Does Prelim surgery teach you to be a surgeon?

[e2k]

Dear surgery folks,

I've come to the conclusion that although I enjoy surgery, I don't want to be a surgeon, and I most definately do not want to do a full surgical residency.

I'm considering doing a prelim year of surgery, then emergency medicine. As there is some surgery involved in emergency, it wouldn't be a waste of time, and also I think it might make me (minimally) qualified to work as an emergency surgeon for Doctors without Borders or other aid agency.

How much surgery do you learn in a prelim year? Do programs just use you as a scutmonkey, or do they try to teach you? Any advice?

Thanks,
ERIC

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[Winged Scapula]

It depends on the program and what type of surgical procedures you wish to do. Many programs focus on peri-operative management during the first two years and you often spend the Prelim year doing different surgical specialties (ie, not all General/Trauma Surgery).

You would likely feel more comfortable doing certain procedures after doing a Prelim Surgical year but honestly I would not recommend it for the following reasons:

you are likely to spend most of your time NOT in the OR but rather managing patients on the ward

a Surgical Internship is painful and for the reasons you are considering it, even for just a year, the yield would be low and the emotional and physical costs high. Unless you are really interested in being a surgeon, I think you will find the year not worth it.

YOu would be better off getting as many procedures as possible while doing an EM residency or by completing a Trauma fellowship after completion of a residency. However, 1 year of Prelim surgery would not make you "qualified" to do much IMHO.

Hope this helps.

 

[godfather]

Your first 2 years in surgery your in the or for like 2 % of your total time time in the hospital. And what you do is basically what any brain dead med student like me could do which is basically hold retractors. As far as needing to do surgery as an Er doc. Your fooling yourself in that even. the real world isn't like the tv show. in the real world er docs are like triage nurses. however their lifestyle is great.

 

[e2k]

Dear Kimberly,

I guessed as much. I had been trying to decide which to do - Prelim surgery or trauma fellowship. However, most trauma fellowships are research-based. You're probably right: it's probably not worth it unless I want to be a surgeon.

As for ER docs being triage nurses: only the bad and lazy ones. I've seen ER docs that work this way, but it's not the right way.

A good ER doc is a primary care doc for the homeless and indigent, an IM doc for every heart attack, a neurologist for every stroke or brain bleed, and a surgeon for every gunshot wound. I've seen this as well, and this is what I am for.

ERIC

 

[Winged Scapula]

I think you would be wise to avoid doing a Prelim year for the reasons you've given. As for the ER doc being "trauma surgeon for the gunshot wound" - not here at least. At most Trauma centers, the ER docs do very little in the way of managing Traumas - the Trauma team is usually comprised of Surgery and Anesth residents and their attendings. If a GSW or other Trauma comes in here, unless it arrives via the ER by own transport (rather than via EMT/chopper, etc.) the ER docs are not involved at all. The entire resuscitation, etc. is handled by the Trauma team and any surgical residents in house. Cracking of chests, thoracentesis, etc. are all done in the Trauma bay mostly by surgery residents. The ER residents don't even do surgical rotations here.

The previous poster is correct - while I have gotten to do some operations skin to skin, most of the time I am simply holding retractors and doing minor stuff - less than I did as a 4th year medical student.

Anyway, best of luck in your endeavors. Consider a Crit Care fellowship which while a lot of Pulmonology, offers you the chance to do lots of procedures as well.

 

[12R34Y]

Kimberly,

I would like some input on this.......

I start medschool in the fall and since I'm a paramedic had always been interested in emergency med. Is it true that ER residents don't get a lot of trauma exposure?

I have talked to maybe 5-6 ER docs I work with who trained at Maricopa medical center in arizona, vanderbilt, etc....they all said that they each got to "crack a chest" 3-5 times during their residencies. Also, working in an ER in a level II trauma center (suburbia---where a surgeon might not be there for 20-30 minutes) the ER docs I work with put in a lot of chest tubes, do trauma assessments, tap bellies and such. where do they learn how to do that all if not in residency? Any info would be great!!

thanks,

later

 

[e2k]

Dear name with many numbers:

I think I can help clear you up.

Even though I am not a resident, I have done extensive research into trauma care in the ER, and the bottom line is that it varies from hospital to hospital.

In some ERs, the surgeons stand back in resuccitation and the ER docs handle everything. Some Surgery departments handle trauma from admit to release. Some rotate days, and many involve both surgeons and ER docs.

Personally, I'm looking for a residency like the first I mentioned.

Also, I don't know much, but I do know there's a huge difference between peritoneal lavage and 'cracking a chest', the first being almost routine in trauma and the last being...last resort. Very few people survive emergency thoracotomy, kind of like CPR.

As a paramedic you'll be familiar with a lot of the procedures done in the ER. However, you might find yourself doing something else entirely after med school...you may get interested in Radiology, Peds, CT surgery, whatever...I was an EMT and I'd love to do emergency but I change my mind every few weeks...

Luck,
ERIC

 

[Winged Scapula]

It really depends on the program and the availability of other residents (ie, a surgical residency or Trauma fellowship). Obviously in some programs EM residents do most of the procedural work, but in many others, especially those with Surgical programs it is the latter who do most of the procedures.

As for "cracking a chest" in the ER - it is infrequently done, and sometimes only for teaching purposes because the survival rate is around 1% or less for open cardiac massage. I'm told everyone here should graduate having done 1 but no more and they really only should be done in extreme instances or for teaching.

 

[12R34Y]

Thanks to both of the previous posters for responding.

I absolutely agree that thoracotomy is the last resort and is infrequently done. I also know that if you have to crack someone's chest they most likely will not survive.

I was just curious as to how ER docs seem to feel comfortable with trauma procedures if they did not practice them much during residency.

I agree with you also Eric. I will absolutely keep an open mind through medical school about what specialty I choose.

thanks again,

later

 

[droliver]

At least here in Louisville, the ER residents are somwhat complementary in their role for trauma. They do a lot of the triage, especially in the stable blunt trauma patients (less so in unstable blunt trauma or penetrating trauma). They do a lot of procedures (lines, arthrocentesis, spinal taps & such). When chest tubes are required we (surgery) put them in or are usually present to supervise ER residents if they do it (FYI: there is a signifigantly higher complication rate when nonsurgerons put in chest tubes ). I've never heard of any ER resident trying a crichothroidotomy here @ the University (thank god!). In general with the more severely injured patients, the ER is less involved with any mangement decisions.

As far as doing ER thoracotomies.....
1) there are VERY few indications for it & if you do need one you will die close to 100% of the time
2) the last person you want attempting this is an ER resident
3) the only times it gets done for the most part are "practice" ones on people who are already dead

 

[12R34Y]

Thanks for the info guys.

later

 

[12R34Y]

I think there are obvious big differences between large university-based medical centers ER staff v.s. suburban, private ER's.

I've worked in both and in the level 1 trauma center that i worked there was NOT an ER residency program. ONly surgery. Naturally, I saw surgery residents do ALL of the trauma and procedures with little supervision from ER staff docs. I just assumed that if the university had an ER residency program that ER residents would be more involved in trauma and trauma related procedures.

The reason I say that.....I work in an suburban, private ER now and there is no in-house surgery at all. It is a level II trauma center and the surgeon must be there within 20 minutes or so. Because there is no in-house surgery or residency programs in this hospital the ER staff do ALL kinds of stuff that apparently surgeons do in large teaching facilities.

Our ER staff place chest tubes on medical patients quite often. Tension pneumo's in COPDer's, spontaneous pneumos etc... When we do get trauma if the surgeon isn't there the ER doc is the only one there. They do the airway, assessment, procedures etc...once the surgeon does arrive it is very much a collaborative effort. I've seen several incidents where the surgeon puts a chest tube on one side while the ER doc sets up to put one in on the other side etc....

My point to all of this rambling is that I just assumed that ER docs did this kind of stuff in residency so that when they practiced outside of an academic center with tons of residents that they would be able to perform these procedures.

Where do ER docs learn to do this? From the ones I have talked to I assumed it was residency. Am I wrong? (wouldn't suprise me in the least)


later

 

[Winged Scapula]

I also assume they are largely learned during residency althought it would not be out of the realm of possibility to learn some procedures (particularly those that are rarely done) after completion of residency, while working.

Obviously, as pointed out by several posters, it largely depends on the environment and likely the presence of in-house surgery. Like droliver notes, here at PSU ER residents do not manage/show up for traumas - it is all managed by the Trauma team during the day and any in-house surgical residents during the night. I've seen an ER resident step into the Trauma Bay once during my 4 months here.

In choosing an ER program, you would be wise to ask how the two (if there are both programs) residencies work together, whether or not you do any surgical/SICU rotations (where you might presumably do more procedures) and how division of procedural work is done during traumas.

Best of luck to you.

 

[12R34Y]

Excellent points Kimberly.

Another question.....I've glanced at ER residencies on the web for various programs (usually out of boredom) and during the first two years it looks like ER residents do a lot of rotating through various services like Int. Med, Ped, PICU, OB, anesthesia, surgery etc....

When a resident from outside the department like in surgery rotates through for 1 month, how much do they REALLY let you do? For example, Kimberly mentioned trauma/SICU rotation. If an ER resident was to rotate for 1 or 2 months on that service are they pretty much just grunts or do they let them do stuff?

thanks again for the insight.

later

 

[Winged Scapula]

Obviously I can only speak from experience about here, but each member of the team is generally treated equally with procedures/tasks divied up. Desirable learning procdures - ie, putting in central lines, chest tubes, are gnerally rotated among the junior house staff on service. I will admit that there might some favortism toward giving the surgical residents procedures which they may be realistically expected to do and become proficient at as opposed to allowing ER, Peds, Anesth, residents to do them.

But non-surgical residents would be better placed to comment on whether they thought they got their fair share of procedures while on Surgical rotations.