I've seen programs that are trauma light such as Bellevue in NYC to the extreme at USC and Maryland. What is everyone's thoughts on how much trauma is needed to train a superb em doc? And what places offer the best mix and balance?
How much trauma do you need
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I think in general, trauma becomes the easiest part of what we do. Its algorithmic for EM docs (unlike trauma surgeons, who have to actually take patients to the OR and follow them in the ICU). Also, trauma generally comes with a whole team of people to help you if you feel you need it...
I personally had more than enough trauma after my first year of residency. With that said, a good rule of thumb is to decide what kind of practice environment you plan on working for the rest of your life and match that in residency. Then you'll be very well prepared.
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In the future, the ATLS guidelines will consist of a half page description on how to place an IV and give the patient contrast media for their pan-man CT scan. The last sentence of the paragraph will contain information on how to best contact the trauma surgeon.
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Most EDs, especially in the community, are not going to be trauma centers let alone Level I trauma centers. So you may not have general surgery in-house, nor ophtho, ortho, or ENT.
So in the rare occurence while working in the community ED that you get a walk-in GSW or itinerant EMS bringing in a major trauma, it's relatively easy: you stabilize, scan, and transfer out to a major trauma center.
What would be more challenging are the more common minor traumas such as extremity fractures, fight bite, tendon injuries, facial and ocular trauma, etc., and learning ED management and disposition. When should you transfer? If the consultant should come in, how to do that? And if the patient is appropriate for discharge, how and when to get follow-up.
Residency should teach you how to manage major trauma at a major trauma center, and how to manage minor trauma in settings where no specialists are around.
So in the rare occurence while working in the community ED that you get a walk-in GSW or itinerant EMS bringing in a major trauma, it's relatively easy: you stabilize, scan, and transfer out to a major trauma center.
What would be more challenging are the more common minor traumas such as extremity fractures, fight bite, tendon injuries, facial and ocular trauma, etc., and learning ED management and disposition. When should you transfer? If the consultant should come in, how to do that? And if the patient is appropriate for discharge, how and when to get follow-up.
Residency should teach you how to manage major trauma at a major trauma center, and how to manage minor trauma in settings where no specialists are around.
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I asked a bunch of residents about this on the interview trail they all (including those at USC) said that trauma is overrated. Its cool as a med student but by the time you've been running them for 6 month or so you've got it and its done.
They said for them by the time they hit their senior year its very algorithmic and boring.
They said for them by the time they hit their senior year its very algorithmic and boring.
D
deleted65604
Trauma at an academic center is mostly cookbook, because ER residents aren't generally involved in the decision making. All programs will claim an equal partnership with trauma, but the fact is, ER academic attendings don't want equal partnership with the trauma service. They want to assist with procedures and then vacate the premises to continue to move the meat in the main ED. In the rural setting, or when you don't have residents, trauma is much more fun, scary, and interesting, because the ER doc is actually making the decisions and carrying out treatment.
ER attendings notes usually look like the following, "Patient seen and stabilized in the ER. Dispo per trauma service."
ER attendings notes usually look like the following, "Patient seen and stabilized in the ER. Dispo per trauma service."
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deleted65604
Fun and very inciteful article about the state of trauma surgery.
To answer your question, I think you've got to read this first and possibly correct any misperceptions that you have about trauma.
http://www.annemergmed.com/article/S0196-0644(08)00615-X/abstract
My point is, something needs to change dramatically in the way traumas are taught to ER residents. Obviously, the authors of this article are biased ER doctors that want ER residents to run traumas. I'm not sure that will ever happen.
To answer your question, I think you've got to read this first and possibly correct any misperceptions that you have about trauma.
http://www.annemergmed.com/article/S0196-0644(08)00615-X/abstract
My point is, something needs to change dramatically in the way traumas are taught to ER residents. Obviously, the authors of this article are biased ER doctors that want ER residents to run traumas. I'm not sure that will ever happen.
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Being a graduate of a program that had less than 50% penetrating trauma and someone who currently works in a center that sees plenty of GSWs and stabbings, I haven't yet found a deficiency, but sometimes I am the last to know of my deficiencies.
What would you say are some of the finer points of penetrating trauma care that I and others may not be as skilled at?
It may be naive, but my view has always been temporize the airway, decompress the chest if necessary, gain large bore venous access and begin RBCs and FFP resuscitation. FAST the unstable and send to OR. If they code, more likely to qualify for thoracotomy etc.
Those that may have minor external wounds may actually be very sick in penetrating trauma (or blunt for that matter)...Is there more that I am missing for the ED doc?
Sincerely,
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I'm pretty sure that outside of Afghanistan there are not many hospitals that see 50% penetrating trauma. I was more lampooning ED applicants' fixation with trauma and trauma stats (a crime I was seriously guilty of also).
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Ahh! I missed the sarcasm, sorry. I'm glad; I was truly wondering what more there was to this 🙂
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This discussion, re:importance/interest in trauma comes up at least once/year. Every time it comes up, the universal response tends to be "trauma is cookbook, overrated, becomes boring, etc..". I don't necessarily disagree with that but there is a different way to look at this.
You can argue that the most important part of EM residency is learning to take care of the truly sick pt's and move everyone else through as safely & efficiently as possible. The residents at programs that have lots of trauma (USC, Vegas, Kings County, Lincoln, Maryland, etc..) are just seeing more sick patients mixed in with their "medically sick pt's". So what that its cookbook and the trauma team comes and takes over. It just adds to the volume and acuity that those residents are exposed to.
You can argue that the most important part of EM residency is learning to take care of the truly sick pt's and move everyone else through as safely & efficiently as possible. The residents at programs that have lots of trauma (USC, Vegas, Kings County, Lincoln, Maryland, etc..) are just seeing more sick patients mixed in with their "medically sick pt's". So what that its cookbook and the trauma team comes and takes over. It just adds to the volume and acuity that those residents are exposed to.
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Places with severe trauma aren't necessarily and often not congruent with those that have really complicated medically sick patients....I thinks its not a fair assumption to make.
Both polytrauma patients and transplant rejection constitute sick patients. You may not see the later at a county hospital and you may not see the former at a rich tertiary center. With the later you often have to immediately consult transplant and hand-off while with polytrauma you just go to surgery so both are probably over-rated. Just pick what interests you the most when choosing residency or find a rare program that does equally well.
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Agreed.
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I hope this isn't derailing the thread too much, but what are some examples of sick patients where there isn't algorithmic care to how everything is supposed to be done? Sepsis is the main example I think of when I think of a really sick patient, but now their care is pretty standardized thanks to EGDT and other research. Can anyone think of examples of types of patients where you can't easily draw up a flowchart for how they should be managed? I'm not trying to make an inflammatory post here; I'm genuinely curious if these things exist anymore or if protocol medicine is the future of how we're going to do everything.
definitely a protocol for a lot the magic is in coming up with the differential, then drawing up the tests to determine if you are right. It is a little easier in trauma because you know what the differential is: a gun shot.
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GI bleeder with an acute MI.
CHF'er who is septic.
Hypotensive pt in a fib with RVR.
...and many other cases where treating one problem worsens another.
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Back to the original thread: I think that people are generally correct when they point out that one needn't see a lot of trauma to know how to manage most trauma just as one needn't do a lot of intubations to know how to manage most airways. What this misses, however, is that you need to see a lot of trauma (or do a lot of airways) to have a high probability of managing a total clusterf^*k case during residency. Because, fortunately, these are rather rare.
If all you've ever intubated are young isolated head injured patients and septic pneumonias with normal anatomy, then you'll be in trouble when the guy with a mouth full of blood from his penetrating neck injury rolls in.
The frightening reality is that no residency can guarantee you'll get this experience during your training. The best you can do is to not select a place because it's "kush" and to really work your butt off to try and see as much as you can while you're practicing on someone else's license!
If all you've ever intubated are young isolated head injured patients and septic pneumonias with normal anatomy, then you'll be in trouble when the guy with a mouth full of blood from his penetrating neck injury rolls in.
The frightening reality is that no residency can guarantee you'll get this experience during your training. The best you can do is to not select a place because it's "kush" and to really work your butt off to try and see as much as you can while you're practicing on someone else's license!
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...and at many community shops, in both instances, you call the helicopter.
I have seen both at my community shop - and yes, you get good at arranging expedient transfers. I was shocked when I first moved out here at the incredible pathology that shows up at ye olde neighborhood hospital.
But you have to figure out how to stabilize first, and your transplant rejection may also be in CHF and failing BIPAP... and your polytrauma may need 2 chest tubes, and an airway due to a crushed larynx (think dirtbike vs barbed wire fence...) Hence, the broadness of residency training where you see as much as you possibly can to cram in all the experience you can. (*on someone else's license! Which is sooo true!)
ETA: Speaking of bad combos: true example from last week:
Acute Anterior MI with tombstones, with new dense L hemiparesis with hemorrhagic conversion and a big intracardiac clot. Fix That!
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gulp...actually, better make that a double gulp
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Yeah, I thought he was "just" dissecting at first... that's what can happen when you ignore that chest pain for 3 days! Bad, bad news, and he didn't do well.
There is no algorithm for that. In fact, there was very little consensus with the specialists about what the heck to do.
There is no algorithm for that. In fact, there was very little consensus with the specialists about what the heck to do.
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I am shocked...shocked to hear there was a bad outcome in that case! Sounds like the hits just kept on coming. Did you keep ordering labs and imaging just to see how completely hosed he was in every possible way?
Word. I imagine you and they could have all agreed on a STAT palliative care consult though.
