Dismiss Notice
Hey Texans—join us for a DFW meetup! Click here to learn more.

em and trauma surgery???

Discussion in 'Emergency Medicine' started by xdismalx, Oct 31, 2002.

  1. xdismalx

    xdismalx Junior Member
    7+ Year Member

    Joined:
    Oct 31, 2002
    Messages:
    11
    Likes Received:
    2
    I was wondering if anyone knew of residencies that incorporate both emergency medicine and trauma surgery so that one would, in essence, be a dual disciplined doc...

    thanks,
    xdismalx
     
  2. Note: SDN Members do not see this ad.

  3. Path

    Path Junior Member
    7+ Year Member

    Joined:
    Oct 26, 2002
    Messages:
    18
    Likes Received:
    1
    Well, The two fields are very different. To become a trauma surgeon, you need to do 5-7 years of surgery residency and then a 1-2 year trauma fellowship. The trauma surgeon is essentially able to operate on anything that comes in to the ED.

    An EM physician cannot operate. There will be places where the EM physicaian actually does a thoracotomy, but that's about it. To be double certified, youd have to do a whole lot more of residency.
     
  4. xdismalx

    xdismalx Junior Member
    7+ Year Member

    Joined:
    Oct 31, 2002
    Messages:
    11
    Likes Received:
    2
    Thanks Path, that helps. But I have another question...As a trauma surgeon, are you trained to do the same type of work that a EM doc would do? i.e. not strictly surgery, but also the basic(not meant to be derogatory "walk-in" medicine of an EM doc.
     
  5. tonem

    tonem Senior Member
    15+ Year Member

    Joined:
    Sep 13, 1999
    Messages:
    620
    Likes Received:
    3
    A trauma surgeon is a surgeon. They pretty much either do surgery, evaluate a patient to see if they need surgery, or take care of patients after surgery.
     
  6. mikecwru

    mikecwru M.D. = Massive Debt
    7+ Year Member

    Joined:
    Oct 21, 2002
    Messages:
    948
    Likes Received:
    12
    Status:
    Attending Physician
    If you do a strong EM residency and work in a place where EM is strong you will be able to do whatever a surgeon can do in the trauma room before the patient is wheeled to the OR. A lot of places alternate days where EM/Trauma surgery is running the trauma.

    As with anything, it varies with the doc, but trauma surgeons are usually not as comfortable or just not as good (usually the later, because they're surgeons, they think they're good at everything!) at dealing with the variety of medical problems that are going on outside the trauma room.

    It's my personal bias that there is more variety, and more obscure stuff to know in EM. Also, most trauma surgeons do not do trauma exclusively... they rotate their time through trauma and do general surgery (appys/choles/ass) most of the time.

    mike
     
  7. tonem

    tonem Senior Member
    15+ Year Member

    Joined:
    Sep 13, 1999
    Messages:
    620
    Likes Received:
    3
    From a resident training standpoint the service that runs trauma in the ED can be deceiving. For example, at Pitt the Trauma Service runs all the traumas in the ED. What isn't obvious until you start delving deeper is that there is always an EM intern and resident on the Trauma Service. So that "surgeon" running the trauma may actually be a senior EM resident.

    As far as EM physicians doing everything a trauma surgeon can do, I'm not so sure I want any EM physicians doing an exploratory thoracotomy or laparotomy on me or my family (and I'm applying for EM residency). Think about it, do you want some cowboy wannabe surgeon who's done it maybe 10 times plus once or twice on a cadaver or someone who's makes their living doing it.
     
  8. mikecwru

    mikecwru M.D. = Massive Debt
    7+ Year Member

    Joined:
    Oct 21, 2002
    Messages:
    948
    Likes Received:
    12
    Status:
    Attending Physician
    I don't know what ED you're in, but I've never seen an ex lap done in the trauma room. I've seen the most critical patients wheeled to the OR. Remember, I said "in the trauma room."

    As for cracking someone's chest, if I were the patient, I'd want anyone who's willing to try it, because I'm pretty much a goner anyway. A surgeon can sew me back up if it works. And you can make the same argument regarding EM.... would you rather want an EM doc who's done it lots of times doing it, or a 2nd year surgery resident who's seen it once and "helped" once?

    mike
     
  9. tonem

    tonem Senior Member
    15+ Year Member

    Joined:
    Sep 13, 1999
    Messages:
    620
    Likes Received:
    3
    Because you've never seen it, its never been done? If a traumatized large vessel or organ suddenly ruptures because you've successfully treated someone's hypotension, they aren't going to make it to the OR unless you do a crash laparotomy and clamp the vessels. I'd agree that with the widespread use of CT and U/S x/laps aren't as common but they aren't unheard of in the trauma bay.

    In the ED I've been in (to paraphrase you) its usually a chief resident or trauma fellow doing the thoracotomy/laparotomy. Even it was a second year who's done it once emergently, he has done it more times on a routine basis than 99.9% of EM docs. If your argument is that EM docs in bigtown county hospital do it all the time, surgery residents in bigtown county hospital also tend to operate more than your average resident. So there! :p

    This point counterpoint argument we're having just goes to show that there is more than one way to skin (or flay) a cat and trauma and emergency medicine is as varied as there are hospitals in the USA.
     
  10. mikecwru

    mikecwru M.D. = Massive Debt
    7+ Year Member

    Joined:
    Oct 21, 2002
    Messages:
    948
    Likes Received:
    12
    Status:
    Attending Physician
    In the ED where I did my sub-I, I've never seen a belly opened in the ED and no, wasn't saying it can't happen. Maybe because our ORs are right behind the ED on the same floor and relatively easy to get to.

    As far as the chest cracking, I don't think EM docs are as unused to it as you think, but this may vary. We're both probably talking out of our ass by citing things we've seen at a couple of different hospitals, I would have trusted one of the grizzled old ED docs to do it well before some of the surgery chiefs I've seen.

    The trauma teams at the local hospital usually consisted of a couple of interns (ED included) a surgery second year or two and a fourth year surgery guy (the working chief). Attendings were not usually present unless it was one of the big "trauma guys." (coverage rotated through gen surgery). An ED attendings was always there.

    I would like to see a lap done in the trauma bay, though. That would be pretty cool. What city did you see this in?

    mike
     
  11. droliver

    Moderator Emeritus 10+ Year Member

    Joined:
    May 1, 2001
    Messages:
    1,556
    Likes Received:
    75
    Status:
    Attending Physician
    I've never heard of a laparotomy being done in the ER, but you can do peritoneal lavage. In the past they used to do pericardial windows under local in the ER, but that's rare now. Some people have written about diagnostic laparoscopy under local in the ER for trauma, but this is not a common thing at all (it would be expensive to maintain the equipment & laparoscopy for trauma has high false - rates except for a yes/no answer on fascial penetration).

    Having had to do sternotomies & thoracotomies under CONTROLLED conditions, I just cannot imagine a non-surgeon being able to do it successfully under emergent conditions without making things worse or injuring other structures (phrenic nerve,esophgus, thoracic duct, IMA, vena cava). There are very,very few indications (some would argue none) for doing this in the ER & if you aren't prepared or capable of fixing what you get into, you don't need to consider it as you put yourself and others nearby @ risk for blood-borne pathogens (the flash of blood when you get into the chest or pericardium can hit the ceiling & walls sometimes when under pressure). The statistics are miserable for survival & these are from surgeons in the highest volume trauma centers - if you extrapolate this to non-surgeons it's prob. close to 0%
     
  12. womansurg

    womansurg it's a hard life...
    7+ Year Member

    Joined:
    Aug 19, 2002
    Messages:
    1,585
    Likes Received:
    10
    Of course, doc ollie's right (he's always right...smart guy...).

    When I did my trauma sub-I, the ED docs were active members of the trauma team. They did everything in the trauma bay that the surgeons did - including thoracotomies. My first ED thoracotomy was under the instruction of an ED doc, in fact.

    You're right on several accounts: no role for laparotomy in ED. And ED thoracotomy outcomes near zero - the exception being penetrating trauma with signs of life on arrival/witnessed arrest. Their survival rate is about 40%.

    Anecdotal story (but true, came from my own residency): Stabbing victim dropped at front door of charity hospital ED (Level IV center, in other words, not capable of handling traumas at all...). Taken inside where underwent a witnessed cardiopulmonary arrest after intubation. While the poor ED doc was losing it, the IM INTERN did a left anterolateral thoracotomy, released the pericardial tampondade and restored a perfusing rhythm. Meanwhile, surgery resident shows up, takes the guy to the OR, repairs a small cardiac laceration, and the guy ultimately walks out of the hospital.

    Our program director offered that medicine intern a surgery position on the spot - which he respectfully declined.
     
  13. droliver

    Moderator Emeritus 10+ Year Member

    Joined:
    May 1, 2001
    Messages:
    1,556
    Likes Received:
    75
    Status:
    Attending Physician
    I think in the age of specialized trauma centers & FAST scans in the ER, pericardiocentesis would be safer to temporize a tamponade prior to exploration in the OR especially in any center with rapid availability of an operating room. I'm always suspicious of the line from the EMT's "He had pulses @ the door" when some of these people (usually blunt trauma) arrive dead & then go on to recieve heroic CPR for 30 mins in the ER (and believe it or not - stay dead). If I don't personally witness one of these ER arrests, my entusiasm wanes quickly for doing much in the way of ACLS.
     
  14. womansurg

    womansurg it's a hard life...
    7+ Year Member

    Joined:
    Aug 19, 2002
    Messages:
    1,585
    Likes Received:
    10
    Although pericardiocentesis is still officially part of ATLS protocol, our trauma directors have discouraged the use of it in acute trauma situations, and say that its use is currently under review.

    Pericardiocentesis an effective procedure in the extraction of thin, serous or serosanguinous pericardial fluids, as in the case of pericardia effusions. Frank, clotting blood, usually from the ventricle in a trauma situation, is poorly evacuated, and the underlying source for fluid accumulation is not addressed.

    Basically, you either have a patient who is stable enough to undergo pericardial window, or you have an arresting patient, in which case you have one shot at finding and correcting the problem. ED thoracotomy allows for cross clamp of aorta, hilar clamping, temporizing repair of cardiac laceration, any of which might be life saving in the witnessed arrest of a penetrating chest wound.

    That's our local teachings on the subject, anyway.

    We're lucky to have extremely bright, capable EMTs here. They've been reliable in their determination of life signs at the scene and on arrival, so we don't get into situations of unindicated resuscitative efforts too often.

    I've never had an ED thoracotomy ultimately survive. I have, however, had 2 of the 3 bedside thoracotomies I've done while on call survive. These were all performed in patients who were s/p CABG, with witnessed arrest and PEA unresponsive to ACLS protocol. One had a blown ventricle (the death); the other two had dehiscience of the suture line of a graft (one patient) and breakdown of the aortotomy closure - they both survived.
     
  15. droliver

    Moderator Emeritus 10+ Year Member

    Joined:
    May 1, 2001
    Messages:
    1,556
    Likes Received:
    75
    Status:
    Attending Physician
    womansurg,

    hemopericardium usually does not clot as I understand it (if it clots you're in the ventricle) & thus does tend to be able to be aspirated emergently. The pericardiocentesis can temporize things until you get to the OR where definative tx. could be attempted. Doing an open pericardial decompression can quickly turn a small hole into an extravasating ventriculotomy as you unroof it & I know I am not prepared or equipped to temporize that in the ER. We don't have a formal prohibition per se on doing ER thoracotomies, but its been the opinion of a number of our faculty who are preemininent in trauma that you're more likely to lose salvagable patients by doing it under those conditions versus taking them abruptly to a ready OR. This maxim might not apply as you get to smaller hospital, but those patients are prob. unlikely to survive.

    BTW- props on those bedside post CABG saves, I'm sure that was both scary & diffucult :clap:
     
  16. xdismalx

    xdismalx Junior Member
    7+ Year Member

    Joined:
    Oct 31, 2002
    Messages:
    11
    Likes Received:
    2
    I am really glad that you guys are getting the opportunity to flaunt your knowledge, but no one has seemed to answer my question yet. Is there a program out there, somewhere, that integrates b oth EM and Trauma surgery? The reason I ask is that I have heard of a physician called a Traumatologist, who works as both. I've heard there are residencies for this at Ben Taub General Hospital and also at Adam Cowley Shock Trauma. I was unable to find any info online about it. I've heard that the residency involves a combination of internal medicine, EM, and surgery residences.

    Any info would be great:)
     
  17. tonem

    tonem Senior Member
    15+ Year Member

    Joined:
    Sep 13, 1999
    Messages:
    620
    Likes Received:
    3
    A quick google search came up with two possible definitions of traumatologist.

    1) mental health care worker trained to work with people that have experienced trauma ie: PTSD

    2) surgeon trained to handle trauma ie: general surgery residency grad after a trauma/critical care fellowship.
     
  18. droliver

    Moderator Emeritus 10+ Year Member

    Joined:
    May 1, 2001
    Messages:
    1,556
    Likes Received:
    75
    Status:
    Attending Physician
    xdismalx ,

    In common use you would infer that it is a trauma surgeon when you use the term traumatologist (maybe some of the MPH types who do statistical work would adopt this term too, but I've never heard it used out of the context of surgery) . There is no training program that combines ER + surgery residencies as such.

    I'll stop flaunting now
    :)
     
  19. xdismalx

    xdismalx Junior Member
    7+ Year Member

    Joined:
    Oct 31, 2002
    Messages:
    11
    Likes Received:
    2
    thanks Dr. O, someone has finally answered my question.

    btw, I enjoyed the flaunting

    xdismalx
     
  20. peksi

    peksi Senior Member
    7+ Year Member

    Joined:
    Nov 5, 2002
    Messages:
    140
    Likes Received:
    0
    Actually, the term traumatologist is used and applied to surgeons who are often trauma critical care fellowship trained.

    As to your question there are infact EM FELLOWSHIPS that offer training for Emergency Residency trained Graduates to become proficient in many of the advanced proceedures that are used in trauma critical care including thoracotomy, bronchoscopy, endoscopy, trachiostomy, PEG placement, and advanced vent management as well as critical care training and research. These are located currently at Shock Trauma in Baltimore, U Pitt, Christ Hospital in Chicago.

    The rational behind this is that someone may want to gain such advanced nich expertise for marketability to academic programs as well as high volume private trauma centers.

    Currently there is no advanced board certification or critical care credentialling for this training but there may just be some day. One of our Chief residents this year in EM will be the trauma/critical care fellows at U Maryland Shock Trauma for 2003.

    As for a trauma surgeon wanting to work in an ED and see non traumatic illnesses such as chest pain, MI, vomiting etc. I'm not sure that is very likely!
    Trauma surgeons are not trained to evaluate and manage the multitude of no surgical conditions that present in the ED.

    Paul
     
  21. xdismalx

    xdismalx Junior Member
    7+ Year Member

    Joined:
    Oct 31, 2002
    Messages:
    11
    Likes Received:
    2
    WOW, do you know where I can find some info on these fellowships?
     
  22. tonem

    tonem Senior Member
    15+ Year Member

    Joined:
    Sep 13, 1999
    Messages:
    620
    Likes Received:
    3
    I feel like Rodney Dangerfield...no respect.

    Check out the USF traumatologist webpage for mental health workers who wish to be certified in helping people deal with trauma (ie: refugees, disaster survivors, etc...)

    Pitt has fellowships in toxicology, EMS, and research. There has been talk of starting a new 6 year program with two residents a year that will include training in EM, IM and critical care with the goal of being board certified in all three.
     
  23. TVRS

    TVRS New Member

    Joined:
    Nov 6, 2002
    Messages:
    3
    Likes Received:
    0
    xdismalx,

    Your question sounds like it's answered, but I'll give you my two cents. I'm finishing a 3 year EM residency at Christiana Care in Delaware. We're a high volume (130,000 patient) EM training program/level 1 trauma center with plenty of trauma experience. Next year, I'm going to the University of Maryland/Shock Trauma Center for a 1 year Trauma/Critical Care fellowship. The program accepts 8 surgeons, 4 EPs, and 2 anesthesiologists (these #s fluctuate).

    It's essentially a 1 year immersion in trauma and critical care. EPs that have graduated from this program (and others) are currently working in intensive care units around the country. One in particular is the Director of the SICU at the University of Utah (Edward Kimball, MD).

    If you are interested in Trauma, you first have to decide what aspects you enjoy. Is it the acute resuscitation/intervention, operative, or long term management that you enjoy the most. These phases are not mutually exclusive; however, the latter 2 phases are best performed by a trauma/critical care physician.

    It is very possible to be an emergency physician capable of acute resuscitation/intervention. If you feel like you want a more in-depth experience after finishing a 3 or 4 year residency in EM, simply do a 1-2 year fellowship.

    If you or anyone else has any questions about Christiana or UM/STC please email me @ the address below.

    Good Luck!:D

    Munish Goyal, MD
    Chief Resident
    Department of Emergency Medicine
    Christiana Care Health Systems
    Newark, DE
    [email protected]
     
  24. TVRS

    TVRS New Member

    Joined:
    Nov 6, 2002
    Messages:
    3
    Likes Received:
    0
    The first 6 year EM/IM/CC program is in existence. It is at Henry Ford in Detroit. Pitt as well as Christiana Care are looking into starting similar programs. Currently, Christiana has a 5 year EM/IM program. Residents who complete this program can go on to do a 1-3 year fellowship in critical care and become "certified".

    With all due respect, there are trauma surgeons who enjoy emergency medicine. The chairman of Shock/Trauma Center @ UM was in fact the chairman of an EM program and a practicing Emergency Physician and Trauma Surgeon.
     
  25. ljube_02

    ljube_02 Senior Member
    7+ Year Member

    Joined:
    Sep 18, 2002
    Messages:
    482
    Likes Received:
    0
    Do you make more money after the 6 year program than after a regular 3 year EM program?
    Thanks
     
  26. KGUNNER1

    KGUNNER1 Senior Member
    15+ Year Member

    Joined:
    Nov 22, 2002
    Messages:
    261
    Likes Received:
    1
    Status:
    Attending Physician
    I admire all of your enthusiasm in advancing your training past your EM days. I can maybe shed a little light on things. I did a 5 yr EM/IM residency at Henry Ford Hospital in Detroit and now I'm in my 2nd year of a Critical Care fellowship at the Univ. of Pitt. The chest cracking comments aside (I've done my share and had only one live), there are several programs that would take EM grads. Here at Pitt, we fully embrace the EM trained applicant. I need to make a correction, Ted Kimball in Utah is a Pitt grad in EM and Critical Care. I know Ted well. Another Hennipen grad, Scott Gunn, is a faculty member here at Pitt. A Ford grad, Alan Tuttle is a SICU attending at the Univ. of New Mexico. So you see, you don't necessarily need the blessing of a U.S. based board to practice CCM. Another Ford grad who is down here with me is David Huang. We, along with some very enthusiastic people like yourselves, have put together a database of all the CCM programs that are willing to accept EM graduates. There are tons out there. If you are interested in more FAQ type stuff, please visit our website http://www.ccm.upmc.edu/mcctp/emfaqs.html. I'll shut up now. If any of you would like to discuss options in more detail (or just tell cool stories), please drop me an email.

    Good luck.
     
  27. womansurg

    womansurg it's a hard life...
    7+ Year Member

    Joined:
    Aug 19, 2002
    Messages:
    1,585
    Likes Received:
    10
    Hey, just to continue in the ED pericardiocentiesis v ED thoracotomy debate: the following is lifted from Trauma.org, an international website for trauma surgeons.

    Eric Frykberg (ERF) is one of the most recognized names in the trauma community. Sounds like a move away from the use of ED p'centesis and window is underway.

    regards
    -ws

    a message dated 11/27/2002 7:00:36 PM Eastern Standard Time, [email protected] writes:
     

Share This Page