Who runs trauma?

[8744]

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Hey, I would really like to go into emergency medicine but people say that trauma surgery and not Emergency Medicine run all the traumas.

The questions are: Are EM doctors playing second fiddle to the surgery department and how does the EM faculty ensure that their residents gain experience in essential procedures?

 

[EMIMG]

This is a good question to ask. Some programs have it so that on one day the ED staff runs the traumas and the trauma staff does the procedures and they switch off on the other day. Other programs have it so that the EM residents make up a bulk of the trauma surgery service so they get a good experience when they are doing their trauma months. There are other programs which are dominated by either the EM staff or the Trauma Surgery Staff. This is something that should be asked at each program.

I can tell you that the program at which I am the ED staff runs the traumas and does the procedures on a daily basis. We have the full support of the trauma surgeons; however, when they are in the ED and in the trauma room, it is the EM team that runs everything. In addition, we have 1-2 interns on trauma each month so they will often times get to do stuff that is being run by the ED attending.

Another question to ask about trauma is do they have to go off-site to get their experience. For example, there are some programs that do not gain enough trauma at their institution and their residents go elsewhere for 1-2 months to gain additional experience. This allows you to see another institution; however, you will be a visitor, and what will happen for your other 34 or 35 or 46-47 months of your residency.

For those that are interviewing, ask to see a 1st, 2nd, and 3rd year's procedure log so you know what you can expect to accomplish at the end of the residency. This should help you gauge all of your experiences.

Good luck.

 

[scutking]

This depends entirely on your institution. At Parkland, surgery runs trauma hall. The trauma surgery attending is in charge, period. If the surgery attending is in the OR, or otherwise unavailable, the surgery Chief Resident runs trauma. The ER resident has only one role - they are at the head of the bed and do a head and neck exam (which the surgeons repeat anyway). All trauma workups are done by surgery. If the patient needs to be intubated, the ER resident gets one shot at it, then surgery takes over and intubates the patient. This is spelled out very clearly in the Parkland trauma protocols, so there is no confusion.

 

[Airborne]

I agree that who runs trauma is really institution dependent. Where I am at ? the ED residents/attendings run it initially. The Surgical trauma chief is always there and if the situation warrants input, the management is rapidly transferred to surgery ? clearly this is of benefit to both patient and provider.

Intubations are handled by the ED resident/attending and if need be anesthesia. Surgery _rarely_ if at all steps into this role, unless it is an emergency airway that cannot be managed by the ED staff.

Surgery always watches and verifies any ?clears? ? c-spine, etc. - They do not do them, but agree or disagree (extremely rare) with the ED staff as warranted.

Trust me, if S#!T is hitting the fan, ED is happy to have surgery there, and if it is less malignant, surgery is happy for ED to continue on?.

Honestly, this is an interesting observation for both sides of the fence ? it is important to have both back-up and independence for both surgery and ED ? in the end both need to be competent, not overwhelmed and not POed that they?re dealing with something that is taking time from other clinical duties.

Be sure to inquire, or better yet, observe this interaction when choosing a residency.

With kind regards,

Airborne

 

[Sessamoid]

Originally posted by scutking
This depends entirely on your institution. At Parkland, surgery runs trauma hall. The trauma surgery attending is in charge, period. If the surgery attending is in the OR, or otherwise unavailable, the surgery Chief Resident runs trauma. The ER resident has only one role - they are at the head of the bed and do a head and neck exam (which the surgeons repeat anyway). All trauma workups are done by surgery. If the patient needs to be intubated, the ER resident gets one shot at it, then surgery takes over and intubates the patient. This is spelled out very clearly in the Parkland trauma protocols, so there is no confusion.

I see nothing's changed there since I was a lowly volunteer in the ER there (except with the addition of EM residents). Surgery still running the show.

 

[12R34Y]

How common is it for surgery to intubate people? I didn't think they did a whole lot of that in practice.........Is surgery considered better at that than the ED guys?

I was referring to Parkland where the EM physician gets one crack at the intubation before the surgery residents do it (experts apparently in airway care?) is this correct? and a common practice?

later

 

[Sessamoid]

Originally posted by 12R34Y
How common is it for surgery to intubate people? I didn't think they did a whole lot of that in practice.........Is surgery considered better at that than the ED guys?

I was referring to Parkland where the EM physician gets one crack at the intubation before the surgery residents do it (experts apparently in airway care?) is this correct? and a common practice?

later

As far as EM residencies, I'd say that's unusual. Where I trained EM and surgery took turns either running the trauma or doing the airway on alternate days. If the resident couldn't get the tube, then that resident's attending was next up usually. If anesthesia was present and the first attending had no luck, then anesthesia or the other team would take a crack at it. In practice, the first resident usually got it, and the first attending almost never missed, regardless of service.

The EM resident only getting one try at it is, IMHO, only because surgery is a far more powerful department at Parkland than the fledgling EM department (or is it still a division under Surgery?). I've met the Program Director at Parkland a few times, and he's really a wonderful guy (and we're alumni of the same residency), but I don't envy him his job.

 

[DrQuinn]

At my program, surgery runs the traumas about 90% of the time right now. Keep in mind that we only have 6 EM interns on... when I will be a PGY-2, the EM residents will have much more control over the traumas, and when we have a full complement of EM residents (18) the EM residents will run the trauma with surgery there if called upon. We only run it Thursdays and Sundays because we only have one EM intern on each month (20 shifts), so its hit or miss, we can't have any concrete rules yet.

Q, DO

 

[Sessamoid]

Originally posted by 12R34Y
How common is it for surgery to intubate people? I didn't think they did a whole lot of that in practice.........Is surgery considered better at that than the ED guys?

In private practice, the vast majority of surgeons overall will intubate anywhere from once in a blue moon to never. There are notable exceptions. Any trauma surgeon or general surgeon who takes call in a busy trauma center may be called upon to intubate fairly frequently, depending on the trauma census of the hospital.

Otherwise, most general surgeons and ENTs in private practice probably do more surgical airways (trachs) than they do intubations.

 

[DrQuinn]

Originally posted by Sessamoid
In private practice, the vast majority of surgeons overall will intubate anywhere from once in a blue moon to never. There are notable exceptions. Any trauma surgeon or general surgeon who takes call in a busy trauma center may be called upon to intubate fairly frequently, depending on the trauma census of the hospital.

Otherwise, most general surgeons and ENTs in private practice probably do more surgical airways (trachs) than they do intubations.

Agreed. Even here at TGH, the surgery residents on the trauma service don't intubate. We have anesthesia for that, and they will be booted out once our EM program gets larger.

We actually had an ED attending do a surgical airway a few days ago on a medical resuscitation. Sah-weet.

Q, DO

 

[ERMudPhud]

I'm pretty sure this has been discussed before but I'll go ahead and repeat what I said last time. Where I trained Trauma was technically run on alternating days by surgery or EM. But, the truth was that trauma sort of ran itself, it is afterall pretty algorithmic at least during the first 30-60 minutes. Most of the time there was a pretty clear consensus about what needed to be done and in what order. All procedures with the exception of thoracotomy for penetrating trauma were done by EM and EM only. Thoracotomies that were less likely to succeed were done by EM. If a bunch of procedures had to be done at once than they got farmed out to everyone present but EM generally had first pick. See my post in this thread.

http://forums.studentdoctor.net/showthread.php?s=&threadid=77002

As far as airway went that was ours and ours alone. Anesthesia never came to the ED and surgery never intubated. I saw crics done by either service usually working together.

Trauma can work a lot of ways and it doesn't really matter who gets to wear the big hat for the day. Just make sure wherever you go that the EM residents get lots of ET tubes, central lines, and chest tubes. No matter where you go you won't do that many crics, thoracotomies, or DPL's(anymore). Also make sure EM residents are involved enough that they learn how a resuscitation should run.

 

[Sessamoid]

Originally posted by QuinnNSU
Sah-weet.

Q, DO

I can so tell that you clerked under Hedrick. 😀

 

[Sessamoid]

Ditto on the procedures. Make sure you get enough intubations and central lines. Chest tubes are pretty easy. Once you've done a few, it's no problem. Any complications caused by the chest tube are generally solved by the chest tube. It's a procedure that solves its own complications.

 

[DrQuinn]

Originally posted by Sessamoid
I can so tell that you clerked under Hedrick. 😀

😍
That guy is my idol, man, re-affirmed why I wanted to do EM. Its all about a dogmatic approach, dude. (Never heard anyone use the word dogma more than BH).

Q, DO