Now that the job market is collapsing, can we have some real discussion on the best residency programs?

[Apollyon]

I just have a story from 25 years ago: had a guy on the ambulance, multiple GSW OHCA. We got there quickly, and got the guy to the trauma center in short time (approx 5 minutes). I don't recall if we got a pulse back enroute. However, the guy did get salvaged at the hospital (he also had a femur fx on the right, due to a great shot). He walked out of the hospital, intact.

Only to be shot and killed, again, for good this time, 7 years later.

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[southerndoc]

I just have a story from 25 years ago: had a guy on the ambulance, multiple GSW OHCA. We got there quickly, and got the guy to the trauma center in short time (approx 5 minutes). I don't recall if we got a pulse back enroute. However, the guy did get salvaged at the hospital (he also had a femur fx on the right, due to a great shot). He walked out of the hospital, intact.

Only to be shot and killed, again, for good this time, 7 years later.

So we can count that as a non-survivor.

 

[Apollyon]

So we can count that as a non-survivor.

I thought it was 60 or 90 days??? 😂

 

[WilcoWorld]

No, these are two different populations. Their survival rate is based on prehospital arrests where the physician is at the scene (London HEMS is staffed by a physician/paramedic combo).

To say that someone in the field can survive with CPR enroute and then get an ED thoracotomy can survive is misapplying the research for prehospital thoracotomies. We must stick with the research that ED thoracotomies done on OHCA have abysmal survival rates as that is the way the US practices. If we move to a model where EMS physicians are responding to scenes and doing thoracotomies, then we can look at that population's research. If London HEMS waited until the patient was transported to the ER, then their ED thoracotomies would have the same survival rate as our ED thoracotomies.

London HEMS has a published 20% survival for prehospital thoracotomies performed for stab wounds.

If they can save 1 of 5 patients in the ambulance there's no excuse for not trying in the emergency department.

Also stab wounds =/= GSW a bullet tends to do a lot more damage than a blade, and we've got a lot more bullets in the US.

 

[alpinism]

No, these are two different populations. Their survival rate is based on prehospital arrests where the physician is at the scene (London HEMS is staffed by a physician/paramedic combo).

To say that someone in the field can survive with CPR enroute and then get an ED thoracotomy can survive is misapplying the research for prehospital thoracotomies. We must stick with the research that ED thoracotomies done on OHCA have abysmal survival rates as that is the way the US practices. If we move to a model where EMS physicians are responding to scenes and doing thoracotomies, then we can look at that population's research. If London HEMS waited until the patient was transported to the ER, then their ED thoracotomies would have the same survival rate as our ED thoracotomies.

They don’t just perform the procedure for patients who arrest with a physician on scene but on anyone who arrests within 10min of arrival.

If you read the paper multiple patients who arrested prior to physician arrival survived neurologically intact and walked out of the hospital.

 

[southerndoc]

They don’t just perform the procedure for patients who arrest with a physician on scene but on anyone who arrests within 10min of arrival.

If you read the paper multiple patients who arrested prior to physician arrival survived neurologically intact and walked out of the hospital.

I think what I said didn't come across correctly. They performed thoracotomies in the field; not in the ER. Yes, they were likely in arrest before the physician arrived on-scene. I get that. However, it's quite different to arrest on-scene, load them up in the ambulance, and transport them to the hospital. The process is rarely, if ever, accomplished within 10 minutes. They would literally need to be across the street for this to work.

London HEMS flies to the scene based on a 999 call. They activate one of their teams based on the call itself and do not wait for LAS to get on-scene for HEMS to respond. If it's at night, their teams are stationed around the city in cars. They are also dispatched by 999 calls before EMS gets on-scene. A patient transported to the Royal London Hospital by LAS that has CPR in progress will almost certainly never get an ED thoracotomy unless they arrested <10 minutes prior to arrival at the Royal London.

I'm very familiar with London HEMS and its operations. I still know quite a few staff there. I have very fond memories of my London days with their AS365N2 that was originally sponsored by Express Newspapers and then transitioned to Virgin sponsorship before transitioning to their MD902.

 

[Fox800]

London HEMS has a published 20% survival for prehospital thoracotomies performed for stab wounds.

If they can save 1 of 5 patients in the ambulance there's no excuse for not trying in the emergency department.

Again, this setting is not representative of most of our practice environments.

Mostly stab wounds in the UK vs more gunshot wounds in the US (I'm assuming you're in the US). They self-dispatch and perform ED thoracotomy on scene (typically a clamshell procedure). They carry blood products, have ultrasound, etc. On-scene ED thoracotomy is a very highly rehearsed procedure for them. They have well-established guidelines to expediently transfer the patient (by air during the daytime) with a physician in attendance to a trauma center.

Can it be done elsewhere? Sure, if you're in the right area, with the right patient population.

Do you have a surgeon that can respond reasonably quickly to take over care if you get ROSC? Do you have a SICU or something resembling a SICU to manage coagulopathy, hypothermia, give more blood, etc? Or are you at a small community hospital where giving lots of PRBCs to a case like this means you don't have any blood to give to the next patient that needs it?

I would counter that we should use the FAST exam to screen for the extremely small subset of patients that might benefit from ED thoracotomy: FAST ultrasound examination as a predictor of outcomes after resuscitative thoracotomy: a prospective evaluation - PubMed

Results: Overall, 187 patients arrived in traumatic arrest and underwent FAST. Median age 31 (1-84), 84.5% male, 51.3% penetrating. Loss of vital signs occurred at the scene in 48.1%, en-route in 23.5%, and in the ED in 28.3%. Emergent left thoracotomy was performed in 77.5% and clamshell thoracotomy in 22.5%. Sustained cardiac activity was regained in 48.1%. However, overall survival was only 3.2%. An additional 1.6% progressed to organ donation. FAST was inadequate in 3.7%, 28.9% demonstrated cardiac motion and 8.6% pericardial fluid. Cardiac motion on FAST was 100% sensitive and 73.7% specific for the identification of survivors and organ donors.

Conclusions: With a high degree of sensitivity for the detection of potential survivors after traumatic arrest, FAST represents an effective method of separating those that do not warrant the risk and resource burden of RT from those who may survive. The likelihood of survival if pericardial fluid and cardiac motion were both absent was zero.

Keep in mind this was done at a high-functioning busy trauma center in California, the kind of place where the in-house trauma team responds to the ED immediately. Not a community hospital where your general surgeon is at home in bed and takes 5 minutes to call back and then 20 minutes show up. 3.2% overall survival, in an ideal hospital setting (academic level 1 trauma center).

Out of hospital arrest with no pericardial effusion with no cardiac activity? No thoracotomy.

 

[Mushdoc]

community gsw, no point. community stab, I'd try

 

[CajunMedic]

Related: Anyone ever see any of the presentations by the late Dr. John Hinds? This is one of the few I can find on YouTube:



N=1, the only ED Thoracotomy I've seen and participated in was a single stab to heart, arrested less than 5 minutes out, done by the Trauma team, worked for over an hour with most of the transfused blood winding up on the floor and died anyway.

I've had 2 patients requiring pericardiocentesis in the past few months, one was done in the ED by cardiology and the other went to the cath lab to have it done there.

We seem to have a good mix of patients and most of the interns are checked off on central lines and intubations around halfway through intern year. The population here is super sick, with any combination of co-morbidities, or wait until near death to "come down the holler" to meet EMS.

 

[alpinism]

I think what I said didn't come across correctly. They performed thoracotomies in the field; not in the ER. Yes, they were likely in arrest before the physician arrived on-scene. I get that. However, it's quite different to arrest on-scene, load them up in the ambulance, and transport them to the hospital. The process is rarely, if ever, accomplished within 10 minutes. They would literally need to be across the street for this to work.

London HEMS flies to the scene based on a 999 call. They activate one of their teams based on the call itself and do not wait for LAS to get on-scene for HEMS to respond. If it's at night, their teams are stationed around the city in cars. They are also dispatched by 999 calls before EMS gets on-scene. A patient transported to the Royal London Hospital by LAS that has CPR in progress will almost certainly never get an ED thoracotomy unless they arrested <10 minutes prior to arrival at the Royal London.

I'm very familiar with London HEMS and its operations. I still know quite a few staff there. I have very fond memories of my London days with their AS365N2 that was originally sponsored by Express Newspapers and then transitioned to Virgin sponsorship before transitioning to their MD902.

I’m simply pointing out the fact that having a traumatic arrest in the field isn't always a death sentence.

 

[alpinism]

Again, this setting is not representative of most of our practice environments.

Mostly stab wounds in the UK vs more gunshot wounds in the US (I'm assuming you're in the US). They self-dispatch and perform ED thoracotomy on scene (typically a clamshell procedure). They carry blood products, have ultrasound, etc. On-scene ED thoracotomy is a very highly rehearsed procedure for them. They have well-established guidelines to expediently transfer the patient (by air during the daytime) with a physician in attendance to a trauma center.

Can it be done elsewhere? Sure, if you're in the right area, with the right patient population.

Do you have a surgeon that can respond reasonably quickly to take over care if you get ROSC? Do you have a SICU or something resembling a SICU to manage coagulopathy, hypothermia, give more blood, etc? Or are you at a small community hospital where giving lots of PRBCs to a case like this means you don't have any blood to give to the next patient that needs it?

I would counter that we should use the FAST exam to screen for the extremely small subset of patients that might benefit from ED thoracotomy: FAST ultrasound examination as a predictor of outcomes after resuscitative thoracotomy: a prospective evaluation - PubMed

Results: Overall, 187 patients arrived in traumatic arrest and underwent FAST. Median age 31 (1-84), 84.5% male, 51.3% penetrating. Loss of vital signs occurred at the scene in 48.1%, en-route in 23.5%, and in the ED in 28.3%. Emergent left thoracotomy was performed in 77.5% and clamshell thoracotomy in 22.5%. Sustained cardiac activity was regained in 48.1%. However, overall survival was only 3.2%. An additional 1.6% progressed to organ donation. FAST was inadequate in 3.7%, 28.9% demonstrated cardiac motion and 8.6% pericardial fluid. Cardiac motion on FAST was 100% sensitive and 73.7% specific for the identification of survivors and organ donors.

Conclusions: With a high degree of sensitivity for the detection of potential survivors after traumatic arrest, FAST represents an effective method of separating those that do not warrant the risk and resource burden of RT from those who may survive. The likelihood of survival if pericardial fluid and cardiac motion were both absent was zero.

Keep in mind this was done at a high-functioning busy trauma center in California, the kind of place where the in-house trauma team responds to the ED immediately. Not a community hospital where your general surgeon is at home in bed and takes 5 minutes to call back and then 20 minutes show up. 3.2% overall survival, in an ideal hospital setting (academic level 1 trauma center).

Out of hospital arrest with no pericardial effusion with no cardiac activity? No thoracotomy.

Sure for patients who suffer a traumatic arrest prior to arrival that's a reasonable practice.

 

[alpinism]

Here's a question for you guys:

You are working at a rural community hospital with only general surgery.

Get an EMS call for a girl that was stabbed during a birthday party.

Crew rolls in doing CPR saying they lost pulses in route.

Get the US exam which shows cardiac tamponade.

Who's actually going to call time of death?

 

[SpacemanSpifff]

Here's a question for you guys:

You are working at a rural community hospital with only general surgery.

Get an EMS call for a girl that was stabbed during a birthday party.

Crew rolls in doing CPR saying they lost pulses in route.

Get the US exam which shows cardiac tamponade.

Who's actually going to call time of death?

Not before making attempts to relieve the tamponade.

 

[sum dude]

As many of us MS4s are starting to make rank lists and also consider which interviews to drop vs keep, given the job market, it would be really helpful to hear some advice on what programs are the best for finding good employment in the future.

If you look at basically any time the idea of a "best EM program" is discussed, these common phrases are just repeated:
"go where you want to live"
"does not matter at all"
"In before In-N-Out"
"to get hired you just need a pulse"

Of course, with midlevel creep, residency expansions, CMG takeovers, the future (as is often discussed heavily on this forum) is not looking too bright for new EM grads, and will likely be worse when I graduate residency in ~2025. So when there is a glut of EM docs, or god forbid a new model like anesthesia's 1 doc to 4 midlevels, it almost certainly will matter where you trained, perhaps especially to SDGs.

So other than avoiding HCA and brand new programs, can we hear some advice on what programs really are the best? Assume no specific interest in working in any particular geographic market after graduation, so whatever program would set you up the best nationally.

The best program is the one that lets you moonlight in a city you want to live in.

 

[oludir]

I think it's fair game to want to train at a level-1 trauma center, i.e. major tertiary care center.

Training at a level-1 trauma center is arguably worse than training at a level-2 trauma center.

 

[The Knife & Gun Club]

Training at a level-1 trauma center is arguably worse than training at a level-2 trauma center.

After interview trail, and now as a resident with lots of friends at other programs...

I don’t think there is a “best” trauma training.

Some places have level 1, but you’re a consult monkey. Some places don’t have the volume, but there’s fewer consultants/surgeons around so you do more. Some places you split your time at multiple shops, but it dilutes the experience and time doing “real EM.”

In the end there’s definitely some BAD places to train, but not one definitive BEST model. Maybe some attendings out there have different views, but of the ones I’ve spoken to, their opinions are all over the map as well.

Ultimately, as with many other things in training, becoming competent is largely based on an individuals desire to learn and having some baseline level of volume and educators available.

Edit: and also it’s not that important. Trauma is the definition of algorithmic. Practice the protocol, learn the procedures, done.

 

[EMhawkeye]

Yeah have def seen the level one mentality. Oh simple hand lac? Call the hand service to close it.
Hip dislocation? Call ortho to reduce.
While the resident is at the desk watching espn on his phone.

 

[Zebra Hunter]

Training at a level-1 trauma center is arguably worse than training at a level-2 trauma center.

Entirely depends on location, but in general, I agree. Level-2 trauma centers typically have the entirety of the trauma resus performed by ED residents typically due to lack of competition for procedures with surgery or anesthesia. Also, given that these trauma centers are typically not at major academic centers with sub-sub-sub specialists for everything, EM residents are expected to manage everything, which is how you will practice out in the community.