. If you're taking a physician team leader responsibility, then suddenly you have to be a diagnostician for the entirety of trauma pathology plus, as you said, anything pre-existing or that led to the trauma - in a hyperacute setting with little time. This is anything but "not complicated". Chest ultrasound alone is the topic of entire books. I would argue that trauma doctors need strong TEE, POCUS, and general imaging and diagnostic skills. If you're not critically assessing the patient and the patient's workup prior to crashing into the OR, and just transfusing and putting a tube in, then you are not rising to what should be the standard for a trauma anesthesiologist in 2019.

 

[pgg]

Those are fair points.

 

[nimbus]

PGG I think you're a sharp doc, but I hate this sentiment.

Trauma is only "not complicated" if you leave all the diagnosis to the surgeon and emergency doctors. Or in other words, if you just take responsibility for the nursing tasks (basic transfusion and airway), then sure it's not complicated. If you're taking a physician team leader responsibility, then suddenly you have to be a diagnostician for the entirety of trauma pathology plus, as you said, anything pre-existing or that led to the trauma - in a hyperacute setting with little time. This is anything but "not complicated". Chest ultrasound alone is the topic of entire books. I would argue that trauma doctors need strong TEE, POCUS, and general imaging and diagnostic skills. If you're not critically assessing the patient and the patient's workup prior to crashing into the OR, and just transfusing and putting a tube in, then you are not rising to what should be the standard for a trauma anesthesiologist in 2019.

But in the real world lots of doctors are doing trauma with no TEE and very little if any POCUS.

 

[deleted162650]

But in the real world lots of doctors are doing trauma very little if any POCUS.

You can make up for it by using a little extra HOCUS POCUS.

 

[T-burglar]

But in the real world lots of doctors are doing trauma with no TEE and very little if any POCUS.

In an ideal world trauma centers would be required to meet certain standards as medicine advances. It is not news to me that the world falls short of ideal.

 

[deleted162650]

I would argue that trauma doctors need strong TEE, POCUS, and general imaging and diagnostic skills.

You need all that stuff to determine that the guy needs a tube and a transfusion???

 

[ThetisAntithesis]

Don't mind me, just passing through.

This thread just got me super excited for med school!!!

I open a 7cm micropuncture kit into my MAC kit. Volume going in through whatever IV I have, steep tburg, push a bunch of pressor and then tell crna to hold a valsalva while I stick tiny vessel and thread the micropuncture wire. These are frequently lines where I have to confirm using short and then long axis that the needle is dead center in the tiny vessel before attempting to thread. Continue seldinger until big line in.

For the a-line, I'll get out a 12cm 20g catheter and go straight to brachial or axillary. More proximal arteries have enough muscular structure where they'll usually be stickable even in the shockiest pts. Not to mention, in extremes of volume status, pt temperatures and pressors, a radial art line rarely accurately reflects the central aortic pressure (similar to radial vs fem arterial pressure after a circ arrest and long bypass run etc).

This post in particular made me go "Whaaaat? How do you know all that? And enough to write it out in detail??"

 

[MoMoGesiologist]

You can make up for it by using a little extra HOCUS POCUS.

best provided by one of your friendly neighborhood CRNAs

 

[OrgoCoop]

Don't mind me, just passing through.

This thread just got me super excited for med school!!!



This post in particular made me go "Whaaaat? How do you know all that? And enough to write it out in detail??"

That’s why he gets paid a lot.

 

[nimbus]

Don't mind me, just passing through.

This thread just got me super excited for med school!!!



This post in particular made me go "Whaaaat? How do you know all that? And enough to write it out in detail??"

TBH only a small fraction of physicians will truly understand what he wrote, namely cardiologists, IR, vascular surgeons, intensivists, anesthesia and EM docs. It would be Greek to the vast majority of other doctors who are experts at other things. And it’s practical “get the job done” knowledge you acquire as the need arises. You certainly won’t get much exposure in medical school.

 

[OrgoCoop]

I open a 7cm micropuncture kit into my MAC kit. Volume going in through whatever IV I have, steep tburg, push a bunch of pressor and then tell crna to hold a valsalva while I stick tiny vessel and thread the micropuncture wire. These are frequently lines where I have to confirm using short and then long axis that the needle is dead center in the tiny vessel before attempting to thread. Continue seldinger until big line in.

For the a-line, I'll get out a 12cm 20g catheter and go straight to brachial or axillary. More proximal arteries have enough muscular structure where they'll usually be stickable even in the shockiest pts. Not to mention, in extremes of volume status, pt temperatures and pressors, a radial art line rarely accurately reflects the central aortic pressure (similar to radial vs fem arterial pressure after a circ arrest and long bypass run etc).

I will say that this paragraph is a nice summation of why I love anesthesia and am pursuing a career in it.

Cerebral approach to problems with an emphasis on critical thinking -> abstract and creative approaches to handling problems -> execute typically in a tactile way -> enjoy watching instant results and satisfaction of good patient care