Trauma Anesthesia

D712,

Trauma anesthesia exist both in PP and academics. Most PP groups wouldn't loose a lot of sleep if they were not the trauma group in town. It changes the dynamics of call if you are a busy level one center.

As for "trauma" anesthesia.... Well, you absolutely DO NOT need a year of CCM to do trauma. You only need a good residency that is associated with a trauma hospital.

Jackson would fit the bill for sure....

 

There are places trying to sell trauma "fellowships" as well. That's just another name for slave labor.
Rank programs at level 1 trauma centers and you'll do more trauma than you could ever want. If you want to do peds trauma, just make sure your peds fellowship is at a busy level 1 trauma center. I'm at one now, and we don't get much trauma. So if trauma was your thing, you'd probably be better off somewhere else.

 

Or do a deployment in Ass-crackistan. That works as well.

by the way, trauma anesthesia is a misnomer. There is very little 'anesthesia' in trauma. Mostly it is - give blood and give more blood, and do it fast.

You don't need a fellowship for that.

 

Are you in SoCal Il? I see LA Children's is looking for peoples.

 

Hell, if you can do a liver transplant and have the pt survive, you can do any trauma that rolls through the door...

 

Dude.

You are branding

TRAUMA ANESTHESIA

like you need a degree in

ASTROPHYSICS

to make it happen.

I feel ya.....anyone hears the word

TRAUMA

most freak out.


Dude, such a

DICHOTOMY!

The dichotomy being TRAUMA ANESTHESIA sounds so bold, so important, so complex, and yet from a pragmatic standpoint

TRAUMA CARE IS SIMPLE:

1)ABC
2)"Ok, dudes breathing, let's get a cuppla 16 gauges in the MO FO while we complete the

SECONDARY SURVEY

Foley, labs, call for blood products

COMING TO THE OPERATING ROOM FOR A GANGSTA INDISCRETION?

1) PUT DUDE TO SLEEP
2) Maintain ISOVOLEMIA, and clotting....IV fluids, Hespan, blood, ffp, etc
3) Keep'em WARM to prevent coagulopathy

 

I work at a very trauma-heavy institution.
And its not particularly difficult in my opinion.
Healthy males in the twenties s/p GSW
= RSI, two big IVs and A-line +/- central line and some PRBCs poss FFP or platelets. Normothermia and check labs.
Game over. Liver transplant ect are much more complex.
And trauma itself is become more and more non-operative management w/ IR.
Probably only 1/4 of the trauma codes i get get OR management and maybe 1/20 are brought up emergently.

 

I ranked a program very high because of their trauma experience, looking at it now- I dont see the big deal......

 

if you paid attention, then the experience made you a better anesthesiologist,

 

+1

Seriously.

The physiology of trauma? The tank is empty.
The pathophysiology of trauma? The tank is frickin empty.
The anesthetic implications? Fill the tank, and don't give a bunch of stuff that makes a semi-full tank act like it's empty.

 

I actually laughed out loud at this... don't know why, but I found it to be funny as hell.

 

This is hilarious. I think the underlying pathophysiology of trauma (the inflammatory cascade) could hold a lot of academic interest, but I agree with the others that this probably doesn't play much of a role in clinical practice. I do, however, think a lot of fun could be had doing these kinds of cases. You probably see a lot of fun stuff and have the potential to see a lot of patients get better (well, until the chronic disease of trauma recrudesces).

 

There are some great caes that come thorugh the trauma bay.

Cracking the chest open to do cardiac massage... in the trauma bay...

2, 3 and 6 mo. old siblings. All 3 coming in with cardio/respiratory arrest 2/2 carbon monoxide poisoning...

GSW to the head, to OR, brain edema so bad a fronto-parietal lobotomy is undertaken...

MVC with transected trachea and extensive cranio-facial-airway trauma...

Aystolic patient in drowning accident with temp of 8 degrees Celsius....

MVC with type A aortic dissection blows his aortic valve > circ arrest.

3 y/o amish kid that put his hand in to a meat grinder... arm chewed up all the way past the elbow...

etc.. etc.. etc....

These are just a few I remember off the top of my head.

Trauma experience is good...

You do enough of them during residency. You don't need a fellowship and become free labor to fill someone else's pocket.

 

I always thought this was an academic exersize - or just something to appear heroic - I don't think I had ever seen it actually do something.

However....

Yesterday in the pain clinic we were doing pulsed radiofrequency to a guy's sciatic nerves for his bilateral phantom limb pain - and I was asking about his trauma experience....he had stepped on a pressure plate IED - and he proceeded to tell me how he had died several times (I was thinking...yeah, i've heard that before), THEN he shows me the huge scar across his chest and told me how they had to grab his heart directly and squeeze it to keep him alive. WTF?! The guy is sharp as a tack as well.

I was impressed - changed my thought on the whole 'crack the chest' mentality.

 

My best trauma case actually happened while I was a fellow.

GSW to the chest.

Patient was hemodynamically stable and was evaluated at our trauma center and spent the night in the ICU before he was transferred to the big house for definitive cardiac repair.

Bullet went through the left atrium and into the aorta where it ran out of kinetic energy and blood flow took over. Bullet was found in the femoral artery.

Dude had a wide open fistula between the aorta and the left atrium with minimal pericardial fluid/ extravasation. Cool echo.



As for as the original question. I do a fair amount of trauma in PP. Mostly motor vehicle (Motorcycle/ ATV/ Boat etc), falls, GSW etc with the major difference from my training being the number of motor vehicle vs large animal (horse, cow, etc) accidents I get here. Thankfully I have a great group of surgeons here which leads to the other major difference... We don't take dead people to the OR here like we did in residency.

I will echo what the others have said about trauma anesthesia... pretty straight forward. The vast majority of trauma happens to a very narrow demographic of young, relatively healthy individuals and it is pretty dichotomous... either the trauma is bad enough that they die immediately or they come pretty stable and need just a little amnestic and lots of fluid. It gets a little more interesting at the extremes of age, but once again they either die immediately or they just need judicious anesthesia with a little less fluid replacement.

The only reason to do a trauma fellowship IMHO is if you are interested in the administration of a large trauma system (especially the pre-hospital portion) and find a place that will give you experience with it. Harborview would be great for this if the anesthesiologists had a larger role within the overall trauma management system. Between Airlift Northwest, Medic One, and Harborview ER there are some interesting challenges. However, it is all run by the surgeons and the anesthesiologists play a minor role so you would not likely get the experience that you are looking for there.

- pod

 

yeah

BUT I MEAN

its all JUST

PROP/SUX/TUBE

tank em up

PRESSURE UP GAS UP PRESSURE DOWN GAS DOWN

make sure and save time for the crossword

this way youll be a rokkstar

 

Was he a leprican ginger with a hand full of 4 leaf clovers?

 

Never seen it work in the trauma bay....

Seen it work in the CVICU with a good outcome.

 

Holly shait....

Even Idiopathic has an inner Jet.

 

Pretty funny btw.

 

i probably saw 5 ED thoracotomies as a resident, all 5 made it to the OR alive, 2 or 3 had a surgeons finger on a hole in the ventricle, 4 of 5 made it out of the OR alive, Im not sure whos alive now.

One things for sure though, they didnt die in the ER

 

Scopolamine if necessary.

 

My med school had a burn center that I rotated through as an MS3 and 4, and almost invariably the anesthesia provider for the cases was a CRNA. Sounded like people didn't get that excited about it; pretty similar to trauma as far as being mostly fluid replacement issues.

 

F'ing burns...
Ketamine for a dressing change, maybe some glyco.
FFP, drip drip drip.
Maybe some red stuff.
Skip the Sux.
If I never do another one, that's more than fine.

 

BTW, sick kids really disturb me too, but don't let that limit your career.
When it's really bad, I've got plenty of this...

Taking out a big tumor for the win, reconstructions, that's where it's at. Nothing like it. Changing kids lives, giving them hope.

 

Trauma can be fun and exciting when you are a young Jedi honing your skills. But a trauma fellowship is about as ridiculous as an ambulatory anesthesia or regional anesthesia fellowship.

 

You, my friend, have good taste. Even if you can't spell it.
Now put some in your next script...
Ardbeg is a sorry one trick pony and it gets all the press.
(though I'll drink Uigeadail)

 

i bet they all made it out of the OR, thanks in no small part to what was likely an organized and experienced trauma anesthesia team.

 

burns are stupid. i remember before i cam to vandy, watching some show about vandy medicine and there was some guy doing a burn anesthesia fellowship (?!). looking back i think, that cant be right...maybe it was burn ICU or perhaps he was a surgeon, but it sure sticks out in my mind. after doing about 100 of those OR cases, i cannot imagine that as a sole career.

 

Question to the anesthesia residents and attendings at trauma heavy institutions: Who authored your massive transfusion protocols? Was it the surgeons, the anesthesiologists, or both?

On that same note, what are your ratios of blood to FFP and platelets?

The combat literature has really changed things over the last 5-10 years, but even in the last 2-3 years I've noticed a big swing in the pendulum (previously blood was bad, NS was good, hypertonic was an option...now blood is great, NS is horrible, hypertonic is heresy).

 

our protocol was cowritten by trauma and anesthesia physicians. we shoot for 4:4:1 ratios, but it ends up being closer to 6:4:1 in practice, in my experience.

 

6:6:1 although I think there is a lot of variability between providers

 

This is what we do, I try to stick to it.

 

Save the Factor 7

 

We do 6:6:1:1

Our massive transfusion protocol was created jointly by two of our residents and the director of the blood bank (an awesome Pathologist).

 

Is anyone using Tranexamic acid in their trauma centers? We've been having a discussion about using it recently.

 

I've found fresh whole blood is nice, when you have the option

 

yes we would all rather have whole blood, its fairly prohibitive here though

 

Where does the variability come from?

That would be nice if it was an option.

When I was in Wichita, we always did 1:1 as well. Earlier on in my training, we were giving 7.5% hypertonic saline as well....stopped doing that after the literature showed it's bad.

Luckily, I'm semi-retired from trauma care...I never really liked it much. Sure the big bloody OR cases were sexy, but the day-to-day bullcrap was intolerable.

 

Anesthesiologists either seem to love or hate OB. I generally like OB. It's the only time patients are happy to come to the hospital, and the patients really love and appreciate their anesthesiologist.

I especially like OB in our military population - 98% of the patients are young and healthy, all of them have insurance and good prenatal care, there's almost no drug/alcohol/tobacco abuse. Bad outcomes are extremely rare. On the civilian side I like OB a lot less ... far more drug use, far more screwed up family/social/economic situations, less or no prenatal care, far more obesity, insurance is often an issue. Going back and forth from the military to civilian gigs, I avoid OB on the civilian side, and I can see why so many of us dislike OB anesthesia.

OB call universally sucks though, because babies are very inconsiderate when it comes to my schedule.

 

1. level 2 trauma center is the same as a level 1 trauma center, except without the academics, so there's definitely a lot of PP jobs with lots of trauma. Level 3 and below are where you only get the occasional broken bones
2. That being said, trauma is 24/7, generally poor payor mix so you'll be relying on a hospital stipend, and it's stressful, in that you have to move somewhat quickly at times. When you're 60yo, you may not want to wake up at 2am and run down to pump blood and drugs.
3. In less emergent trauma, it seems like there would be lots of opportunities for regional anesthesia
4. +1 don't bother with CCM, and +1 to going to a residency with a busy trauma center
5. Is there no love for Lagavulin 16y?

 

I've never seen it available, but I heard a speaker at the PGA from Shock Trauma
(I think Dr. Dutton) say the almost exclusively use whole blood for their resuscitation.