Help -- ED-run Traumas

[MissMedicine09]

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I'm an MSIII trying to investigate possible residencies. I worked for 2 years prior to med school in Hennepin's ED and fell in-love with the fact that there the ED residents have a lot of control in the Trauma Bay and do the majority of the procedures/rescusitations there. I know that I want to work in a Level I ED but know that in the majority of them the Trauma Surg team has the autonomy. Can anyone recommend residencies that are trauma heavy where the ED residents & attendings have a larger role in the care of the critical trauma patient?
Thanks, it'd be a big help!

 

[southerndoc]

Please do a search of the forum as this topic has been discussed in-depth before. The search button is at the top of the page or the forum heading ("Search this Forum").

 

[RockfordWF]

I'm an MSIII trying to investigate possible residencies. I worked for 2 years prior to med school in Hennepin's ED and fell in-love with the fact that there the ED residents have a lot of control in the Trauma Bay and do the majority of the procedures/rescusitations there. I know that I want to work in a Level I ED but know that in the majority of them the Trauma Surg team has the autonomy. Can anyone recommend residencies that are trauma heavy where the ED residents & attendings have a larger role in the care of the critical trauma patient?
Thanks, it'd be a big help!

Look for residency programs that are at trauma centers, but do not have surgery residencies.

I found that these programs seem to fit your description.

 

[antiveggies]

At Christiana we are present for all traumas. We have an alert and code system where all trauma alerts are run by the ED residents, and codes (the more serious traumas who are intubated, unstable, life threatening wounds, etc) are run by a mix of surgical chief and ED residents. we have ED attendings present, and trauma surgeon attendings.

so for alerts the ED PGY2 is airway (we do all of our own airways in the ED both trauma and medical), PGY3 runs the trauma alert, other ED PGY2 and PGY1 and the Trauma resident (either an ED intern or surgical intern) take a side of the chest.
for trauma codes, PGY3 is airway, PGY2, other ED residents available, and trauma res take a side of the patient, and surg runs the codes.

so you can see we are present for all traumas, we just change roles slightly when a trauma code is called. i dont know if i'd say we are trauma "heavy", but we manage critical traumas everyday. im not sure what you mean by larger role in the care of critical trauma pts - but we secure airway, stabilize, resus, etc and let the surgeons do their thing when they need operative care

 

[kungfufishing]

In Mississippi we alternate running the trauma activations. The lower level EM resident is in charge of all trauma airways from day 1 on the job. Upper levels run trauma activations on even days, surgery on odd days, and EM upper level directs all non activation traumas. Although we get lots of experience directing trauma resuscitation, I would point out that trauma just isnt that complicated and isnt really all that interesting, either. This discussion, or one like it, happened in the past 6 months on these boards. You will probably get training adequate to manage trauma at pretty much any accredited residency.

 

[malingering]

I can't speak for other programs, but at mine (Detroit Medical Center-Sinai Grace), we do everything. The surg residents take over after the patient is out of the trauma bay and admitted, but all procedures are ours. Also, we get a ton of trauma. PM me if you've got any questions.

 

[corpsmanUP]

I really wish med students applying to EM would think through the whole trauma obsession, because it's really overblown. This is not meant to minimize the importance of being competent at trauma. Most of us will graduate from EM residencies and go work in private hospitals with ED's of 30,000 or so give or take, and we will see no more trauma than sepsis, or MI's, or pneumonia, or bread and butter EM patients. But yet this is the measuring stick that so many newbies use to measure a program. Trauma is quite monotonous, and can easily take away from the learning experiences of other important disease processes, especially at programs where trauma is a huge percentage of the volume. Trauma is very algorithm based, and I couldn't imagine being at a place where I had to deal with the dispositions of trauma patients after the initial stabilizations. I love it when we activate the trauma team because I only have to deal with the airway, and then I go back to my other many patients waiting for dispo's.

 

[deleted109597]

I really wish med students applying to EM would think through the whole trauma obsession, because it's really overblown.

They get over it after they start experiencing it. If they had to do a prelim surgery year, they would get over it in July.

 

[EM2BE]

And sadly, I am one of a few med students who was quite happy to find out we don't do much in most trauma rooms. I found I liked the part of emergency medicine without traumas quite appealing. Odd duck leaving now.

 

[Dr. Dukes]

And sadly, I am one of a few med students who was quite happy to find out we don't do much in most trauma rooms. I found I liked the part of emergency medicine without traumas quite appealing. Odd duck leaving now.

I was shadowing an EP in Boston before I came to school, and on one shift of his EMS brought in a guy who had been stabbed in the abdomen and was eviscerated (which was cool as crap, by the way). EM and Surg messed around in the trauma room for maybe 5 min then Surg took him to the OR. Walking out, the EP turned to me and said: "Those are the best cases, we get to have a little fun with the airway and FAST, and then the patient leaves and I don't have to deal with them again..."
I could see trauma getting old, but there is a reason on residency videos they always show the trauma team evaluating a trauma patient: trauma gets old when you do it, but its cool at first.
Remember, everyone applying to EM residencies hasn't gotten over it, it is still cool...

 

[southerndoc]

I was shadowing an EP in Boston before I came to school, and on one shift of his EMS brought in a guy who had been stabbed in the abdomen and was eviscerated (which was cool as crap, by the way). EM and Surg messed around in the trauma room for maybe 5 min then Surg took him to the OR. Walking out, the EP turned to me and said: "Those are the best cases, we get to have a little fun with the airway and FAST, and then the patient leaves and I don't have to deal with them again..."
I could see trauma getting old, but there is a reason on residency videos they always show the trauma team evaluating a trauma patient: trauma gets old when you do it, but its cool at first.
Remember, everyone applying to EM residencies hasn't gotten over it, it is still cool...

Some of the more aggressive places would have taken this patient straight from the ambulance bay to the OR. There's no reason for a FAST in this patient since he's destined for the OR anyhow (unless you had multiple traumas and needed to prioritize patients).

 

[WallowaWanderer]

I really wish med students applying to EM would think through the whole trauma obsession because it's really overblown.

Well, since you called us med students out on this, I have to address the issue. When looking at residencies, I am one who DOES consider the role that I will have in traumas. It's NOT an obsiession, but it's another thing I ask about just like I ask about critical care, scheduling, and didactics. I would much rather be in charge of the really sick trauma patients that roll into the trauma bay than have to stand idly by while surgery takes over. It means more experience for me. Of course I don't want to go up to CT with them or whatever, but that's not what we mean when we ask about "what role do your residents have in trauma?"

Most of us will graduate from EM residencies and go work in private hospitals with ED's of 30,000 or so give or take, and we will see no more trauma than sepsis, or MI's, or pneumonia, or bread and butter EM patients.

Believe me, there's no shortage of MIs, pneumonia, or bread and butter EM stuff at Hennepin or any of the other programs that handle their own traumas. It's just an additional strength of the program - it doesn't mean they give that up for the cases are traditionally handled by EM. I agree with you that balance is important, but we can have balance and handle our own traumas as well.

But yet this is the measuring stick that so many newbies use to measure a program.

Seeing how traumas run can give you a sense of how the Department is thought of within the institution. It's not the whole picture - just another piece of data.

Trauma is quite monotonous, and can easily take away from the learning experiences of other important disease processes, especially at programs where trauma is a huge percentage of the volume.

That is a really good point, but is really an issue of trauma volume as much as it is of how trauma is handled by Surg/EM. Hennepin doesn't have the problem you suggested.

Trauma is very algorithm based

Is sepsis not algorithm based? STEMI? GI bleed? There are strong algorithms behind all of those disorders, yet it is very important to get experience with these patients.

and I couldn't imagine being at a place where I had to deal with the dispositions of trauma patients after the initial stabilizations.

What's so hard about that? The sick patients will go to the OR or unit right away and the stable paitients you will handle like anyone else.

Hope you don't feel like I'm attacking you. But I just wanted to articulate why one medical student does take trauma into account and why.

 

[Dr. Dukes]

Some of the more aggressive places would have taken this patient straight from the ambulance bay to the OR. There's no reason for a FAST in this patient since he's destined for the OR anyhow (unless you had multiple traumas and needed to prioritize patients).

I think they did FAST because they had "young" PGY-2 doing it and they were waiting for the Trauma Attending for some reason (it was a while ago, so I don't remember the exact play by play). I asked him why even wait in the ED, and he basically said you don't gain anything from skipping the ED, and it gives people a chance to catch their breath, collect themselves, and get everyone on the same page.

As to the FAST, again, I don't 100% remember the specifics, I think it was a "we've got time to kill, lets teach" kind of thing.

 

[Hercules]

Solid reply and points WallowWanderer and your view seems balanced. I completely understand corpsman's complaint though. Trauma seems to be the question most asked by students and is probably one of the least important aspects of your training. It should definitely be part of your assessment of a program, but you can rest assured you will be trauma trained and competent coming out of virtually any RRC approved EM residency.

I think critical care time and especially pediatrics are much more variable from program to program. Remember kids will be about 25% of your practice and that's an area that is not standardized from program to program. Sorry for the tangent and I will now return you to your regularly scheduled programming...

 

[docB]

"Running" a trauma is not anywhere near as important as knowing how to manage a trauma. Here's a post from another thread on the same topic.

Yes every EP needs to know how to run a trauma. However, I stand by my initial assertion that going to a residency where the ED "runs the trauma" is not that valuable. "Running the trauma" in academic centers usually means standing in the corner and occasionally barking orders. "Running the trauma" when your the EP in a small ED means Doing the airway, primary and secondary surveys, work up and disposition. My feeling is that spending more time doing these things is worth more than standing back with your arms folded.

 

[MissMedicine09]

Okay, so I appreciate everyone's input on here but it really hasn't addressed the original question. Many of the comments seem to suggest that I am naive and/or a novice because I "am obsessed with trauma." I guess just for the record I worked in EMS for 5 years and then at Hennepin for 2.5 years. I've also been around EM my entire life (my dad's an ER doc) and I just know what "gets me going." I really love the medicine in Emergency Medicine but I also know that I wouldn't be happy/satisfied with my job if I worked at a place that wasn't a major Trauma Center (and it seems like the Medicine cases that present to EDs vary less than do the Trauma cases). I really like Trauma -- I would go into Trauma Surg itself instead of ED except that I wouldn't be happy with gen surg being a large part of my career. I guess I don't understand why that needs to be judged so much -- I think it's okay that I and other Med Students really enjoy managing Traumas. Anyways, to those of you who have PMd me with suggestions I really appreciate it -- they've really helped me start narrowing my search. I still would love other people's suggestions for ERs (level I) where the Trauma Surgeons play more of a back-seat. One suggestion someone gave me is to look for Level I EDs that lack a strong surgery residency -- any suggestions on places such as these?
Thanks again!

 

[Seaglass]

If you feel you need to be "in charge" of a lot of major trauma to be happy in life then you need to be a trauma surgeon. Most level 1s have good surgery residencies since you need to have a trauma surgeon in house to be a level 1, and that requirement is met by having residents in house 24/7. Additionally I think outside resdency you will have a hard time finding an ED that is busy with trauma that isn't either a teaching hospital (where you will be letting the residents do a lot and you will have trauma surgeons) or a private hospital with a trauma service (where the trauma surgeons want to be involved).

We're not picking on you, it's just we've seen lots of "trauma junkies" get jaded on it pretty quickly.

 

[arctic187]

Okay, so I appreciate everyone's input on here but it really hasn't addressed the original question. Many of the comments seem to suggest that I am naive and/or a novice because I "am obsessed with trauma." I guess just for the record I worked in EMS for 5 years and then at Hennepin for 2.5 years. I've also been around EM my entire life (my dad's an ER doc) and I just know what "gets me going." I really love the medicine in Emergency Medicine but I also know that I wouldn't be happy/satisfied with my job if I worked at a place that wasn't a major Trauma Center (and it seems like the Medicine cases that present to EDs vary less than do the Trauma cases). I really like Trauma -- I would go into Trauma Surg itself instead of ED except that I wouldn't be happy with gen surg being a large part of my career. I guess I don't understand why that needs to be judged so much -- I think it's okay that I and other Med Students really enjoy managing Traumas. Anyways, to those of you who have PMd me with suggestions I really appreciate it -- they've really helped me start narrowing my search. I still would love other people's suggestions for ERs (level I) where the Trauma Surgeons play more of a back-seat. One suggestion someone gave me is to look for Level I EDs that lack a strong surgery residency -- any suggestions on places such as these?
Thanks again!

If you are choosing someplace that is NOT a major trauma center then I think it would be important to run the limited traumas that do come in.

I rotated at a hospital where ED ran the traumas and you had to escort them to CT scan, do all the leg work, follow labs, etc. If you did this at a busy trauma center you would have no time for non-trauma patients.

What I would suggest is to look for a Major trauma center that has a great relationship with the trauma service. Although it doesnt meet your criteria of running all the trauma, Temple is a great place for exposure to trauma. They still see frequent GSWs, stabbing, head trauma and still see MVCs/blunt trauma. They also get transfers from several of the community hospitals. The residents do 2 months on trauma, 1 month in the SICU (run by trauma). The ed residents get plenty of exposure running traumas during those months, and start running the non-hasted trauma until surgery arrives. Trauma attendings do a procedure workshop for the ED residents. ED residents always do the airway and frequently do lines, chest tubes and the occasional thoracotomy in the trauma bay. ED residents get a ton of exposure without getting bogged down. Hope this helps.

 

[MissMedicine09]

Arctic187 -- very helpful, thanks!

 

[AmoryBlaine]

I really wish med students applying to EM would think through the whole trauma obsession, because it's really overblown. This is not meant to minimize the importance of being competent at trauma. Most of us will graduate from EM residencies and go work in private hospitals with ED's of 30,000 or so give or take, and we will see no more trauma than sepsis, or MI's, or pneumonia, or bread and butter EM patients. But yet this is the measuring stick that so many newbies use to measure a program. Trauma is quite monotonous, and can easily take away from the learning experiences of other important disease processes, especially at programs where trauma is a huge percentage of the volume. Trauma is very algorithm based, and I couldn't imagine being at a place where I had to deal with the dispositions of trauma patients after the initial stabilizations. I love it when we activate the trauma team because I only have to deal with the airway, and then I go back to my other many patients waiting for dispo's.

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