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Trauma Anesthesia

Discussion in 'Anesthesiology' started by doctor712, Aug 4, 2011.

  1. doctor712

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    Hi All,

    Quick question, as far as practicing Trauma Anesthesia for the most part, are the vast majority of these jobs in academic centers? In other words, what I'm curious about is, can you be in private practice and still staff a Level 1 Trauma Center? I imagine most Trauma Centers, like Ryder down here, are affiliated with a large teaching hospital/school, but I wonder if it's the norm elsewhere to outsource to pp groups?

    Numero Dos, is Anesthesia then CCM fellowship the pathway to take if you want to be "the trauma guy?" Or could you in theory do Anesthesia/Peds and be the "kid trauma guy?"

    Thanks!
    D712
     
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  3. sevoflurane

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    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....
     
  4. IlDestriero

    IlDestriero Ether Man
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    :thumbup:
    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.
     
  5. doctor712

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    Cool, thanks for the replies.

    D712
     
  6. epidural man

    epidural man ASA Member
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    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.
     
  7. imfrankie

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

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

    jetproppilot Turboprop Driver
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    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
     
  10. nycitygas

    nycitygas ASA Member
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    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.



     
  11. nycitygas

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

    Idiopathic Newly Minted
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    if you paid attention, then the experience made you a better anesthesiologist,
     
  13. fakin' the funk

    fakin' the funk ASA Member
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    +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.
     
  14. RT2MD

    RT2MD Now searching for substance P
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    I actually laughed out loud at this... don't know why, but I found it to be funny as hell. :laugh:
     
  15. cchoukal

    cchoukal Senior Member
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    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).
     
  16. sevoflurane

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    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.

    :smuggrin:
     
  17. epidural man

    epidural man ASA Member
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    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.
     
  18. periopdoc

    periopdoc Cardiac Anesthesiologist
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    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
     
  19. Idiopathic

    Idiopathic Newly Minted
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    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

    :rolleyes:
     
  20. sevoflurane

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    :eek:

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

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

    Seen it work in the CVICU with a good outcome.
     
  22. sevoflurane

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    Holly shait....

    Even Idiopathic has an inner Jet.

    :)
     
    #21 sevoflurane, Aug 5, 2011
    Last edited: Aug 5, 2011
  23. sevoflurane

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    Pretty funny btw.

    :laugh::laugh:
     
  24. Idiopathic

    Idiopathic Newly Minted
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    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
     
  25. Impromptu

    Impromptu ASA Member
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    Scopolamine if necessary.
     
  26. doctor712

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    Yeah, but don't you have to do a neuro exam at some point??? :laugh::laugh::laugh::laugh:

    I hear you loud and clear WRITER DUDE! I asked all this because I have been helping out with about 1/2 dozen chapters on trauma anesthesia and, ya know, read as interesting to me. truth be told, your description sounds spot on to what I'm reading when I think big picture. At least reading up on burns was interesting...
    :D
    D712
     
  27. doctor712

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    :laugh:
     
  28. WholeLottaGame7

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    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.
     
  29. doctor712

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    Dr. CC,

    I guess I was also asking for the reason you stated here. I might take some HEAT for this, and again, remember who is writing this here, not an MD, resident, M1, yet. Here goes. Other night I went in with my mentor who was covering OB call with his team. Cool. Fun night for me! Love learning, watching asking, squirting (just kidding). 9pm, time for C-section. What did she get? Epidural. 10pm, time for...C-section. What did she get? Epidural. 1130pm, C-section #3 for night. What did she get? Epidural? Patient four in pain, vaginal, Epidural.

    Anyway, OB just seemed highly-regionally-monotonous. (n=3, I get it, these cases could have probably gone in many different ways). Look, I know that there is a certain level of monotony
    with ANY area of medicine, and certainly anesthesia. That comes with the turf. But if you like it, that's why peeps like Jet post that they LOVE WHAT THEY DO. Great. I pray I'm there in 30 years, looking back. So, if tons of epidurals night after night don't do it for me, then, maybe I won't go into OB, or Pain Management. So, maybe that's what it is rather than just OB.

    But trauma at least, seems like there could be more "fun." First thing, lots of different types coming at you (granted, Jet and others have broken that down into one or two types: need blood, stay warm, airway, keep alive, etc) in a hurry, I dunno. I guess Hearts gets monotonous if you do it every day, sure. But, again, that's not the point. After 15 heart cases at CCFL, I sort of felt like I could see a BIT OF A pattern, but that's ok. It still seemed FUN. Sometimes, anatomy does it for you, the physiology, who knows. I loved those heart cases. Not necessarily the 6.5 hour ones but hey! But if you love it, great. I love it all, but if I had to pick Trauma vs OB, I think I'd go Trauma. Just seems more...fun. (note: not to disrespect the people who are entering the OR wishing it wasn't their night to be a trauma patient).

    Again, grain of salt here coming from me. Sick kids really disturb me, and I think this could be a very real place for me to practice. But Trauma sounds inn'eresting...

    D712
     
    #28 doctor712, Aug 5, 2011
    Last edited: Aug 5, 2011
  30. IlDestriero

    IlDestriero Ether Man
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    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.
     
  31. IlDestriero

    IlDestriero Ether Man
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    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...
    [​IMG]
    Taking out a big tumor for the win, reconstructions, that's where it's at. Nothing like it. Changing kids lives, giving them hope.:thumbup:
     
  32. doctor712

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    do you remember how each of these turned out?
     
  33. doctor712

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    IlDes, are you just playing with me, or can you read my mind and you've posted the ONLY AGED DRINK that I will religiously enjoy whenever I see it on a bar? LOVE LAPHROAIG...! Ahhhh, my lonely Boston nights of last year watching the Sox on the bar TV on Boylston Street.

    D712
     
    #32 doctor712, Aug 5, 2011
    Last edited: Aug 5, 2011
  34. Ketafol20

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    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.
     
  35. IlDestriero

    IlDestriero Ether Man
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    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)
     
  36. doctor712

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    After work at the studio, I would wander around town and look for new seafood restaurants where, if lucky, I could watch either the Bruins or Sox or Celtics game as well. I really knew NOBODY in that town and few co-workers lived near Back Bay or South End.

    Usually, I just ended up at this place:

    http://www.abeandlouies.com/

    or this place next door over...

    http://www.atlanticfishco.com/

    I don't like Scotch. Never have. One night, after a HUGE SHRIMP cocktail, some steamed lobster and creme brulee no doubt, watching hockey, holding court and making some "friends," the 'tender slid over a new friend of mine... "Try this out...you may like it."

    Sir Laphroaig.

    She also let me try about 4 other comparable types, Ardbeg was surely one of them. As for Laph, I tried the 15 y o, Quarter Cask, and at the ripe old price of 57$ for a drink, 30 y/o. It was a love affair. To this day, I have no idea why. It just tastes like NOTHING ELSE.

    D712
     
  37. Idiopathic

    Idiopathic Newly Minted
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    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.
     
  38. Idiopathic

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    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.
     
  39. SLUser11

    SLUser11 CRS
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    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).
     
  40. Idiopathic

    Idiopathic Newly Minted
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    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.
     
  41. Arch Guillotti

    Arch Guillotti Senior Member
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    6:6:1 although I think there is a lot of variability between providers
     
  42. IlDestriero

    IlDestriero Ether Man
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    This is what we do, I try to stick to it.
     
  43. imfrankie

    imfrankie Anesthesiologist
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    Save the Factor 7
     
  44. psychbender

    psychbender Cynical Member
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    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).
     
  45. MTGas2B

    MTGas2B Cloudy and 50
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    Is anyone using Tranexamic acid in their trauma centers? We've been having a discussion about using it recently.
     
  46. MTGas2B

    MTGas2B Cloudy and 50
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    I've found fresh whole blood is nice, when you have the option :)
     
  47. Idiopathic

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    yes we would all rather have whole blood, its fairly prohibitive here though
     
  48. SLUser11

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    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.
     
  49. pgg

    pgg Laugh at me, will they?
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    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.
     
  50. Oggg

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    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?
     
  51. nycitygas

    nycitygas ASA Member
    7+ Year Member

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    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.
     

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