Trauma Anesthesia

[doctor712]

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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.

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?

Pgg, yes, thanks for the insight. I'll formulate more of an opinion as the years pass. I do agree of course that the women are much HAPPIER and thankful for the anesthesiologists' presence and magic fingers. Complaining, complaining, complaining, SILENCE and SMILES. as a father of two, even i was thankful to stop hearing all the cursing for once when my two boys were born!!!

Oggg, No love for the Lagavulin, sorry. 🙂 Just not peaty enough for me. If I'm gonna drink something that could power a F-18 Jet, I like a little flavor, and uniqueness. It's very personal though. Maybe I'll give it another shot. Thanks for the insight as well! Great answers both.

thanks,
D712

 

[MTGas2B]

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.

In forward military settings, its an option for massive transfusion. Outside of that setting I don't know of anywhere else its used. It can really save on a limited stock of component therapy in a small isolated location, like mine. I doubt you'd find a military place using it exclusively. Its pretty time and labor consuming to fire up the walking blood bank.

 

[MTGas2B]

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?

Slight correction regarding level one traum centers. While the bulk are part of academic medical centers, private practice level one trauma centers do exist. An example from the part of the country I'm most familiar with, Portland Oregon. Two level one trauma centers, first is the university, OHSU, the other Legacy Emanuel. Anesthesia services are provided by a private group, OAG. They do have IM residents and TY interns at Legacy Emanuel, and I think the surgery residents from OHSU rotate there.

Staying on thread, you still don't need a trauma fellowship to work a job at a place like that. And if you wanted a trauma heavy job, but didn't want to work in academics, it is possible.

 

[epidural man]

In forward military settings, its an option for massive transfusion. Outside of that setting I don't know of anywhere else its used. It can really save on a limited stock of component therapy in a small isolated location, like mine. I doubt you'd find a military place using it exclusively. Its pretty time and labor consuming to fire up the walking blood bank.

It seemed like using whole blood was getting more troublesome - the powers that be were putting a lot of administrative burdon to do it correctly, but I know some places were using it.

This increased burdeon came on the heels of the guy that got transfused with HIV+ whole blood. He ended up dying anyway, but still....

Also, there are some HCV, HBV, and other infectioius transmission that have occured with whole blood over there.

 

[fakin' the funk]

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

WOW. LA inflow-outflow view

 

[JSBMD]

I trained at a VERY busy trauma center in LA. Fantastic experience, I learned how to act quickly and think in the midst of crisis. For that reason, I think without adequate trauma exposure, a residency program will short-change its residents. However, I also (sort of briefly) worked at a trauma center in PP. I can tell you that trauma don't pay. Sorry to bring petty economics into this, but it turns out that most gunshot victims and drunks who crash their cars at 1am don't have Aetna insurance. Usually you find out, after the fact, that you spent the whole night doing charity work. Also, sadly, I've probably saved the lives of many murderers, just so that they can go out and seek revenge on whoever shot them. I have definitely seen prior lap scars on many, many trauma "victims", from previous gunshot wounds that were repaired.

Do enough of that, and you too will be a cynic.

OB, on the other hand, as stated before, is a place in the world where we can do some genuine good. The hours suck, so this is something for those in their 30's and 40's in my opinion. But, the patients, surgeons, and nurses truly appreciate what we do.

 

[Idiopathic]

It seemed like using whole blood was getting more troublesome - the powers that be were putting a lot of administrative burdon to do it correctly, but I know some places were using it.

This increased burdeon came on the heels of the guy that got transfused with HIV+ whole blood. He ended up dying anyway, but still....

Also, there are some HCV, HBV, and other infectioius transmission that have occured with whole blood over there.

pardon my ignorance. why would this be a greater risk with whole blood?

 

[epidural man]

pardon my ignorance. why would this be a greater risk with whole blood?

Oh, I am sorry. Good question.

Whole blood in Ass-crackistan comes from what is called a walking blood bank.

Casualties come in, there is an announcement on the FOB (forward operating base) to activate the walking blood bank. Soldiers that have been identified as donors then come and donate their blood. These guys have been pretested and the blood sent back to the states for testing, etc. However, there could have been a time lag between this testing, and the time they nailed a hooker at their last R&R.

The FOBS are now required to do rapid tests on the fresh whole blood for HIV, HCV, HBV, Malaria, RPR. Anyway, to run all those rapid tests takes about 45 min to 1 hr. By that time, your patient might be dead. And the accuracy is always in question.

Although fresh whole blood is by far way better than component therapy, it is almost faster to have packed cells and ffp flown in by helicopter. I was at a remote place in western ass-crackistan and we had 30 units in the fridge at almost all times. (That is very expensive by the way). We threw a lot of blood away.

Also, I think the FDA is being dickheads (is that a surprise?) and are trying to shutdown the walking blood banks, or make it so difficult to do because of administrative BS, that no one will do it.

It is too bad too since fresh whole blood is really amazing. And would you rather be alive with HBV, or dead? It never made much sense to me. Stupid FDA.

 

[fakin' the funk]

...GANGSTA INDISCRETION?...

Love this phrase

 

[fakin' the funk]

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).

I saw Pittet give a lecture at your joint once. Really cool stuff, the coagulopathy of trauma. I wonder if we'll be giving tranexamic acid routinely for big-time trauma any time soon.