Who is running the trauma?

Discussion in 'Clinical Rotations' started by richierich, May 13, 2002.

  1. richierich

    richierich Senior Member
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    I am torn right now between Gen surg with a trauma fellowship or ER. At my school surgeons run the trauma and the ER attending is there but the majority of the time just writes their note and leaves. I was just wondering if this is now the norm or in most situations are the surgeons still in a consultative capacity?

    The lifestyle differences truly is the biggest factor at this point.

    Any help would be appreciated?

    Richard
    USF c/0 '04
     
  2. Guitarzan the Jungle Man

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    In general, surgeons run all trauma cases. The end all being that IF a trauma requires an operation they should go from door to OR in about 30min. That being said you are not required to do a Trauma fellowship to do trauma work. Anyone who graduates from a US surgical residency will get plenty of experience running traumas. More and more trauma is non-operative or blunt injuries so getting to take a patient to the OR for exploration is becoming more and more rare...such is life.
    ER doctors participate a great deal in Trauma patients and management especially in non-trauma center hospitals and the residency is about 3 years shorter.
     
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  3. tonem

    tonem Senior Member
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    It varies tremendously from coast to coast and between institutions in each region. Thats why its important to ask that question when you're interviewing at various programs if that aspect of emergency medicine is important to you.
     
  4. droliver

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    At our program it tends to be a nice synergy b/w the ER & surgery. The ER screens most of the blunt trauma unless there is advanced warning of someone severly injured, then our trauma alert system pages the surgery residents ahead of time. If we're there we do most of the major procedural stuff (chest tubes, crichothyroidotomies, thoracotomies, etc...) while the ER usually intubates the patient and will frequently put in central lines. Ocassionally there can be some tension b/w the two disciplines, but usually the ER residents have disappeared after the first few moments and have no interest in futher involvement with the patient.

    All in all, our system works pretty good b/c when someone is really hurt you can usually tell immediately and we tend to take over. The ER serves as a nice buffer to some of the busiwork for the clearly less injured, but frequently can miss/undertreat some of the not as obviously hurt. The redundancy of the the surgical trauma evaluaion afterwards tends to pick up most of these.

    If you're going into ER for a career, I'm not sure a real heavy trauma exposure/responsibility is needed. As a non-surgeon, the things that you can do are pretty limited (but VERY important) and consist of stabilizing patients for transport (IV access & fluid resuscitation, airway mgt., chest tubes if needed). I think a stronger background in the medical disciplines probably gets you more bang for you buck especially since they let you get board-eligible in 3 years for ER (a ridiculously low amt. of time for the specialties demands)
     
  5. ApacheIndian

    ApacheIndian philomath
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    I don't know firsthand but a friend of mine told me that as soon as a trauma case rolls in the Surgery Residents take over. He told me that he saw even R2s taking control barking orders while the ER doc stood in the background like a showroom dummy. To quote Dr. Steven Polk... "ER docs are nothing but glorified interns."
     
  6. A little elf

    A little elf Member
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    Now, now, Dr. Cuts...that typical surgery attitude is already being cultivated in you...like tonem said, it varies GREATLY depending on what part of the country and training program that you are in. Besides, trauma really loses it's appeal after you've been doing Q3 call on the trauma service for 3 months in a row. By the way, good luck with that, Dr. Cuts...you signed up for it, I didn't. But then again what do I know, I'm just going to be a dumb EM doc.
     
  7. ApacheIndian

    ApacheIndian philomath
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    LOL little elf! There's NO amount of money that one could pay me to be a surgeon lol! Me? Surgeon!? lol... no way man I was just relaying what a friend of mine told me (HE'S going for Ortho). Oh no, no surgery for me lol... may I please refer you to the poll I just posted... I'm thinking Rads, Anesthesia, or Path for me. Oh, and no offense by that quote... just something I read, not necessarily my opinion.
     
  8. At the hospitals I've worked at, as soon as the ambulance radios in "Level 1," the ER calls the trauma pager. This is the case most everywhere I've heard of-- trauma surgeons run trauma cases. Studies have shown that the most significant predictor of mortality in the first hour is time to the OR-- that's the whole idea of the "Golden period" in these cases. That being said, there's no way I'd go into trauma... it sounds like fun, but you really should do a couple of trauma rotations in med school to see what it's really like!
     
  9. Freeeedom!

    Freeeedom! Senior Member
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    As Droliver said, it varies from hospital to hospital coast to coast...with the trend being a 50-50 relationship or a more EM dominant role. Usually, the EM docs will respond first in either case...and at a certain point, it is all cookbook anyway.

    There is a huge difference between surg and EM, huge. I chose EM, and every day I am glad I did so.
     
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  10. md03

    md03 Senior Member
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    I've done a lot of research into this as well. I originally started med school thinking I would likely do ER, but now I've decided to do surgery and will probably do a trauma fellowship.

    I realized that the procedures of ER won't be enough to keep me happy. I love the OR environment and I love to operate. The suturing an ER doc does won't be enough for me. At my school, we don't have an ER residency, so there is no question who runs the trauma. I also have the great fortune to go to school where there is one of the busiest trauma centers in the US AND they hire a few med students from every class for a very part time job of suture tech. So since my M1 year I have spent roughly 3 evenings a week suturing for money, and also have become intimately acquainted with the inner workings of the trauma center. When there isn't people to sew, I can go particpate in the traumas, and if there aren't students on the rotation, scrub. I realzied early on that I would be very frustrated as an ER doc not getting to take the patient to the OR and do the surgery (same goes for the GI bleeders, perforated ulcers and hot appendix.)Plus, I love the ICU environment. I want to take care of sick patients. (a lot of an ER doc's patients aren't that sick)

    When ER docs are involved in trauma, they are only involved in the intital workup/stabilization.

    The questions you need to ask your self are
    Would I be happy never going to the OR again after I graduate from school?

    Would stabilization of patients be enough for me as an ER doc, or would I want to be involved in their subsequent treatment?

    Do I want to deal with the lifestyle of a surgeon (careful here, lifestyle varies a lot at different programs and can also vary depending on your ultimate practice setting?

    Can I live with the fact that an ER doc is a hospital employee and can be fired (for example, if the hospital gets too many complaints about an ER doc. "too many" can be surprisingly few, and the comlanints can be about trivail stuff, like they thought you weren't nice enough")

    Talk to some ATTENDINGS in both ER and surgery (general and trauma) and ask about both the advantages and drawbacks of both. Hearing the drawbacks of ER from a speaker for our EMIG made me realize that the drawbacks of ER would drive me nuts. My surgery rotation confimed that my ultimate career must involve the OR.

    Hope this helps.
     
  11. richierich

    richierich Senior Member
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    md03,

    Seems that you and I are on the same wave length. I appreciate the info tremendously, as I do everyone who has posted here.

    I am just starting my 3rd year and will have to see if surgery is for me.

    Thanks again to all

    Richard
     
  12. Sheerstress

    Sheerstress Senior Member
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    In the most serious traumas, the surgeons will do most of the definitive care.

    The emergency physcian is probably most indispensable at small community hospitals where the surgeons might not even take trauma call.

    In such cases, their role is largely one of trauma STABILIZATION, i.e. evaluate the patient's condition and stabilize as necessary before shipping them to a tertiary care facility. Usually, the most this entails is intubation, central lines, chest tubes, and traction splints. ED thoracotomies are quite rare, and in extremely rare cases, a EM practitioner might be called to do burr holes under the consultation of a neurosurgeon. In a nutshell, it's basically everything you learn in ATLS.
     
  13. A little elf

    A little elf Member
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    Sorry that I was so touchy earlier...rough day...sorry Dr. Cuts. Anyway...I totally agree with sheerstress and the other posters...it all depends on what you are looking for in a career. EM has so much to offer besides trauma...making medical decisions based on limited info, etc. You truly need to be a good medicine doc as well as a doc who is good at procedures.
     
  14. Sevo

    Sevo Senior Member
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    </font><blockquote><font size="1" face="Verdana, Helvetica, sans-serif">quote:</font><hr /><font size="2" face="Verdana, Helvetica, sans-serif">Originally posted by richierich:
    <strong>I am torn right now between Gen surg with a trauma fellowship or ER. At my school surgeons run the trauma and the ER attending is there but the majority of the time just writes their note and leaves. I was just wondering if this is now the norm or in most situations are the surgeons still in a consultative capacity?
    </strong></font><hr /></blockquote><font size="2" face="Verdana, Helvetica, sans-serif">At our university hospital, the surgeons run the show for any level 1 trauma. The idea being, I guess, that the speciality best suited to fix 'em the fastest gets 'em.
     
  15. Winged Scapula

    Winged Scapula Cougariffic!
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    As others have said (and as we've discussed in an earlier thread), the management of Trauma varies widely from program to program. Here all Traumas (except the minor, Level III ones) are managed by the Surgery Department, with the ED attending generally writing a note and then leaving. ED residents don't even attend the Traumas here. A Trauma alert goes out and all Surgical residents receive the page - the Trauma team responds during the day (with additional backup as needed, ie, generally for multiple traumas) and all Surgical residents in-house respnd on weekends and after hours.

    Depending on whether your case load is mostly blunt (as it is here) or penetrating, your time in the OR as a Trauma Surgeon will vary widely as well.
     
  16. Freeeedom!

    Freeeedom! Senior Member
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    Gen surg guys,

    It sounds like you have already made up your mind...which is good. I was dead set on orthopedic surgery during years 1-3, and then changed my mind. Personally, I HATED surgery (too boring etc), and one must LOVE what they are going into.

    But also remember that from residency to residency your job at a trauma may be different...but for the most part, penetrating trauma is cookie cutter.
    Best of luck.
     
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  17. droliver

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    Actually Freeeedom, the decision tree for penetrating trauma is not that straight forward & is moving towards more non-operative management of transmediastinal and abdominal GSW (which no one previously would have considered)with a much greater degree of judgement and serial exams involved. Penetrating neck wounds, mediastinal trauma, and extremity GSW are also very complex decisions about what the appropriate tx. is these days (exploration vs. CT vs. Angio vs. non-invasive vascular studies).

    To each his own, but if surgery was boring to you, you are going to be miserable doing ER after a few years (the worlds largest FP clinic <img border="0" title="" alt="[Wink]" src="wink.gif" /> ).

    I also get amused @ med students who want to go into ER who are trauma-centric. Almost 100% of them by the time they finish their residency would like nothing more than to never see trauma again. Its very stressful, it doesn't pay well, people die, and its full of liability. I see most of my friends who did ER make their choices for work on places with the least amount of Peds, OB, and trauma they can find.
     
  18. njbmd

    njbmd Guest
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    Hi there,
    Trauma Surgery and Critical Care run the traumas at my institution. I toyed with the idea of Emergency Medicine but found that EM was 90% clinic medicine(after I did the ER elective) and the real adrenalin rush went to the surgeons so I opted for General Surgery with Trauma/Critical Care fellowship after. The most that ER is going to be able to do is attempt to stabilize and turn over to the surgeons for definitive care. Even the blunt traumas end up under the care of a surgeon.
     
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  19. Mr. happy clown guy

    Mr. happy clown guy Senior Member
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    You guys are whacked!!!

    I have no idea where you did your EM month, but I agree with F, surgery was Eh...dull. Ohhh nothing more exciting than taking out gall bladders or maybe an appendix 10 times a day. wow. That is the life of a general surgeon.

    Now.
    See, this is what it sounds like when each group makes fun of each other. Silly ain't it.

    Penetrating trauma IS cook book once you get used to it. Guys, who cares. When a trauma comes both teams respond and who gives a rats ass which team clears the spine or does the rectal??? If it is a surgical case, it goes to surgery. Big deal...but the life of a general surgeon in a community hospital certainly doesn't revolve around trauma bays...
    Some people thought surgery was dull, some think it is interesting...who cares?
     
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  20. Freeeedom!

    Freeeedom! Senior Member
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    Droliver, yep, thought surgery was boring...considered ortho for a while (since I was a PT for years), but after 2 mos, I thought it was boring too. I did 5 months of ped and adult EM in 3 different states during years 3 and 4 and really liked it. People (including myself) that choose EM do so for the variety, you see MANY patients in an hour...acute to chronic cases. But I also chose it for the LIFESTYLE, NO CALL, FLEXIBILITY, and virtual zero overhead during practice. It allows for future business opportunities as well, because of the shift work and great amount of time off.
    People like different things, that is why there are so many specialties!
    Sorry if I offended if I thought surgery was boring...standing during ONE case for 1-5 hours at a time tends to make the mind wander.
     
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  21. droliver

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    Freeedom (did I leave an E out?)

    No offense taken. I made that comment in jest :) . I never really met a general surgeon who got bored with the field though. I've met a # who were very unhappy with either their choice, their circumstances in life, their pertners, their pay, etc... though.

    Mr. Clown Guy- penetrating trauma is only cookbook for the ER. Like I mentioned, the complexity of the decision tree for the trauma surgeon is very much more than rushing them to the OR these days even on some injuries that there was almost complete consensus on 1-2 years ago.
     
  22. Voxel

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    I hope you understand that the lifestyle of a trauma surgeon is much worse than a typical general surgeon. Usually there are less people in the call pool to take trauma call. The only saving grace is that most trauma centers have surgical sla...err... residents to help you out.

    You will work significantly more hours than your general surgery colleagues and take more call and make the same or less salary.
     
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  23. droliver

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    Voxel,

    on the contrary, a report this winter has shown that when billing properly, trauma/critical care surgeons frequently make more than any of the surgery subspecialties except Plastics & Cardiac. A # of non-university hospitals are level I trauma centers with private practice trauma groups taking in-house call. I'm not sure that their hours are more than busy general or vascular surgeons & their call is all at one hospital versus getting dragged all over town seeing consults.
     
  24. godfather

    godfather Member
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    my experiences at a level trauma center have showed that nobody gets bitchslapped as much as the er docs(alot of it is unnecessary but this is the way it was at the hospitals i rotated at). Part of this stems from the fact that everything a er doc knows somebody else knows better ie. medical subspecialties, anaesthesia(for airway management), ent, surgery etc. and when these guys get consulted and sometimes when they don't get consulted the er attending gets bitched and alot of times it's by an upperlevel resident. As far as trauma call goes, at the place i was at if the patient is seriously hurt the er guys including the attending almost play no role. the senior surgery resident (until his attending gets there anyways) is running the show and is clearly the most prominent guy in the room. Surgery and er take turns running the trauma code, but as already mentioned if somebody's seriously hurt the er guys are writing notes while the senior surgery resident is barking all of the orders. Even things like intubation, if it isn't run of the mill, anaesthesia(alot of times an experienced crna) will do it, and i saw this happen alot during my trauma surgery month. During my 2 months of er i really felt like i was in a clinic and i honestly saw virtually know difference between an er doc and a Fp doc. Both in terms of what they do or in terms of what they know. By this i mean they both have to know an awful lot(if they want to be good anyways), but neither of them does enough of anything, especially in terms of procedures to handle what the specialists do day in day out. Thus your constantly getting yelled at surgeons, cardiologists,ob-gyns,peds,anaesthesia, even if you have probably competently handled a problem, but not to the level of the specialist who are always going to second guess your management when things go wrong.
     
  25. droliver

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    Godfather,

    it sounds like there was a real weak ER program where you were. I've really had some good relationships with a # of my ER counterparts, & we both have been able to teach each other things. Good ER doctors can be talented physicians, but like you mentioned they often end up being criticized for "jack of all trades, master of none" type practices & feel compelled to turf out straight forward issues for medical-legal issues. I would not want their job.
     
  26. Vince

    Vince Senior Member
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    Any EM residents or others looking towards Emergency Medicine that can offer some input? I am strongly considering it as a career....with almost 10 years EMS experience, emergency medicine is all I know...and I like it...but I don't know what its like to be an ER doc, day in and day out...

    Is it a well-respected profession, or not? It seems to me, that specialists are gonna complain about all kinds of stuff, but what's the alternative?...one well trained ER doc, or a bunch of specialists hanging out in the ER in case different cases come in?

    I'm just trying to get a better understanding....
     
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  27. Freeeedom!

    Freeeedom! Senior Member
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    What's funny is that EM docs complain about surgeons, internists, FP's, radiologists, cardiologists etc...and each of them complain about EM docs! But ya know, they ALL get along just fine and many are REALLY good friends!

    Just the way any real world interdiciplinary office is.
    EM gets alot of respect due to the difficulty of getting into an EM residency...everyone knows it is very difficult and many top people are in EM programs.

    As far as the "Godfather" goes...I have no idea what planet that guy did EM on (certainly no where I did...CNRA's? upperlevel residents? give me a break big guy!). My mom always told me, " if you don't have anything nice to say, don't say anything at all" ...I have a feeling he didn't get to match EM! HA!
    Calm down godfather.
     
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  28. Mr. happy clown guy

    Mr. happy clown guy Senior Member
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    You always get the feeling that whenever "godfather" resonds he has very little good to say about anything. As if, some EM doctor gave him a "C" during his rotation now he is all "fired up an p!ssed".
    I give little value to what he states...ever.

    for more EM info go to
    <a href="http://www.saem.org" target="_blank">www.saem.org</a>
    <a href="http://www.emra.org" target="_blank">www.emra.org</a>
    <a href="http://www.acep.org" target="_blank">www.acep.org</a>
    <a href="http://www.aaem.org" target="_blank">www.aaem.org</a>
     
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  29. Sheerstress

    Sheerstress Senior Member
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    Back during my preliminary surgery year, it was pretty uniform that the surgeons never trusted what the ED docs said at first report. The surgeons would always anticipate anything, and thoroughly examine the patient themselves (or have one of the senior level residents do it) before initiating even the smallest treatment protocol.

    In my observations, this was most often caused by one of a couple things. It might be that the EM docs (residents or attendings) had not done a thorough evaluation on the patient (for whatever reason) or left out key information when they called the surgeon the first time (e.g. they might have called a kid with diffuse abdominal pain with a fever, nausea and vomiting a "classic" case of appendicitis). Even though these gaffes were the exception more than the rule (for argument's sake, let's say one out of every 15 cases of appendicitis for which the ED consulted surgery), they happened enough so that the surgeons took note of it, and looked down on the ED.

    This brings me to the other factor that above posters have noted: no matter how thorough the EM practioner was, the surgeons (or any subspecialist) could often not appreciate that emergency practitioners are NOT experts on abdominal pain (or orthopedic care, eye care, etc.) to the same extent that they are. ED docs do not take people to the OR, do not provide comprehensive care for the patient, and have a much narrower focus than subspecialists, and for good reason - their primary directive is to rule out the most life-threatening conditions that the patient may present with, and all "clinic care" is secondary.
     
  30. godfather

    godfather Member
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    i'm going to respond without trying to antagonize to many more people. i did my er rotation in a very big city with nightly shootouts. you could not get better er training than spending a few months at this place. However i will admit that the surgery department at this place is real strong, and the trauma surgeons are world renowned. As far as getting bitched at. I think anybody that's done a rotation can attest to seeing a er doc and a floor attending getting into it over whether a patient should be admitted or not. As far as doing anything technically difficult, there isn't anything a er docdoes that a senior medical student hasn't at least attempted and probably done(ie Lp,central line, suturing, delivering babies(actually a junior med student probably delivers more babies than all of the er staff at the hospital i was at), splint, intubations) As far as crna's intubating patients that the er staff couldn't get, this happen 3 times on my rotation during medical codes in which anaesthesia was called(this isn't a knock on the er doc, i realize that if anybody does enough of anything they can get good at it but still it's an observation i observed. As far as me getting a low grade in er, er is actually in academic terms a easy month for us (it's p/f and best of all no shelf exam), as far as er being a hard residency to get, .... hardly, i know a number of fmg's that matched into it, and many DO's match into it also, coupled with the fact that there are like a gillion spots, i hardly consider er like derm, or orhto, but still to show that i have some humility i'll give you that it's more competitive than my specialty, but i honestly feel that had i wanted to go into er coming from a us allopathic school i could easily have matched into it. As far as senior surgery resident running the trauma bay, it's true. Also keep in mind that a senior surgery resident is anywhere from his 5th to 7th year of training where's sometimes a er attending may be just 1 or two years out of residency making 4 or 5 years out of med school, thus when issues arrise a senior resident during is going to do things his way during a major trauma(i'm talking gsw and the like). hell i've seen the senior surger resident yell at er attendings in their 50's when things aren't going the way they should, and judgement calls when time is of utmost importance in a trauma surgery case, and the trauma attending isn't there(and this happens alot) and the senior surgical resident and the er attending are there were always made by the senior residet. Eg of this are things like during a penetrating trauma should the patient get imaging studies done or does this person go straight to the or after being stabilized. Long post but most of these things are my honest to god observations.
     
  31. A little elf

    A little elf Member
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    Like I've said before...it all depends on the hospital that you are training/working at. Take Hennepin County in Minneapolis for example. The EM residents/docs do EVERYTHING...the surgery team just watches and waits to take the patient upstairs (if need be)...the EM residents and docs are the strongest in the hospital...Personally, I believe that there is so much more to EM than trauma that is exciting...people who are in it solely for the trauma should probably reexamine their reasons for entering the profession...just my 2 cents
     
  32. A little elf, is that you? Is it really YOU? After all these months, could this be the very same little elf from the old EMRA board? How we've missed you!

    Good to see a familiar face around here. <img border="0" alt="[Lovey]" title="" src="graemlins/lovey.gif" />
     
  33. Mr. happy clown guy

    Mr. happy clown guy Senior Member
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    </font><blockquote><font size="1" face="Verdana, Helvetica, sans-serif">quote:</font><hr /><font size="2" face="Verdana, Helvetica, sans-serif">Originally posted by godfather:
    "as far as er being a hard residency to get, .... hardly, i know a number of fmg's that matched into it, and many DO's match into it also, coupled with the fact that there are like a gillion spots, i hardly consider er like derm, or orhto,"</font><hr /></blockquote><font size="2" face="Verdana, Helvetica, sans-serif">OOOOHHHH, nice. So, because a DO (like myself) has somehow corrupted the allopathic residency system by matching to the program...it is somehow LESS competitive??? So, DO's are automatically LESS intelligent than you? You are an idiot for even saying such a thing!

    EM 118
    surg 231
    Ortho 148
    Optho 114
    Derm 103 These are the amount of allopathic residency programs for each...granted the total spots may differ...but a GILLION?? Hmmmm, I don't know what a gillion is, but if I could imagine it, I DON'T think that these numbers would define it!

    My friend, the last time I saw a 3rd year surgical resident in an ED (moonlighting at a small st. louis ED), he was virtually crying. He was completely overwhelmed and lost...Not an ED I would want to go to. It was pathetic.
    If you want more examples, I can give em.
     
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  34. droliver

    Moderator Emeritus 10+ Year Member

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    Guys please grow up & be civil :mad:
     
  35. Freeeedom!

    Freeeedom! Senior Member
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    I for one, believe that "godfather" deserved to be "called out". Give anecdotal information, expect to recieve it in turn...there is no reason to degrade FMG's, DO's, or EM docs in particular!
     
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  36. A little elf

    A little elf Member
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    Yeah davidgreen, it's me...kind of miss that old board, things were just getting interesting when they closed shop...the new one isn't any good...oh well, with lively conversation like this, how can you go wrong? <img border="0" title="" alt="[Wink]" src="wink.gif" />
     
  37. MUN2005

    MUN2005 Miner?
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    Is it just me or has this happened every time someone asked a question about EM????? :mad: <img border="0" title="" alt="[Eek!]" src="eek.gif" /> :confused:
     
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  38. Freeeedom!

    Freeeedom! Senior Member
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    I have no idea why people need to attack one specialty to justify their own...each is very different.
     
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  39. Z

    Z

    Just to add my two cents....
    I am a PGY-6 at a very busy general surgery training program with a well respected trauma department. I plan to go into trauma and critical care when I finish residency. At our institution there is no ER medicine training program so surgery residents act as the ER doc for "trauma". This goes for everything from a minor cut on the hand to the multiple gunshot wound victim. While I have little experience dealing with EM residents/attendings in this setting, I do work with them in others.

    Someone mentioned that they always see the surgery attending/resident re-examine the patient from head to toe. From the outside, this might seem like a slight to the intelligence/thoroughness of the ER doc. I think it is just being a good surgeon/doctor. If I am going to operate on someone I should do a complete history and physical exam myself. I am making the decision to cut and must care for the patient post-operatively (trauma or otherwise) so I should be very thorough. Look at it from the patient perspective...wouldn't you want the person who was going to cut you open to at least have examined you and talked to you in a complete manor? This is no slight to the ER docs just the reality of the situation.
    Also, some surgery residents do yell at or make fun of the ER staff. However, I think this is short sighted and counterproductive. I try to educate the person I am working with so that next time things go allot smoother. Occasionally this has backfired and resulted in more calls to me for advice or simple questions because the person knows I will most likely not take their head-off. Mostly, though it has worked in the patients best interest and ultimately that is what is important. These are real people with real lives with real families and relationships and the least we can do for them is forget petty arguments and take care of them.
     
  40. Vince

    Vince Senior Member
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    Dear Z:

    <img border="0" alt="[Clappy]" title="" src="graemlins/clappy.gif" />

    Vince
     
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  41. Mr. happy clown guy

    Mr. happy clown guy Senior Member
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    Like I said, everyone makes fun of everyone...regardless if it a cardiologist, IM or surgery. They walk out and the laughs start.
     
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