Is it possible to practice GS without trauma/ER?

[Sir Jun]

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I love surgery, and I really frankly enjoy "bread and butter" cases like lap choles, hernias, etc. I don't need the "adrenaline fix" that many find in severe trauma cases, etc. In fact, I wonder whether I could mentally sustain myself over the years in terms of dealing with trauma deaths, etc. Because of this, I'm wondering whether a career as a general surgeon is appropriate or not for me.

Anyone else have this problem?

Thanks.

Dan MS3

 

[Pilot Doc]

Is it possible to practice GS without trauma/ER?

Yes.

Trauma is the easiest to avoid. You simply don't hold operative privileges (and therefore the requirement to take call) at a hospital that deals with major trauma. As trauma patients are increasingly shipped to dedicated trauma centers, the trauma exposure at other hospitals has gone down. Private hospitals near trauma centers likely see almost no trauma and rural hospitals stabilize and transfer their traumas.

Avoiding ER call would require a purely outpatient practice. Most hospitals will require ER call as a condition of operative privileges. However, the "adrenaline fix" situations you wish to avoid are rare among non-trauma ER cases.

During residency, your trauma exposure can also be limited by avoiding trauma heavy programs. Keep in mind that the skills developed in trauma care are widely applicable to elective cases and complications.


What it boils down to, as in most of the "Can I be an general surgeon and still X?" questions is lifestyle, location and income. You generally get to pick two (or a double helping of one).

 

[Sir Jun]

Thanks for your response. Income is not a priority of mine as long as I can do what I love. (although I too am a pilot--no money = no flying right now). Your comments about learning skills through trauma is something that I've been thinking about too and it's something that an attending told me about recently. She said that by taking trauma call she gets to keep her skills in top shape, and I feel that she is right.

Another case. A great laparoscopic specialist who I worked with extensively is open about hating trauma, yet he has been forced to take trauma call at our academic institution because he's new and there's a relative shortage of trauma surgeons here right now. I just don't want to end up in his position; until we get some more trauma surgeons here, this man is a miserable person.

Dan

 

[EMRaiden]

Sometimes its easier that that... I work in the ED of a Level 3 Trauma Center. On Thanksgiving day the Surgeon of the day called in and informed me that he was only on for "Level 4 Emergencies", and had no intention of coming in.

To this day I have no idea of what a "Level 4 Emergency" is.

 

[Pilot Doc]

A great laparoscopic specialist who I worked with extensively is open about hating trauma, yet he has been forced to take trauma call at our academic institution because he's new and there's a relative shortage of trauma surgeons here right now. I just don't want to end up in his position; until we get some more trauma surgeons here, this man is a miserable person.

Dan

Ultimately, that attending chose to take trauma call. For whatever reason - location, research opportunities, etc, he decided to stay in a situation requiring trauma call. If he is truly a great laparoscopic specialist, there are private groups all over the country who would love to hire him.

If you're interested, take a look at
Practice Link or
General Surgery Jobs
The jobs with no trauma will typically so state.

 

[shag]

Trauma is an essential part of surgical training, which will show up on boards. More importantly, there may be situations in practice when even a lap specialist may have to place a chest tube or a trach. For this reason, I believe that basic trauma skills (i.e. ATLS) are just as "bread and butter" as lap choles and SCC removal.

As a resident, you will have to rotate on a trauma service. If you are at a trauma heavy center like U of Miami, UAB, or UT memphis, then you can plan to spend a lot of time taking care of trauma patients. You can avoid a lot of your trauma experience by training at a private hospital or an academic center that doesn't have a trauma center.

Regardless, you will have to spend enough time on trauma that if you absolutely hate it, then this may not be the career for you. If it is more of an intense dislike, then perhaps you can tough it out.

 

[Vincristine]

While residency includes trauma, and probably way more trauma than you'd like, let's remember that 5 years out of the 20-40 you will practice is NOT very long. I think it's relatively simple to avoid trauma. In my town there are two hospitals -- one a level 1 trauma center, the other not. Anything even remotely trauma-ish goes to the trauma center which means the general surgeons at the other hospital get almost none and people in that ER think seriously before calling the gen surgeon on call (from home). The other option is private practice.

 

[Vincristine]

Sometimes its easier that that... I work in the ED of a Level 3 Trauma Center. On Thanksgiving day the Surgeon of the day called in and informed me that he was only on for "Level 4 Emergencies", and had no intention of coming in.

To this day I have no idea of what a "Level 4 Emergency" is.

Someone correct me if I'm wrong, but trauma levels are such that Level 1 is the highest, so "level 4" would be the equivalent of a kid falling off his bicycle and the least severe trauma. (In NICU's on the otherhand, level 3 is the highest level of care.)

 

[supercut]

You can probably avoid being responsible for ultimate care of trauma pts in your career. However, I imagine it would be difficult to avoid any trauma at all. And it's even harder to see how you could avoid ED at all. (appys are still considered a bread and butter case, right? They generally don't come in to your office). You'll probably have to share call with your practice group,and may have to stabilize a trauma pt for transfer to a trauma cener.

You will have to rotate on trauma as a resident. Even if you hate trauma, it's good because you'll learn how to take care of really sick pts. Some of your own pts in your practice will unexpectedly become really sick. Also some GS emergencies (perforated colon for example) can get really sick.

You could look for a job in a large practice (thus fewer call days) or in a smaller area (thus not having to come in much when you are on call). Before med school I worked in a rural hospital in a town that had one general surgeon. He did mostly what you describe..smaller elective cases. Being the only surgeon, he was essentially on 24/7 call. But the town was small enough that he only had to come in a few times a month. Sometimes it was for something like taking a pt with a large complex laceration to the OR for washout and closure under anesthesia. Sometimes it was for an appy. Occaisionally for something else but by far mostly lacs and appys.

 

[kinetic]

Such a facility may or may not have a physician immediately available. The initial patient encounter may be the responsibility of a nurse. Early assessment and resuscitation place a heavier burden on rural emergency nurses than their urban counterparts. The nurse may await the arrival of a physician from outside the hospital. The responding physician usually is a primary care provider and infrequently encounters the multiple injured patient. The level IV center is expected to provide advanced trauma life support prior to the patient's transfer to a higher level trauma center. The American College of Surgeons (ACS) notes that the level IV facility is not meant to provide a downgraded option for a less than fully committed level III hospital. Resources for the Optimal Care of the Injured Patient: 1993. Committee on Trauma, American College of Surgeons.

 

[kinetic]

Such a facility is usually staffed by your mother, who will be responsible for the initial patient encounter. She will provide band-aids and boo-boo support as needed. The level V center is expected to provide lemonade prior to the patient's transfer to a higher level trauma center. The American College of Surgeons (ACS) notes that the level V facility is not sterile, so eat at your own risk. Resources for the Optimal Care of the Injured Patient: 1993. Committee on Trauma, American College of Surgeons.

 

[Vukken99]

The real question is what is the difference between Trauma I and II

I will let anyone else answer this then I can say you know about trauma organization.

Now, I recently was in Las Vegas taking the ATLS course.
Very good course indeed with good lectures and stuff.

I met a vascular surgeon from a reputable trauma center in California and he said he is not fellowship trained in Trauma but he does most of the trauma in these center.

If you have completed general surgery and if you have ATLS certification.
You can do trauma...and all the guidelines are out there....so not so difficult to do...

Plus trauma is where a surgeon can show he can manage critical resuscitation with emergency operative skills. I loved ATLS...

I love it even more when i got the ATLS card from the ACS...

 

[shag]

The purpose of ATLS is to allow non-trauma surgeons (i.e. Dr. Rural BeeFEee) to stabilize a patient for transfer to a trauma center. For residents, this is a good intro into initial assessment/stabilization of the trauma patient, but is by no means a trauma fellowship.

A gen surg with adequate training can handle most minor to moderate traumas, but a fellowship trained trauma surgeon is essential for managing the critically ill multi-injury patient.

 

[Apollyon]

A gen surg with adequate training can handle most minor to moderate traumas, but a fellowship trained trauma surgeon is essential for managing the critically ill multi-injury patient.

Not true (at least at Duke, where only 1 of 5 trauma attendings has done a trauma fellowship).

 

[praying4MD]

Not true (at least at Duke, where only 1 of 5 trauma attendings has done a trauma fellowship).

I agree. I also know of someone who just took a position straight out of residency as faculty at a Level I Trauma Center at an academic institution and he opted NOT to do a Trauma or a Critical Care Fellowship. This is not an exception to the rule either.

 

[Celiac Plexus]

A gen surg with adequate training can handle most minor to moderate traumas, but a fellowship trained trauma surgeon is essential for managing the critically ill multi-injury patient.

Absolutely untrue. Every general surgeon at my my program (and my medical school for that matter) managed "critically ill multi-injury patients" at one time or another. If you completed a general surgery residency, you should be able to do this. I have noticed at my program that 3rd and 4th year residents handle these kind of patients all the time. At my program we have only 2 trauma surgeons right now. One is old and never did a fellowship. The other is younger and has done a fellowship. I think that the only advantages to doing a fellowship in critical care/trauma are: 1. if your gensurg residency was light on trauma and you need extra training, 2. it's a nifty little marketing tool to negotiate extra money from an employer, and 3. if you want to stay academic, then it's just yet another hoop you can jump through.

 

[Energon]

Celiac Plexus, is that really you??? good to have you back. Since you and woman surg bailed, there has been no one to provide us with sarcastic surgeon humor 🙁

 

[Jeff698]

The real question is what is the difference between Trauma I and II

Level I

Provides comprehensive trauma care, serves as a regional resource, and provides leadership in education, research, and system planning.

A level I center is required to have immediate availability of trauma surgeons, anesthesiologists, physician specialists, nurses, and resuscitation equipment. American College of Surgeons' volume performance criteria further stipulate that level I centers treat 1200 admissions a year or 240 major trauma patients per year or an average of 35 major trauma patients per surgeon.


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Level II

Provides comprehensive trauma care either as a supplement to a level I trauma center in a large urban area or as the lead hospital in a less population-dense area.

Level II centers must meet essentially the same criteria as level I but volume performance standards are not required and may depend on the geographic area served. Centers are not expected to provide leadership in teaching and research.


*

*
Level III

Provides prompt assessment, resuscitation, emergency surgery, and stabilization with transfer to a level I or II as indicated.

Level III facilities typically serve communities that do not have immediate access to a level I or II trauma center.


*

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Level IV & V

Provides advanced trauma life support prior to patient transfer in remote areas in which no higher level of care is available.

The key role of the level IV center is to resuscitate and stabilize patients and arrange for their transfer to the closest, most appropriate trauma center level facility.

Level V trauma centers are not formally recognized by the American College of Surgeons, but they are used by some states to further categorize hospitals providing life support prior to transfer.

From: http://www.amtrauma.org/tiep/reports/ACSClassification.html

Take care,
Jeff

 

[shag]

Apollyon, praying, and celiac,

The common thing in your examples is that you are at busy academic trauma centers. Working as a junior attending on an academic trauma service is basically a trauma fellowship in and of itself. Of course, there is a bit more responsibility and a lot more money...

If you had a car accident in East Ohio or North Alabama, would you want the general surgeon at the 20 bed rural hospital cracking your chest or performing a trauma ex-lap on you? Even if he/she is ATLS certified and has "trauma surgeon" on his/her business card?

 

[Apollyon]

If you had a car accident in East Ohio or North Alabama, would you want the general surgeon at the 20 bed rural hospital cracking your chest or performing a trauma ex-lap on you? Even if he/she is ATLS certified and has "trauma surgeon" on his/her business card?

Have you taken ATLS? The whole point is to stabilize and transfer; if you're in rural America (which doesn't happen to be Rochester MN or Durham NC), the EM doc will be the one cracking the chest (unless it's a rare day when the GS is not in the OR, but in the hospital, especially at a 20-bed place, like the Stonewall Jackson Hospital in Lexington VA - almost directly halfway between Roanoke and UVa). Likewise, the time for the GS to come from home and scrub, along with having the OR personnel, is likely to be similar to the time to transfer (I don't know how many times the surgeon has left the trauma bay, is scrubbed, and is standing there waiting by the time the pt gets to him; it's got to be similar for GS coming from home). If there's time for an ex-lap, there's time for transfer. We had one like that - scene --> outside hosp --> Duke. When she got to us, her belly was visibly expanding, had a LOT of fluid on U/S, and coded once. Brain was mush and expired in the SICU.

If the place has volume, it doesn't need to be academic. If it doesn't have volume, it won't be a higher level, and that will mean transfer. If it has volume, a GS residency is enough (likewise, your GS residency should have the volume to teach you to manage trauma and surgical critical care).

 

[shag]

Have you taken ATLS? The whole point is to stabilize and transfer;

Absolutely!

The post I responded to initially stated:

If you have completed general surgery and if you have ATLS certification.
You can do trauma...and all the guidelines are out there....so not so difficult to do...

I agree with your statement about stabilization and transfer. In a past post, I stated:

The purpose of ATLS is to allow non-trauma surgeons (i.e. Dr. Rural BeeFEee) to stabilize a patient for transfer to a trauma center. For residents, this is a good intro into initial assessment/stabilization of the trauma patient, but is by no means a trauma fellowship.

My point is that ATLS doesn't qualify you to be a trauma surgeon. In addition, you get better care at a trauma center which likely have fellowship trained surgeons that you would at a small rural hospital where the surgeon does 1 - 3 ex-laps a year. While some trauma cases are straight forward and somewhat routine, multi-injury patients can be quite challenging.

 

[FliteSurgn]

My point is that ATLS doesn't qualify you to be a trauma surgeon.

Right, ATLS doesn't qualify you as a trauma surgeon...but finishing a general surgery residency does qualify you to take care of trauma.

The point is that if you have an interest in trauma and are a fully trained general surgeon, there is no reason that you can't take care of even the multi-injured trauma patient. Most of the trauma staff at our Level I trauma center do not have fellowship training and in my experience, do a great job. There's nothing magical about finishing a fellowship, if you're a good surgeon and understand the principles of trauma care then there's no reason that you can't do it.

I do agree that a surgeon at a podunk hospital should stabilize and transfer the seriously injured though. (That stabilization may include surgical intervention.) There are many reasons for that...most of which are logistical. Small town surgeons don't have the system resources, consultants, and experienced ancillary staff to care for these patients. Like Appolyon mentioned, the surgical volume at the hospital is probably most indicative of the patient needing to be transfered.

As to some of the posted examples...If you have an indication for an emergent ER thoracotomy at that hypothetical rural hospital, you probably won't survive a transfer to a higher echelon of care. If you're bleeding out from an intra-abdominal source, the same may be true. A lot depends on how fast the surgeon can get you under the knife vs. transfer time in these situations. And in a rural area, transfer time can be significant. Would you rather die en-route to the trauma center, or have the rural surgeon rip out your spleen?

Rural hospitals are not going to be within spitting distance of a bigger facility. For example, we only have two Level I trauma centers in our entire state...How does a 2 hour ambulance ride sound to someone with cardiac tamponade from a stab wound to the chest? I love playing devil's advocate. 🙂

 

[praying4MD]

My point is that ATLS doesn't qualify you to be a trauma surgeon. In addition, you get better care at a trauma center which likely have fellowship trained surgeons that you would at a small rural hospital where the surgeon does 1 - 3 ex-laps a year. While some trauma cases are straight forward and somewhat routine, multi-injury patients can be quite challenging.

But the whole point is that the Level I trauma centers that you are so eager to get to, as we ALL are in saying here, do not necessarily have surgeons who have completed a trauma fellowship, but dammit if they aren't some of the best surgeons in the trauma field. period.

I mean really, I am not going to walk up to the Professor and Vice Chairman of Surgery in the General Surgery Division of the Michael E. DeBakey Department of Surgery at Baylor College of Medicine (who also serves as Chief of the Surgery Service and Chief of Staff at Ben Taub General Hospital) and tell him that he needs to finish a trauma fellowship and only hire people who have completed a trauma fellowship. I'm pretty sure he knows what he's doing without my help. 🙂 [Granted he did complete a thoracic surgery fellowship, but that is besides the point. World-reknowned Dr. Kenneth Mattox, for anyone who's wonderig.]

I have seen these surgeons in action, and even minus the fellowship, if i needed an emergency thoracotomy in the shock room, i would one of them working on me, without a doubt.

 

[shag]

The point of my post is NOT to say that fellowship training is necessary to be a good trauma surgeon. Superior skills are a result of practice and experience. I agree that a person can be an excellent trauma surgeon without completing a fellowship. As a matter of fact, there were actually trauma surgeons before fellowships were available.

My initial response was to a post stating that :

If you have completed general surgery and if you have ATLS certification. You can do trauma...and all the guidelines are out there....so not so difficult to do...

Simply put, completing a general surgery residency and ATLS are not by themselves qualifications for being an excellent trauma surgeon. Handling multi-injury patients can be quite challenging, even difficult. "Guidelines" are exactly that, guidelines. The mark of a truly exceptional surgeon is understanding that, and knowing when to deviate from the algorithm.

Experience is absolutely necessary to be an effective trauma surgeon, regardless of whether that experience comes from additional training (fellowship) or serving as a junior attending and learning from true experts.