*Opinion Survey* Importance of transplant cases in training - resident/fellow input appreciated

[CriticallyCarED4]

Background: 4th year trying to create match list.

It seems like hearts are straight forward and the experience can be replaced with any cardiac case using cardiopulmonary bypass. Same with lung in that one-lung ventilation is required for a lot of thoracic cases. In my experience, liver transplant management is the most unique/difficult, and thus harder to replace, what with the coagulopathy, AB derangements, and massive transfusion. Individually those challenges can be found in most sick patients and especially in trauma, but I'm not sure if that makes it entirely replaceable. And so my question - how important is transplant experience in residency? Would I be receiving a sub-par education at a place with either no transplants or only kidney?

Kind of wordy but hopefully we can get a conversation going. Especially interested in those on both sides of the aisle and input from current residents, transplant fellows, and attendings.

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[Pharmado]

That depends completely on what you want to do when you are done. I've personally never done a heart transplant and I never intend to. I've done a good number of liver transplants, but I doubt that I will do them outside of residency because I don't want to work in a busy transplant type of hospital. Kidney transplants don't really require an extra level of training. Lung transplants are a huge pain because you do single lung ventilation on one bad lung. Good educational value, but I doubt I'll ever do them again after residency. In my residency program only CT trained faculty do lung/liver transplants, and at least with the lung transplants I think that is how it should be. I can't say how things are elsewhere, but to do transplants outside of training they likely will prefer fellowship trained anesthesiologists. I wouldn't make transplants a huge factor in your decision, but it does tie in to the overall case complexity that is something you need to consider. Most of us won't ever do transplants again anyways, so I doubt that your career will suffer any. Hope this helps at least a little.

 

[CriticallyCarED4]

That depends completely on what you want to do when you are done. I've personally never done a heart transplant and I never intend to. I've done a good number of liver transplants, but I doubt that I will do them outside of residency because I don't want to work in a busy transplant type of hospital...

Definitely helpful, thanks for the input. I don't particularly want to do transplant, I'm thinking cardiac and/or CC right now. But I've enjoyed the few livers I've sat in on so I'd consider it a perk if the program does them.

 

[Ronin786]

It depends on what you're looking for.

I never really truly appreciated the physiology you always read about until I did some sick transplants. Single lung ventilation and reperfusion syndrome with livers are really cool things. That said, you can still become a good anesthesiologist without doing a bunch of transplants. The next best alternative would be very bad traumas. Those will let you see at least some of the same physiology.

I personally would never recommend a place that doesn't do transplants and/or Level 1 Traumas, but there are a lot of programs out there that don't have those to offer. And in my experience, residents training there are much weaker.

 

[CriticallyCarED4]

It depends on what you're looking for.

I never really truly appreciated the physiology you always read about until I did some sick transplants. Single lung ventilation and reperfusion syndrome with livers are really cool things. That said, you can still become a good anesthesiologist without doing a bunch of transplants. The next best alternative would be very bad traumas. Those will let you see at least some of the same physiology.

I personally would never recommend a place that doesn't do transplants and/or Level 1 Traumas, but there are a lot of programs out there that don't have those to offer. And in my experience, residents training there are much weaker.

I agree, thankfully the places I've interviewed are at least a Level 1 trauma center.

 

[Robotic Wis-Hipple]

I mostly agree with Ronin/Pharmado but I'll give my biased opinion anyways;

Go to a program where you're going to do the big cases. It's 3 years. I'd rather be overtrained for my big boy job than the opposite.

A few bread and butter hearts do not teach you the same things that sick redo's, endocarditis cases, or VADs do.

The same with lung transplants. They aren't all off mechanical support and done as OLV.

Livers are cool with neat physiology and defined stages but I'd guess less than 5% of graduating residents will ever do another one.

So sure, you may already know you're looking to work in private practice doing "general" cases, but our population isn't getting any younger or healthier and going to a place that gives you the experience of big cases, transplants, and real trauma literally can only help you.

 

[partydoc]

I mostly agree with Ronin/Pharmado but I'll give my biased opinion anyways;

Go to a program where you're going to do the big cases. It's 3 years. I'd rather be overtrained for my big boy job than the opposite.

A few bread and butter hearts do not teach you the same things that sick redo's, endocarditis cases, or VADs do.

The same with lung transplants. They aren't all off mechanical support and done as OLV.

Livers are cool with neat physiology and defined stages but I'd guess less than 5% of graduating residents will ever do another one.

So sure, you may already know you're looking to work in private practice doing "general" cases, but our population isn't getting any younger or healthier and going to a place that gives you the experience of big cases, transplants, and real trauma literally can only help you.

+1

 

[Mman]

Overall I think transplants are not a large part of what you need to learn in residency, but livers and lungs are unique. A heart transplant is just a pump case on a really bad heart (at least before going on bypass, afterwards it's usually easy). Kidneys and kidney/pancs are mostly just regular abdominal cases. A liver, though, can be a coagulopathic disaster and a lung can be a hemodynamic/oxygenation nightmare way beyond any other thoracic case (unless you cheat and do it on bypass).

 

[Shimmy8]

CA-3 here and I've done 20+ livers, most of them extended criteria and sick as ****.

Now I rarely get phased in big bloody cases/disasters/traumas. In addition to the actual clinical training, I think just as important is gaining the confidence and attitude to approach big cases.

 

[urge]

CA-3 here and I've done 20+ livers, most of them extended criteria and sick as ****.

Now I rarely get phased in big bloody cases/disasters/traumas. In addition to the actual clinical training, I think just as important is gaining the confidence and attitude to approach big cases.

What is the allure of a bloody case? Hanging blood is not a skill that takes long to acquire.

 

[CriticallyCarED4]

What is the allure of a bloody case? Hanging blood is not a skill that takes long to acquire.

True but knowing which products to give based on TEG takes some experience. Especially if the pt's coagulopathic.


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[Robotic Wis-Hipple]

What is the allure of a bloody case? Hanging blood is not a skill that takes long to acquire.

But in the biggest bloody cases you need to count and divide to make 1 : 1.

 

[CriticallyCarED4]

Thanks everyone for chiming in. I'm of the general consensus so far. I like the tough stuff and want to start with everything under my belt. But if I had to choose I wouldn't cry if I match into a program without heart/lung.

My end goal is academics or split my time btwn CC and the OR at a trauma center for a few years. Possibly doing a palliative fellowship on top of CC but I'm still young and idealistic. We'll see if I feel the same in 4-5 years






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[CriticallyCarED4]

I think just as important is gaining the confidence and attitude to approach big cases.

+1



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[nimbus]

CA-3 here and I've done 20+ livers, most of them extended criteria and sick as ****.

Now I rarely get phased in big bloody cases/disasters/traumas. In addition to the actual clinical training, I think just as important is gaining the confidence and attitude to approach big cases.

+1

I have partners with 20+ years experience who still try to dodge big hairy cases. It's pathetic. Don't be one of them. That's your opportunity to shine.

 

[Mman]

CA-3 here and I've done 20+ livers, most of them extended criteria and sick as ****.

Now I rarely get phased in big bloody cases/disasters/traumas. In addition to the actual clinical training, I think just as important is gaining the confidence and attitude to approach big cases.

One thing I'll say is that a bad trauma is not like a bad liver. The liver transplant is a planned event. It's an elective induction and you've got time to put the lines in that you want and get everything ready and in general the bleeding/reperfusion happens at known times. A bad trauma just shows up almost announced and you are trying to induce the patient and put lines in while the surgeons are hurriedly cutting and trying to clamp whatever is bleeding. Liver txp patients don't really die on the OR table unless something really weird happens. A bad trauma can die at the blink of an eye. I've had more than a few GSWs to the chest that died in the OR and those were far more crazy situations than any liver I ever saw as a resident. You gotta think and move a lot faster with a trauma than you do with a liver.

 

[Shimmy8]

^ I don't disagree. I think it's a mentality thing too though. I just overall think that in my particular situation my liver transplant experience has given me confidence that has spilled over to other cases as I've become more experienced.

Had a GSW to the chest die on table over the summer and completely agree that it was a totally different animal, but the craziness wasn't far off from a few of our livers. (To be honest, we transplant waaaaaaay to0 many people who shouldn't be getting livers. It's comical, really).

 

[partydoc]

we transplant waaaaaaay to0 many people who shouldn't be getting livers. It's comical, really).

dont even get me started

 

[sevoflurane]

Yes. Transplants are important.

As a resident or fellow you WANT to be exposed to those cases. You may never see them again in your career.

Liver transplants are an exercise in medicine. A lot to think about. Very interesting physiology. Reperfusing and having a TEE probe in place is always fun to watch and treat. They can be very challanging yet offer a wealth of experience in one case.

I also find Heart transplants and l/r/b vads important if your are going to do hearts (with or without fellowship). TEE for vads/ecmo and heart transplants is different than that for valves or cabgs. Again, being exposed is important.

Trauma is another one that is uniquely important. I recently had a 14 y/o GSW to the chest. Very difficult case and the pace was fast.

I think a good residency has liver and heart transplants + L/R/B Vads as well as a busy level I trauma center. Preferably pediatric and adult traumas.

 

[GravelRider]

Unless you plan on going into academics then you likely won't do liver or lung transplants again. The pathophysiology of a sick end stage heart failure or end stage liver disease patient is interesting and ultimately important to understand. I think the important thing about being at a transplant center is that it will improve your ICU experience in addition to the OR experience. At some point those liver bombs are getting admitted to the MICU before their transplant with massive upper GI bleeds, encephalopathy, SBP, and just circling the drain until they get lucky enough to get a liver. The same goes for the hearts. You won't flinch at an EF of 30% after you've dealt with a few patients with an EF <10% and on home milrinone. To me the important thing about being at a transplant center is that those are the places that tend to "own" the sickest patients around.

 

[sigrhoillusion]

dont even get me started

Can never figure out how some patients are on their 4th kidney transplant, when some people can't even get one... Obviously, I'm talking about outside of compatibility issues. And often it doesn't seem to come down to money. I saw quite the few repeat kidneys on medicaid/care patients.

 

[partydoc]

Can never figure out how some patients are on their 4th kidney transplant, when some people can't even get one... Obviously, I'm talking about outside of compatibility issues. And often it doesn't seem to come down to money. I saw quite the few repeat kidneys on medicaid/care patients.

we've done repeat transplants on patients who stop taking their anti rejection meds

 

[teacher2md]

we've done repeat transplants on patients who stop taking their anti rejection meds

What?? How are they allowed another kidney?

 

[Robotic Wis-Hipple]

What?? How are they allowed another kidney?

Rules is rules. Until you're important enough or raise a big enough stink.

 

[GravelRider]

Rules is rules. Until you're important enough or raise a big enough stink.

There is usually a monthly transplant meeting where the decision to list transplant recipients is discussed. Aside from the medical issues, psychological and socioeconomic issues are usually discussed. I've been to these meetings and have seen patients rejected from being listed because of medical noncompliance or some other factor.

Kidney transplants can be different because you can get a family member or someone else to donate a kidney to you regardless of need. I don't doubt that there maybe some kind of underground market where kidneys are bought and sold.

 

[Ronin2258]

I batted .500 on survival with liver transplants when I did them in residency, mostly due to surgical issues. One of them who died (my first on-table death,) I had to do the pre-op assessment in front of his family/extended family. He asked the pointed questions, and I had to give him honest answers, much to the fear of his family. They appreciated my honesty when they came to view the body post-surgery.

Kidneys are a bit less stressful. Sure, it's heavy vascular, but you aren't re-enacting the first two minutes or so of this as SHTF:


As for heart transplants? No. Thank. You. Dodged that bullet like Neo in The Matrix. Never did one. Never wanted to do one.

I know there are some of us that live for transplants. But it was definitely not my thing.

 

[BobBarker]

Like everybody said kidney/pancreas cases are just big abdominal cases with some rabbit juice thrown in.

My favorite cases and I think the most educational were off pump cabg's.

 

[agammaglobulin]

But in the biggest bloody cases you need to count and divide to make 1 : 1.

I think this illustrates the misconceptions that all 'bloody' cases are the same. I've rarely used a strict 1:1 strategy in a liver transplant as there are several other variables (coagulopathy, reperfusion, etc) and use TEG to guide which products to give. Trauma is more commonly 1:1 as they are usually not coagulopathic, although they can be (Trauma Induced Coagulopathy). It's not as simple as 'just transfuse 1:1' in trauma. At what point do you start transfusion 1:1? Right when they come to the hospital? in the OR? After 1L EBL? 2L EBL? Do you wait for the Hct to drop below 21 before giving blood? (If you drained a person of all their blood, the final drop would have a normal Hct...) Trauma has it's own unique challenges, just like transplant. I'd recommend a program that has transplant AND trauma.