how much trauma is enough trauma?

[rebel7]

Funny how thoughts come up as soon as u hit the sac lol
if I wanted to do anything but trauma surgery/fellowship, do I really need to get exposed to a lot of trauma cases? Makes it easier looking for a low or non trauma center while applying... Wat do u say?

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[thedrjojo]

Funny how thoughts come up as soon as u hit the sac lol
if I wanted to do anything but trauma surgery/fellowship, do I really need to get exposed to a lot of trauma cases? Makes it easier looking for a low or non trauma center while applying... Wat do u say?

When I was on the interview trail this year, places with High Trauma load (like, rotations every year and almost 1 full year of 5 spent on trauma) built up its importance as a place where you really learn to manage patients, typically residents get a lot of responsibility on those patients, great learning of anatomy when you do actually operate, and since like 20-25% of the boards (so I was told) was trauma, having a large exposure really helps you on the boards. Places with low trauma or farmed out trauma (6 weeks to a couple of months) say that trauma isn't really operative anymore, that it is just a babysitting service that residents hate, that it is all algorhythm based and once you learn the algorhythms you really don't need to do it any more unless that is what you want to do (ie fellowship/attending job). There is probably some truth in both of those points, and goes to show that there is more than one way to skin a cat. I have 0 interest in Trauma, but the place I ended up matching is actually mainly known for its Trauma and you rotate on the trauma service all 5 years! For me, the other pros of the program outweighed this negative to me (I think its you need it a few times, maybe as an intern, midlevel, and senior/chief to see the different aspects of trauma at different skill/knowledge levels).

 

[SouthernSurgeon]

When I was on the interview trail this year, places with High Trauma load (like, rotations every year and almost 1 full year of 5 spent on trauma) built up its importance as a place where you really learn to manage patients, typically residents get a lot of responsibility on those patients, great learning of anatomy when you do actually operate, and since like 20-25% of the boards (so I was told) was trauma, having a large exposure really helps you on the boards. Places with low trauma or farmed out trauma (6 weeks to a couple of months) say that trauma isn't really operative anymore, that it is just a babysitting service that residents hate, that it is all algorhythm based and once you learn the algorhythms you really don't need to do it any more unless that is what you want to do (ie fellowship/attending job). There is probably some truth in both of those points, and goes to show that there is more than one way to skin a cat. I have 0 interest in Trauma, but the place I ended up matching is actually mainly known for its Trauma and you rotate on the trauma service all 5 years! For me, the other pros of the program outweighed this negative to me (I think its you need it a few times, maybe as an intern, midlevel, and senior/chief to see the different aspects of trauma at different skill/knowledge levels).

I'd agree with this - one of my seniors put it this way to me - he said you will see on the interview trail a huge distinction between "trauma heavy" and "trauma light" residencies, and you will quickly figure out which one is for you.

I have seen him operate and handle tough cases in other settings, and have no doubt that a traumatically injured patient would be in capable hands if he were taking care of them - but it isn't what he wants to do with his career and I don't blame him for picking a "trauma light" residency.

I think the above nailed it - more than one way to skin a cat.

 

[SocialistMD]

Abdonminal trauma isn't difficult compared to thoracic trauma probably due to the relative infrequency of bad thoracic trauma that actually survives to the hospital. If you want to do trauma, that is what you want to find in your residency/fellowship, as it is rare and usually disasterous when it comes in bad, but it is also a place where one can make a great save.

 

[Buzz Me]

We get way too much trauma here, IMHO. Level 1 trauma center, two months as an intern, one as a 2, two as a 3, four as a 4. That doesn't include all the cross-cover calls during the General Surgery rotations throughout all five years.

 

[Baby Boy]

We get way too much trauma here, IMHO. Level 1 trauma center, two months as an intern, one as a 2, two as a 3, four as a 4. That doesn't include all the cross-cover calls during the General Surgery rotations throughout all five years.

Wow, that's a lot of trauma. Having said that, one out of three rooms on your oral board exam will be trauma/critical care whereas 9 out of 60 months of your clinical training will trauma.

 

[thedrjojo]

We get way too much trauma here, IMHO. Level 1 trauma center, two months as an intern, one as a 2, two as a 3, four as a 4. That doesn't include all the cross-cover calls during the General Surgery rotations throughout all five years.

My residency is (will be, since I haven't started) even worse: 1-2 months as an intern, 8 weeks as a 2, 3, 4, and 5 all the the main hospital (state level 1 trauma) and then the secondary hospital has trauma (regional level 1 i believe) but not sure how that breakdown is, so all in all, about 12+ months in trauma

 

[Buzz Me]

Wow, that's a lot of trauma. Having said that, one out of three rooms on your oral board exam will be trauma/critical care whereas 9 out of 60 months of your clinical training will trauma.

Agreed. We see so much trauma here all the chiefs are overprepared for the oral boards (for that subject).

 

[M.Furfur]

Do you guys know which gen surg programs are famous for their trauma exposure?

 

[SocialistMD]

A great deal of the trauma literature comes out of the following programs. Does it mean they have a better or worse trauma experience? I don't know, but it probably contributes to their being known as programs that are famous for their trauma experience.

Emory (Feliciano)
Baylor (Mattox, Wall)
Colorado (E. Moore)
Eastern Virginia (Britt)
UCLA (Demetriades)
UT-Memphis (Fabian)
UT- Southwestern (Gentilello)
Miami (Stylianos [who does peds])

 

[blue2000]

A great deal of the trauma literature comes out of the following programs. Does it mean they have a better or worse trauma experience? I don't know, but it probably contributes to their being known as programs that are famous for their trauma experience.

Emory (Feliciano)
Baylor (Mattox, Wall)
Colorado (E. Moore)
Eastern Virginia (Britt)
UCLA (Demetriades)
UT-Memphis (Fabian)
UT- Southwestern (Gentilello)
Miami (Stylianos [who does peds])

I would add University of Washington (Harborview) to the list. Only level 1 trauma hospital for over 25% of the US (includes Alaska, so a little fudging when you consider population). You'll be well trained in trauma/critical care by the time you complete residency there.

 

[darjeeling14]

I'm not sure how much literature comes of out Wayne State, but I would add this to the list too as far as trauma experience.

 

[Buzz Me]

A great deal of the trauma literature comes out of the following programs. Does it mean they have a better or worse trauma experience? I don't know, but it probably contributes to their being known as programs that are famous for their trauma experience.

Emory (Feliciano)
Baylor (Mattox, Wall)
Colorado (E. Moore)
Eastern Virginia (Britt)
UCLA (Demetriades)
UT-Memphis (Fabian)
UT- Southwestern (Gentilello)
Miami (Stylianos [who does peds])

Agreed.

How about LA County and Cook County? Or the old Charity?

 

[SocialistMD]

I would add University of Washington (Harborview) to the list. Only level 1 trauma hospital for over 25% of the US (includes Alaska, so a little fudging when you consider population). You'll be well trained in trauma/critical care by the time you complete residency there.

While I don't discount your claim for UW, as they are a well-respected trauma program, I think your claim of 25% of the US needs to be better qualified in that it isn't 25% of the population, but rather 25% of the land mass; a number that only really means something if they're also treating bears, beavers and birch trees...

 

[SouthernSurgeon]

A great deal of the trauma literature comes out of the following programs. Does it mean they have a better or worse trauma experience? I don't know, but it probably contributes to their being known as programs that are famous for their trauma experience.

Emory (Feliciano)
Baylor (Mattox, Wall)
Colorado (E. Moore)
Eastern Virginia (Britt)
UCLA (Demetriades)
UT-Memphis (Fabian)
UT- Southwestern (Gentilello)
Miami (Stylianos [who does peds])

Correction - Demetriades is at USC, not UCLA. UCLA seemed pretty weak on trauma.

 

[M.Furfur]

Does more exposure usually correlate with higher chances in matching into a good trauma fellowship? Or is it safer to stick to a top gen surg program that doesn't necessarily have much trauma?

 

[SLUser11]

While I don't discount your claim for UW, as they are a well-respected trauma program, I think your claim of 25% of the US needs to be better qualified in that it isn't 25% of the population, but rather 25% of the land mass; a number that only really means something if they're also treating bears, beavers and birch trees...

I think UW's numbers are pretty high, though. I can't remember exactly, but I read an article recently by them, and I think they do more than 6,000 traumas/year.

Does more exposure usually correlate with higher chances in matching into a good trauma fellowship? Or is it safer to stick to a top gen surg program that doesn't necessarily have much trauma?

It's pretty hard to not match into a trauma fellowship. They are notoriously easy to get into.

One more comment is that most places have a good trauma experience. If you go somewhere known for a heavy trauma workload, you'll find yourself hating trauma pretty quickly.

 

[Rabbit Hole]

What is the scope of trauma that you are able to address as a general surgeon? I can understand abdominal and thoracic trauma, but what about head injuries and severe crush injuries? For example, persons in car accidents or motorcycle accidents (most gruesome in my opinion).. how well are you supposed to be prepared to treat these cases? Do they even make it into the OR? I'd imagine with severe injuries they would not be stable enough to even make it into surgery.

 

[SocialistMD]

What is the scope of trauma that you are able to address as a general surgeon?

Everything but the brain and bones. Granted, some are trained to stablize those patients (burr holes, splinting), but that is not universal for all general surgery residency programs.

 

[Buzz Me]

What is the scope of trauma that you are able to address as a general surgeon? I can understand abdominal and thoracic trauma, but what about head injuries and severe crush injuries? For example, persons in car accidents or motorcycle accidents (most gruesome in my opinion).. how well are you supposed to be prepared to treat these cases? Do they even make it into the OR? I'd imagine with severe injuries they would not be stable enough to even make it into surgery.

Neurosurgery for head bleeds, Ortho for fractures.

Then Plastics/ENT/OMFS for facial trauma, Ophtho for eyes. Sometimes GU for genitalia/bladder injuries.

 

[the duck]

What is the scope of trauma that you are able to address as a general surgeon? I can understand abdominal and thoracic trauma, but what about head injuries and severe crush injuries? For example, persons in car accidents or motorcycle accidents (most gruesome in my opinion).. how well are you supposed to be prepared to treat these cases? Do they even make it into the OR? I'd imagine with severe injuries they would not be stable enough to even make it into surgery.

No. No one who is in a car or motorcycle accident goes to the O. Ever.

 

[Rabbit Hole]

Everything but the brain and bones. Granted, some are trained to stablize those patients (burr holes, splinting), but that is not universal for all general surgery residency programs.

Neurosurgery for head bleeds, Ortho for fractures.

Then Plastics/ENT/OMFS for facial trauma, Ophtho for eyes. Sometimes GU for genitalia/bladder injuries.

Thanks guys. I'm curious about the scope of procedures a surgeon should be able to do if they work in a rural area or in a hospital with a low level trauma center. Of course the patient can be transported but if it is a life or death situation and you don't have a neurosurgeon or ENT guy around.. would you be liable for whatever intervention you make? Or maybe this is something the ER guys are responsible for?

No. No one who is in a car or motorcycle accident goes to the O. Ever.

I realize that most victims are either doa or don't even survive the ride to the hospital. I was just talking about the patients who have a chance at surviving.

 

[Buzz Me]

Of course the patient can be transported but if it is a life or death situation and you don't have a neurosurgeon or ENT guy around.. would you be liable for whatever intervention you make? Or maybe this is something the ER guys are responsible for?

Which "interventions" are you talking about here, exactly? Intubations, central lines, chest tubes? Then yes, the ER can do these at many institutions.

But OR-based procedures? Obviously only surgeons can take patients up to the OR.

 

[thedrjojo]

A great deal of the trauma literature comes out of the following programs. Does it mean they have a better or worse trauma experience? I don't know, but it probably contributes to their being known as programs that are famous for their trauma experience.

Emory (Feliciano)
Baylor (Mattox, Wall)
Colorado (E. Moore)
Eastern Virginia (Britt)
UCLA (Demetriades)
UT-Memphis (Fabian)
UT- Southwestern (Gentilello)
Miami (Stylianos [who does peds])

I might be a bit north eastern biased, but SUNY Downstate (King's County - i think something like 30-40% penetrating trauma), SHOCK trauma (but a better fellow experience than resident experience), UMDNJ-NJMS (gotta give a shout out to my home program, although our penetrating trauma is decreasing, still is very high), I have heard Las Vegas is one of the top fellowships as well, not sure of the resident experience. There is PLENTY of trauma out there, plenty of programs that do trauma, and my impression is that it is not an uber competitive fellowship (most slots don't fill through the match each year is what my impression is).

 

[thedrjojo]

I realize that most victims are either doa or don't even survive the ride to the hospital. I was just talking about the patients who have a chance at surviving.

I think he was being sarcastic. These people are the ones that get the ER thoracotomies, get rushed to the OR for Ex Laps, get the massive transfusion protocol started (essentially a predetermined order of blood products for people expected to need more than 10 units or something like that... some of the trauma here they have pumped like 40-50 units into the person ). Part of the reason these patients are unstable and crashing is internal injury, vascular disruption, and one of the major indications to go for immediate ex lap is instability (overly simplifying the statement). Trauma surgeons operate on some of the sickest and most dire patients, and even though I don't have any interest in doing trauma, my resident experience in it is going to be a phenominal training experience.

 

[Rabbit Hole]

Which "interventions" are you talking about here, exactly? Intubations, central lines, chest tubes? Then yes, the ER can do these at many institutions.

But OR-based procedures? Obviously only surgeons can take patients up to the OR.

I think he was being sarcastic. These people are the ones that get the ER thoracotomies, get rushed to the OR for Ex Laps, get the massive transfusion protocol started (essentially a predetermined order of blood products for people expected to need more than 10 units or something like that... some of the trauma here they have pumped like 40-50 units into the person ). Part of the reason these patients are unstable and crashing is internal injury, vascular disruption, and one of the major indications to go for immediate ex lap is instability (overly simplifying the statement). Trauma surgeons operate on some of the sickest and most dire patients, and even though I don't have any interest in doing trauma, my resident experience in it is going to be a phenominal training experience.

Thanks guys, my curiosity is quenched.

 

[SocialistMD]

I'm curious about the scope of procedures a surgeon should be able to do if they work in a rural area or in a hospital with a low level trauma center. Of course the patient can be transported but if it is a life or death situation and you don't have a neurosurgeon or ENT guy around.. would you be liable for whatever intervention you make?

Don't get creative if there is a hospital where you can refer a patient. There really aren't facial trauma emergencies (other than to protect the airway, which can be done with either an ET tube or a surgical airway, both of which are taught in ATLS), so you always have time to transfer bad facial injuries. Likewise, if you are at a rural hospital and get a patient in with a head injury, you stabilize them and transfer them as fast as possible to a place that has a neurosurgeon. If they don't make it, they don't make it (it happens), but if you try to intervene and the patient dies, you may have to justify to the lawyer why you did something you aren't trained to do and explain how it wasn't what caused the patient's demise.

I might be a bit north eastern biased, but SUNY Downstate (King's County - i think something like 30-40% penetrating trauma), SHOCK trauma (but a better fellow experience than resident experience), UMDNJ-NJMS (gotta give a shout out to my home program, although our penetrating trauma is decreasing, still is very high), I have heard Las Vegas is one of the top fellowships as well, not sure of the resident experience.

You are equating penetrating trauma volume to a program being "famous." I don't think they are synonymous, but that doesn't make your method more or less valid (though, I'll admit, there is possibly a regional aspect, as I hadn't heard of King's County's trauma experience (despite my sister-in-law being an ER attending a couple of blocks away) nor UMDNJ-NJMS's (of course I had heard of Shock Trauma, but the University of Maryland isn't really known as a program with great trauma experience despite being attached to ST). I listed the names of authors that I know from the trauma literature and the institutions from which they hail, but did so explaining that it was one way to explain why one might have heard of said programs. Again, it is just how one chooses to define it, and I don't think the trauma training is any better or worse at any one institution.

 

[Rabbit Hole]

Don't get creative if there is a hospital where you can refer a patient. There really aren't facial trauma emergencies (other than to protect the airway, which can be done with either an ET tube or a surgical airway, both of which are taught in ATLS), so you always have time to transfer bad facial injuries. Likewise, if you are at a rural hospital and get a patient in with a head injury, you stabilize them and transfer them as fast as possible to a place that has a neurosurgeon. If they don't make it, they don't make it (it happens), but if you try to intervene and the patient dies, you may have to justify to the lawyer why you did something you aren't trained to do and explain how it wasn't what caused the patient's demise.

This is one of those "worst case scenarios" I hope to never find myself in. Thanks for pinpointing my concern - I had trouble trying express it clearly earlier.

 

[Winged Scapula]

As Socialist notes, your primary job is to evaluate and stabilize the patient. If you can safely and effectively offer treatment the patient needs, then you provide it, as long as it is within the scope of your practice. Otherwise, you arrange transfer to a facility and a practitioner who can provide that care. Some patients will not survive to obtain that care.

There is an interesting phenomenon in the transition from pre-med to med student to resident and attending. The former two often insist on the idea that doing something, anything is better than doing nothing. The latter two have seen what harm can come, especially when "cowboys" attempt things they have little to no training in.

 

[Pickyournose]

If you are sharp, you can't have too much trauma. There are lots of subtle differences in different patients. I had a lot of ortho. It helped even though I don't do ortho now