Role of EM Docs in Trauma

[Lespedeza]

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I am an MSIII rotating through surgery at a Level II trauma center. While walking back from a trauma call last night, my resident told me that the ED attendings are the ones to put out the trauma call based on whether or not they think the trauma case coming in will require surgical intervention. I've noticed that the trauma attending or resident is the one to then run the trauma while the ED attending is relatively uninvolved.

I am very interested in urgent care -- and there are many aspects of EM that I find to be very attractive. However, I'm falling in love with the intensity of trauma and am somewhat disappointed that the ED attendings aren't directly involved (from what I have observed). My questions are as follows:

1) Is the situation I have described typical at other institutions? Particularly Level I trauma centers? Also, if putting out a trauma call is based on the attending's judgement, would it be inappropriate for him or her to run the primary/secondary survey before deciding a patient may or may not need surgery?

and

2) I did an SDN search and read that a small percentage of trauma fellowships accept ED docs; however, the info was dated (2002) and it seems this opportunity may be quite competitive. Does anybody have any information regarding ED docs in trauma fellowships?

Thanks so much in advance! I don't get to rotate through EM until my 4th year and I am just trying to be as informed as possible so I can get the most out of my rotations.

 

[BSEMD]

bump

 

[southerndoc]

This topic has been discussed ad nauseum. If you search for the topic, you'll probably find some quality posts about this.

BSEMD, why must you bump a thread that has remained unanswered for only an hour and 8 minutes?

 

[Jeff698]

In addition to the several metric tons of posturing you'll find in the many threads on this subject, let me add the following based purely on my experience.

1) Let the surgeons have the trauma. I'm in the community and want no part of it. It slows me down b/c, after the first 'fun' 20 minutes comes then decidedly 'unfun' 3 hours of babysitting and bed-blocking.

2) Trauma is a chronic disease. It happens, in large part, to people who aren't very pleasant. I have enough nasty people in my department who don't understand the basic societal rules of manners or, for that matter, hygiene. I'll happily pass on adding more.

3) Trauma is not a condition known for it's high reimbursement. I'm an employee w/o an RVU incentive but trauma won't help my institution. It sucks up beds for many hours, blocking out patients with, say, chest pain. A happy institution makes me happier.

4) Trauma patients keep my waiting room full. Trauma patients often need CTs. Lots of them. CTs need to be read. That takes time. If I can't turn the rooms over, the patients back up in the waiting room. Nobody likes this.

5) Trauma patients don't say nice things on Press-Ganey forms (see #2). My hospital likes PG surveys (and doesn't care that much that I don't) therefore I have to care about this.

The bottom line is that, for my community hospital, trauma is nothing but trouble. I've discussed this with my general surgery colleagues and we're on the same page.

Hope this helps.

Take care,
Jeff

 

[Arcan57]

From a community standpoint, Jeff nailed it. There are academic institutes where ED takes a very active role in trauma, and manages the majority of it except for the small minority of patients that require immediate operative intervention. Trauma is something that med students love because the initial 10 minutes is high intensity/high reward. And there are ED physicians that can run amazing trauma resuscitations with massive transfusions using 1:1 pRBCs to FFP, intubating patients with expanding carotid hematomas on patients with horribly disrupted mid-faces, putting in chest tubes to relieve tension pneumos, and pelvic binders to close open book pelvic fractures. And in some EDs the above happens a couple of times a month. Far more frequent is the drunken, belligerant, just slaughtered a young family with their MVC that has a horrible lac that's going to take hours to sew. Or the too intoxicated to reliably exam, pan-CT MVC, who 8 hours into their stay finally sobers up enough to complain of some extremity trauma (usually fingers, but occasionally knees) needing further x-rays. Or the ever popular patient who screams when anything is touched that was in MVC with the same energy transfer one usually associates with a firm handshake.

 

[DoctorMedic]

seems like overall ED attendings here arn't fans of trauma? am i wrong on that?

 

[dchristismi]

Trauma can be very fun from a EM perspective, assuming you have the bay, the equipment, and the staff to manage the above. I work at a community hospital that is not a trauma center. We only get it if it codes in our neighborhood or comes via homeboy ambulance. The major stuff, that is. Minor stuff (ambulatory MVCs, even when EMS straps them to boards) is no big deal. But major trauma shuts down everything and overwhelms the system.

Trauma in residency is major fun. I loved it in residency. Give me that carload of ejected teenagers, or the gunfire into a crowd. I had a great team, great trauma surgery backup and a system to deal with it. Hence why training at a Level 1 is a big deal.

Can I handle it now? Yep. I had great training.

Doesn't mean I want to though, because I don't have the equipment and manpower to do it well. Therefore, I'd rather not.

Where I trained, the "trauma alerts" got a full trauma team response. Everything else (Trauma reds, yellows, and greens) were handled exclusively by EM. They would only call surgery if something was found warrenting surgical intervention or admission. The system determining the status of a trauma was all EMS driven.

Oh, and the Trauma Fellowship where I trained was a WHOLE LOT of ICU rounding, routine call, and occasional operating, which is why surgeons do this fellowship. I can't take out an appendix, much less patch together someone's fractured liver.

 

[roja]

seems like overall ED attendings here arn't fans of trauma? am i wrong on that?

Yes. I like trauma. Alot. It's not your fault. Its a common misperception that EM docs deal with often: EM= trauma. Trauma is fun. I like trauma. However, it is not the be all and end all. In fact, while adreneline pumping, any good EM doc knows that the job in trauma is to stabilize the patient enough to put the patient in someone's hands who can fix the problem if its operative. Or manage the endless ICU level issues.


So, trauma protocols depend on where you are. And keep in mind there is VOLUMES more to what makes up ED. And much more that is much much harder and more exciting. (IE: severe aortic stenosis with rapid afib who is septic and hypotense.)

 

[WerdSalid]

Arcan57: great post. you nailed it.

 

[Winged Scapula]

As noted above:

trauma is fun for the first few minutes which is why almost no one except medical students (and weirdos like roja 😉 ) likes it. Because they realize that MOST of trauma is unrewarding, monotonous and even if you get the excitement of an ex-lap or craniotomy, those 60 minutes of fun translate into days to weeks of talking about PEGs and trachs, ICPs, tube feeds, pressure sores, social issues, etc.

I would like back those weeks I spent sitting in the CT scanner with drunks while Chief on Trauma Surgery.

That is most definitely NOT fun.

 

[AmoryBlaine]

Trauma is no different from alot of other things in EM: we manage what we can and often cannot provide definitive care.

I'm personally against this whole idea of EM residents/docs "running" all trauma and then only calling surgeons when they feel like they need to. I think that we should just acknowledge that trauma is a surgical disease...

And I totally agree that the average trauma patient is a drunk ******* with a deep facial or scalp lac who is half sitting up on the cart in the hallway calling for a sandwich and a urinal.

 

[Arcan57]

Trauma is no different from alot of other things in EM: we manage what we can and often cannot provide definitive care.

I'm personally against this whole idea of EM residents/docs "running" all trauma and then only calling surgeons when they feel like they need to. I think that we should just acknowledge that trauma is a surgical disease...

And I totally agree that the average trauma patient is a drunk ******* with a deep facial or scalp lac who is half sitting up on the cart in the hallway calling for a sandwich and a urinal.

I think there is value in the EM running trauma model, as this is the model in-place in almost every ED outside of academic Level I trauma centers. Calling trauma on patients that have a high likelihood of being discharged just adds to length of stay as the trauma junior talks to the trauma senior who then waits for the attending to call back.

And as illustrated by WS's posts (both here and in the surgery forum), trauma is rarely a disease entity requiring operative intervention (at least by a general surgeon) and is far more a critical care/social work defined specialty.

 

[roja]

I would argue that 'running' a trauma (or a resuscitation of any kind) entails being involved with your consultants and communicating with them in all things. However, in high stress chaotic environments, you need to know who is ultimately in charge.

Where I trained, EM 'ran' the traumas but that doesn't mean we didn't involve trauma. Its a collaborative process. But to avoid confusion, EM made the final call with surgery as the consultant.

 

[BSEMD]

This topic has been discussed ad nauseum. If you search for the topic, you'll probably find some quality posts about this.

BSEMD, why must you bump a thread that has remained unanswered for only an hour and 8 minutes?

Is that a problem?

Wait, that sounded defensive...what I MEANT to say was, because I'm interested in the answer. As it stands, the remaining posters did answer the OP's question well, and were helpful.

 

[southerndoc]

Is that a problem?

Wait, that sounded defensive...what I MEANT to say was, because I'm interested in the answer. As it stands, the remaining posters did answer the OP's question well, and were helpful.

Yes, you're impatient and not realistic if you think someone will answer your questions in only an hour. Patience is a virtue.

 

[Rendar5]

Is that a problem?

Wait, that sounded defensive...what I MEANT to say was, because I'm interested in the answer. As it stands, the remaining posters did answer the OP's question well, and were helpful.

I think the point was that you bumped a topic that doesn't mean bumping as it was very high up on the first page and did not need a bump post in order to bring it to people's attention.

To the OP: I personally love trauma, but from what I've seen so far at my residency, which is comparably little, is that if it's minor trauma, we take care of it, but if it's anything that necessitates a consult, it becomes a surgical case with us helping to stabilize and sharing in the procedures with the rotating surgical residents.

Re: Roja's post: I had a case of an aortic stenotic with afib coming in with sepsis and hypotension when I did medicine 3rd year and she's totally right. That is scarier/more exciting **** than any trauma I've ever seen (thank god I had a great resident who knew her **** directing the patient's care).

 

[DoctorMedic]

Roja i wasn't trying to say that all EM does is trauma, i am very aware of the medical cases that can be very serious and increase the pucker factor as well. It was just that i noticed a consensous among the attendings here that they would rather leave trauma to the surgeons and not deal with it.

 

[BADMD]

Roja i wasn't trying to say that all EM does is trauma, i am very aware of the medical cases that can be very serious and increase the pucker factor as well. It was just that i noticed a consensous among the attendings here that they would rather leave trauma to the surgeons and not deal with it.

Earlier in my career, I thought trauma was awesome. I looked forward to trauma activation. As I did it more and more, I realized that it was, from the EM prospective, fairly cookbook. Do an assessment, stabilize the immediate life threat, then OR or CT. It got kind of monotonous. The stories are interesting, but the actual care isn't.

For the last two year, my fellowship schedule didn't allow me to work the trauma shifts at my hospital. Thus I didn't do any level 1 or 2 trauma. I found that I really didn't miss it. Now that I'm no longer constrained by that schedule, I am doing trauma again and I'm not unhappy that I wasn't for the last two years.

Trauma is fine, but I have developed an appreciation for medical illness. It isn't as sexy, but I like it far more.

 

[DoctorMedic]

i agree trauma is very cookbook and medical gives a more dynamic thought process which over time is more stimulating. I guess even after 8 years in EMS I still enjoy trauma the same as medical so its interesting to hear others opinions.

 

[Febrifuge]

... Trauma is fine, but I have developed an appreciation for medical illness. It isn't as sexy, but I like it far more.

See, this is why I'm happy that my first post-school job is going to be as a hospitalist PA. Sure, I'll be in my 'native environment,' the ED, admitting medical patients, and if I'm free to help out with a trauma, I'll do so to the extent it's appropriate and welcome. But even a couple years cutting off clothing as a tech, followed by a year sewing those lacs and splinting those extremities, is enough. I can see the steps of the algorithm; I can predict what the patient (and the team) will be complaining about in half an hour.

It's true: the hard stuff, the interesting stuff, the true moments when the clinician is the one skating on the edge of disaster tend to be the complex medical cases. If trauma cases are like refreshing, ice-cold beer, tough medical cases are whiskey, straight up.