importance of trauma training for first job

[donaldfaison]

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Hi all,

Current CA-3 at a non-trauma program. I have been offered a position with a group that covers a Level II trauma center in the inner city that deals with lots of stabbings/GSW/MVAs. I'm just feeling a little uneasy to accept this position given I'm coming from a program with little trauma experience - I have done several livers and other MTP cases. How important is trauma training going into a job like this? Is it wise to be somewhat learning new things like this in my first job out of residency?

 

[Beeftenderloin]

CA-2 at a level 1. Trauma’s aren’t particularly tricky anesthetics. It’s lines and tubes and keeping up with losses. Take the job. You’ll do fine.

 

[Mikkel]

Trauma anesthesia on an otherwise healthy gun club member is easier than a sick as hell ASA 4 patient undergoing a complex surgery.

You'll be fine as long as you're comfortable under stress, can prioritize, and can handle any anesthetic procedure with ease.

 

[caligas]

Read up, do more big cases this year. Ask to sit in on some traumas when you start at the new gig. You’ll be fine.

 

[woopedazz]

Order ROTEM.
Pretend to look at ROTEM.
Announce you have interpreted the ROTEM - preferably after you've pretended to look at it.
Give Tranexamic Acid and order Cryoprecipitate.
Everyone claps for your ability to properly interpret ROTEM.

 

[Mman]

Order ROTEM.
Pretend to look at ROTEM.
Announce you have interpreted the ROTEM - preferably after you've pretended to look at it.
Give Tranexamic Acid and order Cryoprecipitate.
Everyone claps for your ability to properly interpret ROTEM.

I always enjoy the surgeon wanting to send a TEG when we are going to be about a half blood volume behind by the time we get the results. Gee looks like we needed some cryo about 12 units of blood ago.

 

[dannyboy1]

If you can transfuse blood, FFP, and platelets, and leave the patient intubated you will be fine.

 

[deleted126335]

If you can transfuse blood, FFP, and platelets, and leave the patient intubated you will be fine.

Add be quick and slick with lines.

 

[bullard]

I can’t believe nobody has pointed out that taking a job where you have to do trauma is a bad idea.

 

[deleted171991]

I can’t believe nobody has pointed out that taking a job where you have to do trauma is a bad idea.

There is no accounting for taste.

 

[deleted162650]

I can’t believe nobody has pointed out that taking a job where you have to do trauma is a bad idea.

Inner City no less which = crappy payer mix. So either the pay sucks or the group is reliant on a heavy subsidy which carries its own set of problems.

 

[Mman]

I can’t believe nobody has pointed out that taking a job where you have to do trauma is a bad idea.

for as much as those cases can be inconvenient, it does get the adrenaline going a bit and make the night go faster when we get a bad trauma

 

[deleted875186]

Order ROTEM.
Pretend to look at ROTEM.
Announce you have interpreted the ROTEM - preferably after you've pretended to look at it.
Give Tranexamic Acid and order Cryoprecipitate.
Everyone claps for your ability to properly interpret ROTEM.

I love it. maybe I’ll start ordering TEGs on all my cases just for the confidence boost.

 

[deleted875186]

I haven’t done all that many true trauma cases, but I will say there is nothing that complex. IV access, cefazolin, rocuronium, some amnesia, resuscitation.

 

[urge]

Hi all,

Current CA-3 at a non-trauma program. I have been offered a position with a group that covers a Level II trauma center in the inner city that deals with lots of stabbings/GSW/MVAs. I'm just feeling a little uneasy to accept this position given I'm coming from a program with little trauma experience - I have done several livers and other MTP cases. How important is trauma training going into a job like this? Is it wise to be somewhat learning new things like this in my first job out of residency?

Not much to it other than transfusing a lot and moving quickly.

Stakes are usually pretty low.

 

[T-burglar]

Trauma is only straightforward if you feel no obligation to be a doctor . For some reason The idea that resuscitating severe poly trauma is just “transfusion” is as pervasive as it is r3tarded

 

[urge]

Trauma is only straightforward if you feel no obligation to be a doctor . For some reason The idea that resuscitating severe poly trauma is just “transfusion” is as pervasive as it is r3tarded

Feel free to educate us on how to be a doctor during a trauma. An empty snippy comment is not going to cut it.

 

[deleted162650]

Feel free to educate us on how to be a doctor during a trauma. An empty snippy comment is not going to cut it.

I think @woopedazz already explained it:

Order ROTEM.
Pretend to look at ROTEM.
Announce you have interpreted the ROTEM - preferably after you've pretended to look at it.
Give Tranexamic Acid and order Cryoprecipitate.
Everyone claps for your ability to properly interpret ROTEM.

 

[2Fast2Des]

I can't say I miss massive transfusion, it's nice to sleep on call instead of being up all night burning through ungodly amount of blood products on gang banger #345 minding his own business and getting myself more grays on the noggin. Once in a while it's nice just to keep the resusc skills alive but every day would get old..

 

[sleepallday]

How far is the closest Level 1 trauma center?

If its somewhat close, then I would guess this place can't be that bad

 

[deleted697535]

CA-2 at a level 1.

Trauma’s aren’t particularly tricky anesthetics.

You're a second year resident in july and you think trauma anesthetics aren't hard. Is that correct?

That's more than a bit disturbing.

 

[Beeftenderloin]

You're a second year resident in july and you think trauma anesthetics aren't hard. Is that correct?

That's more than a bit disturbing.

Not sure why that’s disturbing. I’m not saying they aren’t hard. Sure they can be hard (work) and certainly stressful at times. I just mean they aren’t particularly complex. Especially compared to a sick liver.

 

[T-burglar]

Blunt polytrauma can have any number of extremity, intra thoracic, intra abodminal, and spine/CNS injuries that have to be diagnosed and managed. Sometimes level 1s come flying into the OR with incomplete work ups.

If you boil the entirety of acute care medicine ( chest abdomen ultrasound , TTE/TEE, coagulation management, blunt cardiac arrest management, emergent CPB for cardiac or great vessel trauma, spine or CNS protection, prevention of secondary neurological injury, the list goes on) down to “massive transfusion” then I don’t know what to tell you

 

[2Fast2Des]

Blunt polytrauma can have any number of extremity, intra thoracic, intra abodminal, and spine/CNS injuries that have to be diagnosed and managed. Sometimes level 1s come flying into the OR with incomplete work ups.

If you boil the entirety of acute care medicine ( chest abdomen ultrasound , TTE/TEE, coagulation management, blunt cardiac arrest management, emergent CPB for cardiac or great vessel trauma, spine or CNS protection, prevention of secondary neurological injury, the list goes on) down to “massive transfusion” then I don’t know what to tell you

Prop roc tube, easy on the prop

 

[Hoya11]

Hi all,

Current CA-3 at a non-trauma program. I have been offered a position with a group that covers a Level II trauma center in the inner city that deals with lots of stabbings/GSW/MVAs. I'm just feeling a little uneasy to accept this position given I'm coming from a program with little trauma experience - I have done several livers and other MTP cases. How important is trauma training going into a job like this? Is it wise to be somewhat learning new things like this in my first job out of residency?

arent there requirements to do a certain number of trauma cases before graduating from any program? some programs rotate out for trauma experience

 

[Mman]

arent there requirements to do a certain number of trauma cases before graduating from any program? some programs rotate out for trauma experience

It's been a while but I seem to remember that anything traumatic coming to the OR counted. ORIFs of various bones or laceration suturing were allowable. It didn't have to be trauma x-laps and thoracotomies.

 

[IMGASMD]

Don’t believe there is an actual trauma requirement.

 

[Modanq]

Trauma equals no anesthesia, large dose of VEC, and blood products.
Throw in a REBOA for funzies and venous access and you are good to go. Thats about it.

 

[shepardsun]

No trauma requirement for ACGME minimum case log and something laughable like 10 or 20 patients with "life threatening pathology."

 

[Mikkel]

No trauma requirement for ACGME minimum case log and something laughable like 10 or 20 patients with "life threatening pathology."

Did that change? I thought trauma was indeed a requirement, but they never specified what trauma was.

I did a ton of sick 100+ year old hip fractures. Bloody livers. Crash sections.

You don't need a trauma room to know how to handle it. Maybe that's a reason why acgme might have changed the language of the requirement.

 

[shepardsun]

No trauma as of 2017 when I started. The entire resident case logging system is kind of weird, to be honest. Some categories with weird specificity but poor definitions- i.e. major vascular (we do a ton of renal transplants at my program, so some people would count that in the setting of renal artery anastomosis), high risk vaginal delivery, intracranial endovascular, etc, some categories that are incredibly broad and vague (life threatening pathology, 10 cases minimum), no area for documentation of airway skills like jet ventilation or awake fiber, etc etc etc

 

[dchz]

Yeah I feel like there should be auto clicks in the ACGME case log.

Like if your case has CPB it should automatically be a procedure on a major vessel.

I ended up with like 60 CPB cases but only 20 major vessel cases because I was too lazy to log them correctly.

 

[deleted875186]

Yeah I feel like there should be auto clicks in the ACGME case log.

Like if your case has CPB it should automatically be a procedure on a major vessel.

I ended up with like 60 CPB cases but only 20 major vessel cases because I was too lazy to log them correctly.

I don’t think CPB cases count as major vascular. I always took that to mean vascular cases, such as open or endovascular AAA, bypass for PVD, CEA, etc. the case log is very vague.

 

[dchz]

I don’t think CPB cases count as major vascular. I always took that to mean vascular cases, such as open or endovascular AAA, bypass for PVD, CEA, etc. the case log is very vague.

I fail to see a PVD bypass is more of a "major" vessel case than when they stab two cannulas into the aorta. and if it's a CABG they sew just as many things into the aorta as femoral bypasses. In the case of CEA, how is the carotid more of a vascular case than the things they're doing to the Aorta on the regular?

 

[Beeftenderloin]

I fail to see a PVD bypass is more of a "major" vessel case than when they stab two cannulas into the aorta. and if it's a CABG they sew just as many things into the aorta as femoral bypasses. In the case of CEA, how is the carotid more of a vascular case than the things they're doing to the Aorta on the regular?

 

[vector2]

I fail to see a PVD bypass is more of a "major" vessel case than when they stab two cannulas into the aorta. and if it's a CABG they sew just as many things into the aorta as femoral bypasses. In the case of CEA, how is the carotid more of a vascular case than the things they're doing to the Aorta on the regular?

They may sew to the aorta, but logging pump cases (or kidney transplants) as "vascular - major vessel" is clearly not in the spirit of what the ACGME was going for. As far as resident training for vascular cases, the problem is that CEAs are technically only intermediate risk procedures with high risk vascular essentially only being when the abdominal or thoracic aorta is getting clamped, cut, and sewn to, or when you have a dead leg or something that's getting revascularized. Those cases (as far as management) are distinctly different than a typical CABG, and hence why the category is separate. Another problem is that open major vascular is just getting rarer and rarer, and major endovascular is usually a simple MAC case with an aline and two PIVs

 

[deleted875186]

I fail to see a PVD bypass is more of a "major" vessel case than when they stab two cannulas into the aorta. and if it's a CABG they sew just as many things into the aorta as femoral bypasses. In the case of CEA, how is the carotid more of a vascular case than the things they're doing to the Aorta on the regular?

All the vascular things in a cardiac case are done on bypass. You don’t manage any hemodynamics or see the effects of what they’re doing, you just come off of bypass at the end. At least in my mind cardiac cases are very different than vascular cases where they’re clamping and unclamping things.

 

[deleted162650]

All the vascular things in a cardiac case are done on bypass. You don’t manage any hemodynamics or see the effects of what they’re doing, you just come off of bypass at the end. At least in my mind cardiac cases are very different than vascular cases where they’re clamping and unclamping things.

How ‘bout OPCAB’s? In my residency probably 90% of CABG’s were off pump.

 

[dchz]

They may sew to the aorta, but logging pump cases (or kidney transplants) as "vascular - major vessel" is clearly not in the spirit of what the ACGME was going for. As far as resident training for vascular cases, the problem is that CEAs are technically only intermediate risk procedures with high risk vascular essentially only being when the abdominal or thoracic aorta is getting clamped, cut, and sewn to, or when you have a dead leg or something that's getting revascularized. Those cases (as far as management) are distinctly different than a typical CABG, and hence why the category is separate. Another problem is that open major vascular is just getting rarer and rarer, and major endovascular is usually a simple MAC case with an aline and two PIVs

All the vascular things in a cardiac case are done on bypass. You don’t manage any hemodynamics or see the effects of what they’re doing, you just come off of bypass at the end. At least in my mind cardiac cases are very different than vascular cases where they’re clamping and unclamping things.

When you log the case, the check box in question is phrased as "procedure on major vessel". Not "major vascular case".

Also if you scroll up, I did log it as @vector2 stated as I didn't log my CPBs as procedure on major vessel. But in the way the system is set up, I don't see any problem to log CPB cases that way as they are "proc on major vessel".

 

[Twiggidy]

When you log the case, the check box in question is phrased as "procedure on major vessel". Not "major vascular case".

Also if you scroll up, I did log it as @vector2 stated as I didn't log my CPBs as procedure on major vessel. But in the way the system is set up, I don't see any problem to log CPB cases that way as they are "proc on major vessel".

It's basically a technicality that gets encouraged by programs with low numbers of certain cases. If people are logging CPB cases are "major vascular" then they're gaming the system because they probably don't have enough vascular cases to cover the residents ACGME requirements.

Minor vascular:
Fistulas

Major:
AAAs
Major vessel bypass
Carotids

It gets tricky with the angiograms and stents. If I were a PD I would tell my residents to label it major vascular but in reality it's just "put them to sleep, keep the pressure good, and check ACTs"

Heart Room = Cardiac