Trauma elective - cook or UMD?

[danibar]

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Hi all!

I am a foreign medical student coming to the US this winter and I'm trying to decide whether to take a trauma elective in University of Maryland or Cook County hospital. My main concern is "hands-on" work - Are students allowed to do any procedures? Which are allowed? What is the basic workday comprised of? What time do rounds start in the morning? Anyone know which center is better for students?

Thanks ahead of time!

 

[Rendar5]

I'm not too familiar with cook, but I'd also look into Grady and University of Miami as other viable options. The hospital that deals with the most trauma with a decent mix of blunt and penetrating) would probably be your ideal situation so I'd specifically ask around on those questions. Also, som e of the questions you brougth up in your post such as student responsibility and workday could potentially be answered by contacting those programs by e-mail or phone.

 

[LadyWolverine]

By trauma, do you mean a trauma surgery rotation? Are you going into EM or gen surg-->trauma surg? I ask this because if you come to U of MD, get ready for q3 call and several hours of rounding each morning. You'll get to do procedures in the TRU (as a 3rd year I got to put in a couple A-lines, *attempt* a central line (did not get it on first try and resident took over), lots of suturing lacs, lots of general trauma evals/C-spine evals, tons of FAST scans, and maybe 2 ultrasound-guided IVs), but a lot of the really "cool" stuff is going to get snapped up by the residents. The OR is "optional" for students doing electives (those interested in emergency med and not surgery usually opted not to go to the OR).

The thing about the trauma experience at Maryland is that once your patient has been stabilized and surgerized, they can then sit on your team for relatively long periods of time, and you have to round on them every day. Most of them are pretty complicated and involve multiple consultants so it's not unusual to spend 30 mins + on each patient (and, depending on your team, you usually have 20++ patients at any given time upstairs, sometimes MUCH MORE). Usually what you are then managing is routine stuff for the not-so-sick/moderately sick patients (medical issues, calling consults/checking consult recs, making decisions about PEGs/trachs, etc. - trauma is a huge dumping ground for ortho, neurosurg, etc...they do all of the surgery for many of the trauma pts, and then they just leave them with your team to manage them from day to day, while they continue to consult daily. There are NPs that help take care of a lot of this stuff, but ultimately your team is responsible for coordinating everything for each pt.) If they are really sick, they go to the trauma ICU, where they have a dedicated TrICU team who takes over their medical and day-to-day management. Also, anesthesia is always a quick phone call away. Thus, if something happens while you are in the TRU/OR/home/otherwise off the floor (the pt needs a chest tube, the pt needs to be intubated, pt needs a central line, etc.), the ICU team or Anes is going to do the procedure. You will do some procedures on/after rounds on your pts hanging out on the floors, but mostly pulling staples/pulling chest tubes out/changing wound vacs (sometimes this is done in the OR)/re-dressing wounds/etc. I didn't do any more complicated procedures during my trauma rotation on patients that were already upstairs (although we had a couple of "dedicated ICU days" and I got to assist on a central line on one of those days.)

My biggest gripe about trauma was the sheer number of people on the trauma team. We had 4 MS3s, 2 sub-Is, 5-8 junior and senior residents (both EM and surg/surg subspecialty), a fellow, and one attending at any given time. As the medical students, we were low enough on the totem pole that we were always last in line for cool stuff. Even our sub-Is didn't do much as we did because 1. they worked fewer total hours than the 3rd years did, 2. they were not interested in trauma SURGERY as they were going into EM, so they stayed in the TRU most of the time and didn't go to the OR, and 3. it was January/February and they were sorta "checked out".

If your goal is to do lots of procedures (central lines, A-lines, inbuations), your best bet would probably be to do an ICU rotation, like the SICU. However, if you are interested in trauma SURGERY, then things change a bit.

One of my classmates is wrapping up a trauma surgery sub-I currently. I'll point her to this thread and perhaps she can give you some feedback re: procedures.

 

[LucidSplash]

At Maryland, there are two different "trauma" sub-Is. One is the Shock Trauma Surgery sub-I which is similar to what LW is describing. I will say that as a sub-I we actually work more hours than the third years but the schedule is set up differently. As a third year, it wasn't always apparent to me how the resident/sub-I schedule worked - but as a sub-I, I realize now that the schedule just varies significantly. We are q3 overnight and I have worked well in excess of 80 hours/week this month.

Procedurally, it is July and so yes, big procedures like A-lines, centrals, etc were few and far between and as such were snapped up by residents because it is early in the year and everyone wants them. When I did trauma as a 3rd year, there was more available (similar to LW's experience) because it was April and the residents weren't quite as motivated given they had a year of procedures behind them. That said, there are always a number of visiting residents doing an elective rotation on the team and they come here specifically to get experience with chest tubes, lines, etc. So even in the later months, it can be tough for a student to get to try a line.

The other trauma elective is a Trauma ICU elective. I haven't done one of these myself yet but I am scheduled to do one in November. I have spoken to one of my friends who graduated in May - she did a TICU elective and did 9 lines during her month on the service and a few chest tubes as well. So if you are really interested in procedures, that may be a better option for you as the teams are smaller.

Also note that Shock Trauma at Maryland is far less busy in winter months than it is now, in the summer. As a sub-I this past month, there has been plenty of patients and surgeries (emergency and elective) to go around. There are 6-8 residents on the team, the fellow, the attending, two 3rd year students, and 2 sub-Is and I don't think any of us has suffered from lack of patients or stuff to do. They have changed the 3rd year schedule so they only do 2 weeks of Trauma now, rather than 3 like last year, so there should only be two third years on the team at a time, which should mitigate some of LW's gripe regarding team size.

One final thing - will you be coming in the capacity as an official elective at this school or as a visiting observer foreign med student? I ask because there was a British medical student floating around for awhile but she wasn't an official rotator with us. She was doing an elective here as part of her curriculum, but she wasn't an official part of our team and wasn't doing any procedures or carrying patients. You should clarify before you decide to do such a rotation that you would be an official member of the team and not just an observer.

If you have more specific questions re: Maryland Shock Trauma, just ask.

 

[danibar]

Wow!

Thanks a lot for the extensive answers!

Truth be told, I want to be a surgeon and sub-specialize in trauma. Where I live (Israel) the trauma centers are much smaller then the US. Some hospitals don't have a trauma surgeon at all and the general surgeon on call takes in all the trauma, manages the trauma team and then dished out the patient to the OR or to any other department according to injury severity (plastics for burns, ortho, ICU, etc.). in the larger level 1 centers, there are usually 1 or 2 attendings who have completed a trauma fellowship (almost always in the US) and are called in only when needed - so they spend most of their workdays on the general surgery staff (I think there is currently a fellow at Maryland from our hospital (Dr. Miklosh Bale... know him by any chance?) who is going take that position when he is done). The main purpose of my trip to the US is to try and get some trauma experience and help me decide if it's right for me. Doing procedures is important and I want the experience - but if I don't get to put in 300 central lines I'll live. I may also take an ICU elective at home. I just don't want to find myself observing only... No way I'm going to fly across the atlantic just to look!

At the moment I have a positive answer from Cook and I'm waiting for Maryland's reply... Hopefully they will say yes and then I'll have to decide!

A couple more Q's I have for you:

What time do rounds start in the morning? what time do the regular workdays (not on call) end? When do you go home after being on call? How are they on missing a day here and there or leaving a bit early? I will be staying at my grandmother's house and she needs help sometimes... That's why I'm asking.

Is there anyone out there who has done a trauma elective at Cook and can answer some of these Q's?

Thanks again for all the help!

 

[LucidSplash]

What time do rounds start in the morning?

Generally teams start rounding with the attending at 7:30am. Many fellows like to run through the list at 7am or 7:15am before the attending arrives. Therefore, you need your prerounding done by 7 or 7:15am usually. I usually arrive at the hospital at 6am or so depending on how many patients I have.

what time do the regular workdays (not on call) end?

As a sub-I, we follow the resident schedule. This is a rotating schedule (basically a 9-day week) so the time your shift "ends" depends on where you are at in the schedule. On a precall day, you will be either short or long. Short means that you can start signing out your patients at 1pm, long means at 5pm. But that's assuming all the floor work is done. On short days I have left as early as 1:30pm, but usually I leave around 3 or 4. On long days, I have left as early as 5:30, but usually I leave around 6:30pm or 7. I've been here as late as 8 or 9pm.

When do you go home after being on call?

Again, rotating schedule. 1 day per schedule cycle, you leave postcall at 7am, before postcall rounds. Of course this is after you sign out your patients to another member of the team, so usually you can get out by 7:30a. Otherwise, you are either continuity or long. Continuity means after rounds, you do your floor work and when its done you can sign out your patients and leave, ideally by 1pm but again usually by 3pm. Long is the same as precall meaning you can start signing out the team's patients to the oncall team at 5pm, but if the floor work isn't done you can't sign out until it is. It takes a bit to sign out everyone; I've left as early as 6pm and I've been here as late as 8 or 9pm.

How are they on missing a day here and there or leaving a bit early?

Generally you should plan on keeping to the assigned schedule. This is categorized as a sub-I for us, and you are expected to try and act like an intern, who certainly would not get to leave early or miss a day here and there. The 9 day schedule cycle has a precall day off, followed by a call day on where you get to leave at 7am postcall, once per cycle. Perhaps you can plan to help your grandmother on your assigned days off. But altering your schedule or asking for special privileges not available to the rest of the team will not endear you to the residents or the fellow. This is a very demanding rotation in terms of schedule and keeping to the intern's schedule is considered part of the experience. Clearly, if you have a family emergency or something of that nature, it will be understood. But missing a day means that others will need to pick up your patients and do the work you will not be there to do, which is rather unfair to those you work with. Team members are generally very willing to help one another out and work hard to get those people who are scheduled for "short" out as quickly as possible, as they know the favor will be returned when they are scheduled for "short." But that only happens as long as the balance of work is maintained.