Opinion on Combined Anesthesia/ER Residency (civ vs. military)?

[OxToCA]

Due to the prevalence of trauma, traumatic brain injury (TBI), and resuscitation in conflicts and their poor outcomes (brain damage), do you think that a combined anesthesiology/ER residency would be useful in the military?

I followed up with the last author of "The Anesthesiology/Emergency Medicine Combined Residency: Defining a New Future for Trauma Resuscitation" http://link.springer.com/article/10.1007/s40140-015-0130-9 a few weeks ago after meeting him last year, and mentioned that his idea for a combined anesthesiology/ER residency would be useful in the armed forces; I did so after seeing/posting in a thread here https://forums.studentdoctor.net/threads/proposed-em-anesthesiology-combined-program.1172147/ then, being reminded of research I did last year on a new neuroprotective drug undergoing clinical trials (xenon), and noticing that this residency is only offered at Johns Hopkins (nearby Walter Reed), currently.

I want to follow up with him after getting feedback from people here as well as attending USUHS open house and meeting the Director of clinical trials at Walter Reed Army Institute of Research (WRAIR) and possibly an Army HPSP recruiter in DC later this week; they're starting a lot of clinical/translational research in the Armed Forces for CNS disorders and TBI, and I'm interested in doing a clinical pharmacology fellowship at WRAIR via the HPSP or USUHS. If anyone wants to meet near Bethesda on Thursday, feel free to pm me.

For reference, although several threads have been started about this on the anesthesiology sub-forum, every discussion has overlooked its intent for trauma resuscitation per the title of his publication.
https://forums.studentdoctor.net/threads/combined-anesthesia-em-residency.1193564/
https://forums.studentdoctor.net/th...mergency-med-residencies-coming-soon.1209500/
Here's a news story on its accreditation: http://www.theaba.org/ABOUT/News-Announcements/ABA-and-ABEM-Announce-Combined-Residency-Training @Armyhealth

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[SirGecko]

I'm not Emergency or anesthesia so I can't really comment on whether a combined residency makes sense. I will say that the military tends toward less specializing (we don't usually have people doing combined residencies) and our hospital system is not really postured as much at new trauma as the lay public might think. The majority of actual trauma naturally happens fairly far forward, our state side hospitals when managing trauma cases are managing stuff that happened days to weeks ago by the time they get back to the states. I would leave it up to the people in those fields though to say if it's something we could support.

One style pointer for you: you can just link the google search. Linking "let me google that for you" is a sarcastic extra step people use when frustrated at someone's inability to type basic search commands into google. Linking it before anyone even asks you an obvious question just comes across as rude. (I mean it can come across as rude later as well but that's usually intentional) Don't think that's what you intended (maybe you didn't know you can just link the google inquiry?) but it's something to keep in mind for the future.

 

[OxToCA]

One style pointer...

Thanks for the FYI, I just googled tiny link Google or something similar and got the lmgtfy site. You make interesting points, too; its advantage in deployment has a cost-benefit. Part of that could be offset by improving resuscitative neurological outcomes after non-combat related events (e.g. cardiac arrest, etc.) in domestic hospitals, but by how much? Insurance reimbursement and other factors are different in the armed services, etc etc... hmm

 

[IlDestriero]

I think it's a waste of time. They share some procedures, but you're either an anesthesiologist or emergency physician. Major trauma centers don't need double boarded magic to get better outcomes, they need dedicated teams that get a lot of practice. Something sorely lacking at most .mil non trauma centers.


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Il Destriero

 

[pgg]

Aw man, I saw the avatar and thought Ventdependent was visiting.

 

[OxToCA]

I think it's a waste of time. They share some procedures, but you're either an anesthesiologist or emergency physician. Major trauma centers don't need double boarded magic to get better outcomes, they need dedicated teams that get a lot of practice. Something sorely lacking at most .mil non trauma centers.


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Il Destriero

Disagree; for trauma resuscitation in the field/on deployment, it would be valuable enough to add an extra year of training, and might substitute for a critical care fellowship.

 

[DeadCactus]

The patient centered benefits to combined residencies are generally overstated. The benefit is to the physician who can build a career working in a broader clinical context which is great and well worth the extra time in residency for many people. Despite this, the belief that every bit of training/experience needs to be packaged, quantified, and tested is a major plague on medicine in my opinion.

 

[psychbender]

Disagree; for trauma resuscitation in the field/on deployment, it would be valuable enough to add an extra year of training, and might substitute for a critical care fellowship.

Disagree. A competent anesthesiologist or emergency physician should be fully capable of running trauma resuscitation downrange or at a trauma center. The addition of either specialty gives little to the other in this context. I'm biased, but a CCM fellowship adds more to each specialty than doing a second residency.

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[OxToCA]

Disagree. A competent anesthesiologist or emergency physician should be fully capable of running trauma resuscitation downrange or at a trauma center. The addition of either specialty gives little to the other in this context. I'm biased, but a CCM fellowship adds more to each specialty than doing a second residency.

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The author I mentioned is the editor in chief of https://www.journals.elsevier.com/journal-of-critical-care/, so

 

[IlDestriero]

Disagree; for trauma resuscitation in the field/on deployment, it would be valuable enough to add an extra year of training, and might substitute for a critical care fellowship.

I work at a Level 1 trauma center. I don't need an EM residency/trauma fellowship to provide care to these patients.
You can disagree all you want, but the key is a trained multidisciplinary team, sims, case review, and actual trauma. Repeat daily. Several times a day.
You can send a .mil anesthesiologist for a trauma "fellowship" somewhere for a year or have him complete an Em residency if you and the .mil want. BUT since they get no actual trauma at most .mil locations, don't do quality sims for cases that aren't going to happen at the facility, and don't have an experienced multidisciplinary team don't expect too much. The only thing that will happen is loss of skills and they'll end up rustier than an iron cleat on my boat. They are not good at trauma because they don't do it. They used to send NMCSD folks to USC for 3 months. How much do you think they retain after 2 years of zero trauma. (Femur fractures don't count...)
I'm curious what you think I would gain from an EM residency, and how it would impact my care at a L1 trauma center where all the above noted recommendations are already in place.


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Il Destriero

 

[pgg]

I don't think it adds enough value to be worth the effort.

All of the role 3 trauma centers in Iraq and Afghanistan had anesthesiologists and EM physicians on staff. When I was at the R3 in Kandahar every trauma bay had an anesthesiologist at the head of the bed and an EM doc directing the overall care.

At role 2 locations it wasn't uncommon to have neither an anesthesiologist nor a EM doc.

 

[psychbender]

The author I mentioned is the editor in chief of https://www.journals.elsevier.com/journal-of-critical-care/, so

The guy is trying to sell a product to fill a void that is not there. Trauma is not rocket science, and the anesthesiologist/EM doc resuscitating makes up only a small portion of the care team. I really don't see how the military would use such a doctor for the aforementioned reasons.

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[DrMetal]

Due to the prevalence of trauma, traumatic brain injury (TBI), and resuscitation in conflicts and their poor outcomes (brain damage), do you think that a combined anesthesiology/ER residency would be useful in the military?

Is your avatar photo Prince? Sadly, he needed both an anesthesiologist and an emergency physician.

This is a great idea: if there existed a combined anesthesiology/EM service, all the internists and surgeons could direct their wrath at that one service.....It would be efficient.

 

[OxToCA]

You can disagree all you want, but the key is a trained multidisciplinary team, sims, case review, and actual trauma. Repeat daily. Several times a day... I'm curious what you think I would gain from an EM residency, and how it would impact my care at a L1 trauma center where all the above noted recommendations are already in place.-- Il Destriero

I don't disagree with that. I think that new methods for evaluating post-resuscitative neurological outcomes might or might not show a modest difference in patients resuscitated by an anesthesiologist/ER compared to a CCM, ER, or anesthestiologist in combat settings and reduce costs. To answer your question, I don't know what you would gain.

For reference, I contacted the author I mentioned due the paper's military references (2-4, pasted below) and primary research-based argument. Ongoing research at WRAIR for TBI is related (e.g. diffusion tensor MRI instead of CT, etc) ref. "After more than a decade of war, military physicians and researchers have made significant advances... traumatic brain injury (TBI) remains one of the most complex and prevalent. From 2000 to 2014, more than 300,000 service members sustained a TBI, according to the Department of Defense" http://www.hjf.org/research-program...er-for-neuroscience-and-regenerative-medicine since poor neurological outcomes are correlated with resuscitation.

From the introduction, "The role that resuscitation plays in the care of the injured patient has become more apparent as the management of trauma matures in the context of lessons learned from the past decade of conflict in Iraq and Afghanistan. The prompt application of basic medical technologies like tourniquets have saved many lives on the modern battlefield, just as they did on battlefields of the past [1]. Refinements of trusted therapies like blood transfusion have improved outcomes, and rigorous investigations continue to define the margins for improvement in trauma resuscitation [2–4]. The resuscitation expert will consult on patients in the emergency department, manage their medical care in the OR/IR suite, and coordinate their ongoing management in the ICU. The future of physicians in hospital-based practices will be defined by their capacity to rescue, manage, and coordinate care across a wide spectrum of diseases and environments of care."

Although the paper primarily analyzes the structure of the anesthesiology/ER residency, it implies that defining and assessing margins for post-resuscitative neurological outcomes is possible (e.g. fractional anisotropy in white matter, a validated biomarker) and that an anesthesiologist/ER can improve outcomes and/or fill an unfilled role. There's no way to know the former without doing a retrospective analysis of outcomes from anesthesiologists, CCM, and/or ER physicians vs combined anesthesiologists/ER physicians; regarding the latter, perhaps an anesthesiologist/ER can eventually practice in rural settings where there are mostly CRNAs providing anesthesia or in another setting where there's a need.

So, I think that the next publication will interchange 2.-4. with references to new CNS imaging studies comparing anesthesiology/ER with CCM physician's treatment outcomes. Based on its results, it would either support or not support a combined anesthesiology/ER residency.

2. Holcomb JB*, Tilley BC, Baraniuk S, Fox EE, Wade CE, Podbielski JM, et al. Transfusion of plasma, platelets, and red blood
cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA.
2015;313(5):471–82. doi:10.1001/jama.2015.12.
*United States Army Institute of Surgical Research, Ft Sam Houston, TX 78234, USA.
Objective: To determine the effect of blood component ratios in massive transfusion (MT), we hypothesized that increased use of plasma and platelet to red blood cell (RBC) ratios would result in decreased early hemorrhagic death and this benefit would be sustained over the ensuing hospitalization.
Conclusion: Current transfusion practices and survival rates of MT patients vary widely among trauma centers. Conventional MT guidelines may underestimate the optimal plasma and platelet to RBC ratios. Survival in civilian MT patients is associated with increased plasma and platelet ratios. Massive transfusion practice guidelines should aim for a 1:1:1 ratio of plasmalatelets:RBCs.

3. Borgman MA*, Spinella PC, Perkins JG, Grathwohl KW, Repine T, Beekley AC, et al. The ratio of blood products transfused
affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma. 2007;63(4):805–13. doi:10.
1097/TA.0b013e3181271ba3.
*Brooke Army Medical Center, Fort Sam Houston, TX, USA
Background: Patients with severe traumatic injuries often present with coagulopathy and require massive transfusion. The risk of death from hemorrhagic shock increases in this population. To treat the coagulopathy of trauma, some have suggested early, aggressive correction using a 1:1 ratio of plasma to red blood cell (RBC) units.
Conclusion: In patients with combat-related trauma requiring massive transfusion, a high 1:1.4 plasma to RBC ratio is independently associated with improved survival to hospital discharge, primarily by decreasing death from hemorrhage. For practical purposes, massive transfusion protocols should utilize a 1:1 ratio of plasma to RBCs for all patients who are hypocoagulable with traumatic injuries.

4. Holcomb JB, Wade CE, Michalek JE, Chisholm GB, Zarzabal LA, Schreiber MA, et al. Increased plasma and platelet to red
blood cell ratios improves outcome in 466 massively transfused civilian trauma patients. Ann Surg. 2008;248(3):447–58. doi:10.
1097/SLA.0b013e318185a9ad.
*United States Army Institute of Surgical Research, Ft Sam Houston, TX 78234, USA.
Objective: To determine the effect of blood component ratios in massive transfusion (MT), we hypothesized that increased use of plasma and platelet to red blood cell (RBC) ratios would result in decreased early hemorrhagic death and this benefit would be sustained over the ensuing hospitalization.
Conclusion: Current transfusion practices and survival rates of MT patients vary widely among trauma centers. Conventional MT guidelines may underestimate the optimal plasma and platelet to RBC ratios. Survival in civilian MT patients is associated with increased plasma and platelet ratios. Massive transfusion practice guidelines should aim for a 1:1:1 ratio of plasmalatelets:RBCs.

I really don't see how the military would use such a doctor for the aforementioned reasons.

I'll have to think about this one and send my feedback to the author I mentioned; maybe for a new manuscript?

 

[psychbender]

Let's pause for a minute. OxtoCA, are you in the military, an anesthesiologist, our an emergency physician? If you were any one (especially any two) of those, you should understand that this proposed residency is unnecessary.

Acute care of combat casualties is a very small portion of the medical care delivered by the Army and other branches. Even when deployed, not all anesthesiologists or EM docs remain busy taking care of trauma. Stateside is even worse. The Army has one level one trauma center, and sees very little trauma at the other facilities. However, when deploying, docs are pulled from all facilities, and not everyone keeps current with transfusion strategies. Many anesthesiologists in the military spend their days taking care of young ASA 1 or 2 patients undergoing outpatient procedures, so rarely need to give blood. Many EM physicians in the military work in what are essentially urgent care centers, with very low medical acuity and little to no trauma, and consequently lose skills with resuscitation, airway management, line access, etc. Trauma surgeons in the military are not immune, either. I have three trauma surgeons at my hospital that does absolutely no trauma. Do you think they're losing some of their edge doing choles, hernias, lipomas, and clinic all day? Other general and subspecialty surgeons are also utilised for trauma, and may not have done any trauma since their last deployment a few years ago.

Think also about residency. Trauma resuscitation is a small portion of overall EM training, as it also is with anesthesiology residency. You would get less trauma training adding these two residencies together than you would doing a Trauma fellowship after anesthesiology (do they have that for EM, too?).

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[OxToCA]

Let's pause for a minute. OxtoCA, are you in the military, an anesthesiologist, our an emergency physician? If you were any one (especially any two) of those, you should understand that this proposed residency is unnecessary.

Acute care of combat casualties is a very small portion of the medical care delivered by the Army and other branches. Even when deployed, not all anesthesiologists or EM docs remain busy taking care of trauma. Stateside is even worse. The Army has one level one trauma center, and sees very little trauma at the other facilities. However, when deploying, docs are pulled from all facilities, and not everyone keeps current with transfusion strategies. Many anesthesiologists in the military spend their days taking care of young ASA 1 or 2 patients undergoing outpatient procedures, so rarely need to give blood. Many EM physicians in the military work in what are essentially urgent care centers, with very low medical acuity and little to no trauma, and consequently lose skills with resuscitation, airway management, line access, etc. Trauma surgeons in the military are not immune, either. I have three trauma surgeons at my hospital that does absolutely no trauma. Do you think they're losing some of their edge doing choles, hernias, lipomas, and clinic all day? Other general and subspecialty surgeons are also utilised for trauma, and may not have done any trauma since their last deployment a few years ago.

Think also about residency. Trauma resuscitation is a small portion of overall EM training, as it also is with anesthesiology residency. You would get less trauma training adding these two residencies together than you would doing a Trauma fellowship after anesthesiology (do they have that for EM, too?).

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Good points; I'm trying to be thorough since communicating about research with an editor is what it is. I am not in the military, but am joining @Armyhealth

If there are any volunteer opportunities at your hospital, feel free to pm me since I'm relocating to where I can gain military medicine experience while writing my MSc thesis/creating a poster (for translational and medical prostate cancer PET imaging), and would appreciate the opportunity.

 

[IlDestriero]

This isn't new information re transfusion ratios, or special ER physician magic, it's peer reviewed articles available to anyone. It's your responsibility to keep abreast of literature that affects your practice. If you're doing Level 1 trauma, these are the kinds of articles you should review, discuss in multidisciplinary Grand rounds, etc. You don't need a second residency to follow a protocol.
What the .mil should do, and I don't know what they do now as I've been out for a decade, is determine best practices and make that info available/mandatory pre deployment education.
If you're not doing major trauma and are deployed to a combat field hospital or FRSS, one can only hope that you have the insight to recognize that's something you better brush up on.


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Il Destriero

 

[jabreal00]

Not needed and wouldn't be utilized especially in the military. You would either get an anesthesia or ER billet. An ER or Anesthesia critical care fellowship is a much better use.