Should EM run Trauma instead of Surgery?

[bryanboling5]

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I just read an interesting article by Christopher Grande (an Anesthesiologist at Maryland Shock Trauma) describing a rationale for the subspecialty of Trauma Anesthesiology (it's a good article on Trauma management, it's in Critical Care Clinics, Vol. 6, No. 1 Jan. 1990). In it, he argues that Anesthesia should run the Trauma service (as is frequently seen in countries outside the US) rather than surgery. He says that as many as 90% of trauma patients don't go to the OR and so the idea that a surgeon needs to be in charge is not necessarily true.

His argument is that Anesthesiologists trained in Critical care would be ideally suited to the role. He argues that they'd need training in more procedures that normally don't occur in the common practice of Anesthesia (ie Emergent Thoracostomy/Chest Tube placement) that would commonly be used in the Trauma room even if the patient didn't need to go to the OR.

Along his rationale, it seems to me that the EM physician might also be ideally suited to this role. With additional Critical Care training, an EM doc would be a great person to head Trauma. They are already familiar with the rapid assesment of injured patients and with a great deal of the procedures that are involved. With some training in the ICU and even in the perioperative management of trauma patients, wouldn't an EM doc be ideally trained for this?

I'm not saying that Dr. Grande is wrong and that Anesthesia is wrong for the job, but perhaps EM is just as qualified. In addition to Dr. Grande's arguments, there are a great many EM docs who are advocating that EM should be able to be involved in Critical Care just as surgeons, anesthesiologists and IM docs.

What does everyone think of the idea of an EM specialization in Trauma beyond airway management or simply initial assesment? Also, do you think that this would ever be able to succeed in the US given the mindset of surgeons and the varying degrees of respect that they give EM?

 

[trauma_junky]

So, what about the other 10% that could benefit from a surgeon being present?

 

[fourthyear]

Most of the reason a surgeon needs to be there is to DECIDE if a patient needs surgery. I hope I never see the day when an anesthesiologist or EM doc tells a surgeon when a trauma patient needs surgery or not.

 

[The White Coat Investor]

The point of the trauma system is to have the trauma surgeon (along with the radiology tech, lab dude, chaplain etc) right there in case they are needed. I agree that EM ought to "run" the traumas. (By that I mean the initial resuscitations.) The most critical decision in running trauma is the decision to operate, or not to operate. That, however, is the same decision EPs make every day about belly pain. I.E., send home or consult a surgeon. The problem is that it takes an hour for the surgeon to come see the patient. In trauma, you don't have that kind of time. So how many surgeons will show up and stand on the sidelines waiting to be consulted? Not many. I understand Hennepin has got theirs trained however.

The other issue is that general surgeons do 2-8 months of "trauma service" training, whereas EPs do only 1-3 (plus the 1-2 resuscitations per shift). I think it is a bit presumptuous for us to say that we are better at it.

Traumas consume an immense amount of resources, M.D. and otherwise. I don't have the time to sew up someone's entire face, follow up on their labs/x-rays/consults, babysit them in the CT, admit them, round on them, discharge them and still see 15 other patients during my shift. I'm glad we've got some suckers willing to do it.

As far as EPs being trauma docs...if you've got to have the surgeon in house anyway, "just in case," she might as well be doing some work while she's at the hospital. Let her run the service too. EPs are not ideal (nor are anesthesiologists) since they are not trained in inpatient care. (95% of trauma work.) So, to sum up that random rambling, I think EPs ought to run the initial resuscitation, surgery ought to stand there until consulted, and then surgery ought to admit/operate/do the crap.

 

[DOrk]

I plan to specialze in EM, and I'm all for EM physicians playing an integral role in trauma recussitation...including switching off with surg as trauma team leader....I also have a general disdain for surgery and most surgeons....That being said, however, I must agree with fourth year and trauma junkie that surgeons MUST continue to be part of EVERY trauma recussitation. EM physicians are experts when it comes to the initial evaluation and management of trauma patients, but surgeons are best equipped to make decisions about surgical interventions. If EM physicians (or any non-surgeon for that matter) feel qualified to evaluate the most critical surgical patients, then surgeons should no longer be called upon to evaluate ANY LOL's with abdominal pain in the ER. Not having a surgeon in on the trauma team is akin to not having a neurologist on the stroke team...Wouldn't that be silly? Just my two cents....I have a feeling this might start a lively discussion...Tell me what you guys think.

 

[bryanboling5]

I agree that this has the makings of a lively discussion!

I'm not advocating getting rid of trauma surgeons, and I'm not suggesting that the EP's in the ER manage the Trauma patient. I suppose that I wasn't very clear.

What I'm suggesting is an EP, further trained in Trauma (Maryland Shock Trauma has a fellowship for EM for example) and inpatient care. They would be a part of the Trauma team (along with surgeons and anesthesia etc.) and would round in the ICUs and manage inpatients. Then, they'd come to the ER for the Trauma resus and run things. It's sort of a new variation of the "Captain of the Ship" mentality except EM/Trauma is the captain and they direct the team (surgery, anesthesia, rad, etc.)

I totally agree that there needs to be a surgeon on the team. But they could handle the OR stuff.

I've often seen times when the "Trauma" surgeon (here they also do appys and other such surgeries) is called out of the OR to evaluate and do the work up on a patient who doesn't need surgery (and often times it's obvious to the EP that they don't, but Trauma has to come because it's protocol) or come out to see a patient in the ICU (or worse, the ICU patient doesn't get seen for hours until the OR case is done.)

Having an EP who is fellowship trained in Trauma and critical Care would allow the surgeon to stay in the OR and let the EP see the patient. This person would have a year or two of fellowship with specific emphasis on assesing the need for surgery. Then, if need be, they could call the surgeon out of the OR. Also, they'd be on the same team, so you would (hopefully) minimize the trouble with getting surgery to show up, because the surgeon would know they could could trust the EPs judgement.

Hope this rambling makes some sense....

 

[tonem]

Originally posted by bryanboling5
What I'm suggesting is an EP, further trained in Trauma (Maryland Shock Trauma has a fellowship for EM for example) and inpatient care. They would be a part of the Trauma team (along with surgeons and anesthesia etc.) and would round in the ICUs and manage inpatients. Then, they'd come to the ER for the Trauma resus and run things. It's sort of a new variation of the "Captain of the Ship" mentality except EM/Trauma is the captain and they direct the team (surgery, anesthesia, rad, etc.)

I'm not sure how many EM trained physicians are really interested in rounding on patients. The lack of rounding is one of the attractions of EM. Most EM residents that I know dread the trauma service for that very reason. That being said there already are programs EM/IM, EM/Peds, EM/IM/CC, and the already mentioned Maryland program for those few gluttons for punishment.

Having an EP who is fellowship trained in Trauma and critical Care would allow the surgeon to stay in the OR and let the EP see the patient. This person would have a year or two of fellowship with specific emphasis on assesing the need for surgery. Then, if need be, they could call the surgeon out of the OR. Also, they'd be on the same team, so you would (hopefully) minimize the trouble with getting surgery to show up, because the surgeon would know they could could trust the EPs judgement.

There already is a program in place to train the EM physician to assess the need for surgery. It's called EM residency. Outside of the trauma setting we evaluate patients several times a day to determine if they need to be seen by a surgeon. For every patient seen by surgery in the ED at least ten more have presented with similar complaints, have been evaluated, treated or "triaged" (as some surgeons like to call it) to Medicine/GI or out the door. The more astute surgeons already realize that as miserable as their lives already are it would be much worse if they had to evaluate every "belly pain" or (insert potential surgical complaint here) that walks through the door. If our theoretical surgeon still doesn't "trust the judgement" of his EM colleague, he is still mandated to respond to the trauma pager within a certain amount of time or the hospital will lose it trauma center designation.

 

[DrQuinn]

Well said tonem. Anti-rounding is one of the main reasons I realize now why I love EM so much (wasn't an original reason but now that I'm in EM I am sooooooo glad). I absolutely abhor rounding of any sort. I don't mind a serial abdominal or neuro exam... but ask me to compare todays FENA to yesterdays and you'll get a swift kick in the shins.

Q, DO

 

[droliver]

Originally posted by bryanboling5

It's sort of a new variation of the "Captain of the Ship" mentality except EM/Trauma is the captain and they direct the team (surgery, anesthesia, rad, etc.)

I totally agree that there needs to be a surgeon on the team. But they could handle the OR stuff.

Hope this rambling makes some sense....

It makes little sense to me @ dedicated trauma centers. You really need to think like a surgeon to take good care of this population, even in the apparent non-operative ones. You can't easily train people in the skill-sets surgeons obtain b/w their hands on anatomical/surgical background and clinical experience with surgical patients without doing several years of Surgical Training. Adding layers of providers ,after the initial triage, who try to decide subsequent surgical intervention is really a flawed method when those resources are available.

In a practical sense, it might be more suited to non-level I or II centers where you don't have the surgical support & manpower afforded by the training progams to take care of this fairly labor intensive & often morbid group of patients.

 

[scutking]

I agree with Dr Oliver. There MAY be a role for EM trained physicians managing trauma in a smaller Level III center, but even that is stretching it a bit. In a large Level I or II trauma center, I see EM contributing very little, if anything, to the trauma team. It just adds one more layer of physicians between the patient and the surgeon who would ultimately have to operate on them.

 

[edinOH]

I think one point that should be emphasized a little better is the fact that in the "real world" (most community EDs) it is the EM physician who is managing the trauma at his/her sole discretion. It isn't a matter of turf, or who can tx the pt better, but rather of economics and efficiency. It is the EM physician who is managing the airway, inserting the chest tube, placing the lines and managing resuscitation until it is determined that if and/or when surgery needs to be called. Sometimes this is the minute the pt hits the door. More often it is after initial stabilization and imaging.

Unless you are in a level one center it is impractical for the surgeon to be present or be called for every trauma that rolls through the door. In the case of penetrating abd/chest trauma it is a pretty easy call in most cases. It is the blunt injuries that require the indepth assessment and decision making regarding surgical involvement. This doesn't necessarily mean that the ED doc is "telling the surgeon when to operate" as one poster mentioned but rather knowing if and when it is time to get the surgeon out of bed.

The program I am training at doesn't always have surgery in house. In fact, this is one of the reasons I chose this program. I think it is important for me to learn how to manage trauma initially independent of a surgeon since this is most likely how I will be practicing in a short 2.5 years.

 

[southerndoc]

Originally posted by scutking
I agree with Dr Oliver. There MAY be a role for EM trained physicians managing trauma in a smaller Level III center, but even that is stretching it a bit. In a large Level I or II trauma center, I see EM contributing very little, if anything, to the trauma team. It just adds one more layer of physicians between the patient and the surgeon who would ultimately have to operate on them.

Most surgeons at Level II centers do not remain in house.

In fact, I remember when I worked as a paramedic, transporting patients to a Level II facility and it averaging nearly 30-45 minutes to get surgeons in house for critical traumas.