Emergency General Surgery

[DrDawg]

Just wondering how the EGS service is structured at other centers.
- number of residents
- use of NP/PA's
- surgeon of the week vs surgeon of the day
- admit and triage vs admit and manage
- 24, 7 coverage vs select days
- scope of practice
ect

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[poorracerkid]

4 residents during day 3 at night. One chief working 24 hour shift. Mid levels working 12 hour shifts (except weekends when they work 24) and two interns during the day. One intern at night (me currently). No PA/NP (they take care of the chronic trauma patients daily). Surgeon of the day. Admit and manage most of the time unless it's not a surgical issue then goes to medicine. 24/7 coverage. We do trauma and any surgical emergencies that come up and then they go to the trauma room.

 

[thedrjojo]

Emergency General Surgery is not a service at any of my 3 hospitals. We go by the older and antiquated method still

At the University Hospital, General surgery call is rotated between two teams, the General Surgery team (~3 of the 4 weeks) and the Surgical Oncology team (the remaining week of the month). During the day, the residents on that team take the calls from the ER. Those teams generally have a chief, midlevel, and 1-2 interns. No NP/PA's. It's surgeon of the block of days (usually 4-7 straight days for that surgeon). They are on 24/7. Scope of practice is anything that falls under general surgery. Trauma is it's own service, Vascular/Thoracic all go to their own service. Night is covered by an inhouse midlevel night float, and an inhouse intern night float. Midlevel will see the consults and call the chief resident for the team for all new consults. Depending on the attending and situation, the chief resident will tell the midlevel what to do, may have to come in, and may or may not call the attending (usually only if needing to operate that evening, otherwise it waits til the morning).

At our Private Hospital, again, Gen Surgery is rotated between two teams of residents, which covers a few practice groups (A group of 4 with 2 vascular surgeons and 2 general surgeons, the vascular guys taking some general call too, the group of 6 or so trauma surgeons, the bariatric/minimally invasive group of like 5 attendings, and then a few individual practioners). Each attending is on for 24hours and unless someone specifically requests a consultant, it goes to the board. Those teams are similarly a chief (4 or 5), mid-level or two, and two interns. Night float is inhouse 4, 2/3, and intern. Midlevel sees consults, informs inhouse 4 if it is complex, they need assistance, or if it will go to the OR, otherwise calls attending directly after seeing the consult. If its the inhouse trauma attending, they will usually come see the patient then and there, otherwise it usually waits to the morning unless they need to come in an operate. During the day there are NP's on the teams that will assist seeing the consults, but this is a beast of an ER and overnight its common to get 10-15 consults. Scope is similar, general surgery stuff.

The VA is the VA. There is one team at the VA, which has a 5, 4, 2 midlevels, and a gaggle of interns. Call is Q3 between the midlevels and the 4 (painful for the 4 to take "midlevel" call, but that's how the cookie crumbles for this year at least... its the first time it's happened this way, and may change next year). Everything goes thru the chief first (the PGY4 acts as both the mid-level and chief when they are on, not having to call the PGY5 overnight) and then through the attending. And rarely are there ever operations overnight at the VA (or consults for that matter). Scope is everything surgical that walks in the door. Maybe not Ortho, but everything else.

 

[ruralsurg4now]

And rarely are there ever operations overnight at the VA (or consults for that matter).

Note: This is also true for the daytime.

 

[themockjock]

We're pretty old school... at my center EGS is handled by one hospital and all elective specialty surgery goes to the main University Hospital next door. We have 3 EGS teams (plus a separate burn team, but all burns are initially managed in the resus bay by the on-call EGS service before getting sent to the burn ICU) that rotate call, which is q3. Each team has two attendings, a PGY-4/5, 3, 2, and 3 interns. PGY 2s and above are on 24 hour call q3, there is a day and night intern on call days. Attendings are on q6 call, for 24 hours, as they alternate between the two of them on the teams. One of the three teams has a NP who does some floor work, but otherwise there are no NPs/PAs - everything is handled by the residents.

Besides the chief running the service, the PGY-3 manages the SICU (the SICU is open and each of the three teams manages the patients there without dedicated intensivist or midlevel support), the 2 is responsible for all surgery consults that come through the ER including trauma and non-trauma patients, and the interns are responsible for all floor consults.

We admit and manage all patients independently, with rare consults to other services. The other caveat is that there are occasional elective cases that the attendings bring in as well. These are usually smaller things - lap choles, lipomas, etc. Big elective stuff goes to the University Hospital. That said, if another service consults us for elective cases on patients they have admitted (we do a lot of trach and PEGs on MICU patients, for example) the EGS teams do them. I guess because of that it isn't a "pure" EGS service even though 90% of what the teams see falls under that realm.

Scope is also just about everything surgical. We have all the specialties to consult, but most of the attendings are very old school and take pride in the "general" part of their title and will do stuff that now probably generally gets turfed to other specialties. I've seen them independently manage complex facial trauma, do abdominal wall reconstructions s/p shotgun wounds, repair tendons, etc.

 

[Dirt]

We have an acute care service, separate from the trauma/ICU services.

Runs from 7am to 5pm M-F. One attending covers a week at a time. Attendings are essentially the trauma surgeons with a couple of gen surg attendings covering sparingly. Team is a PGY 3 and an intern. They handle all general surgery consults. Patients admitted to us go to the acute care team also covered by the same residents. Specialty consults (i.e. Vascular, thoracic) go to their respective services. The main problems are that the intern gets hosed when an operative consult comes in and the PGY 3 goes to the OR, often other services mid-level residents need to help out with the difficult and/or sick consults, and the other gen surg attendings often dump all sorts of garbage (i.e. intra-abdominal catastrophes, opeb-abdomens, big fat lap-choles that no one wants to do) on the acute care attendings because they have an OR on standby during the day.

The rest of the time, read overnight and on weekends, there is a gen surg attending on call. All consults are handled by the on-call/night float PGY 3, with assistance from the PGY 2 and PGY 4 as needed. Patients admitted go to the respective service of the on call attending. Every consult is called to the attending. Unless obviously emergent, cases often get pushed to the next day or dumped on the acute care attendings, and often times will get punted to acute care service if they require multiple operations (see above)

 

[ACSurgeon]

Just wondering how the EGS service is structured at other centers.
- number of residents
- use of NP/PA's
- surgeon of the week vs surgeon of the day
- admit and triage vs admit and manage
- 24, 7 coverage vs select days
- scope of practice
ect

I've seen a couple of models.

1- community setting with one emergency general surgeon that works every other week, and takes 3-4 call days during their week on. This person admits and manages, but the partners cover during the "off week". The partners take turns seeing consults/taking call during the "off week." NP helps with floor stuff.

2- Academic setting: two emergency general surgeons (exclusive of trauma) who are the day surgeons for all new consults. They admit and manage. They are in the call pool with all general surgeons for night coverage. 2 residents on the EGS service.

3- academic setting. trauma staff cover EGS and trauma. On any given week, there is a trauma staff of the week and an EGS of the week. Night call rotates among all partners. 3 residents and 2 NPs cover EGS (with a different resident/NP team covering trauma). Staff who is on emergency general surgery manages the patients (with some exceptions including complex patients). Scope: all things general surgery that are not vascular or known cancers or established patients of other surgeons at the institutions (colorectal,hpb, etc).