Who runs your codes in the ED?

[futureemdoc1]

Who runs the codes in the ED? EM docs or trauma team?

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[SterlingMaloryArcher]

It would depend if it were a medical code or a trauma code................

 

[futureemdoc1]

My question was about medical. But in your facility do EM docs ever run the trauma codes?

 

[Zebra Hunter]

Why would you think a trauma doctor would run a medical code? Are you pre-med? As for traumas, outside of level 1 and 2 trauma centers, EM docs are the ones that run trauma codes.

 

[futureemdoc1]

Actually a medical student but no EM rotation yet. Thank you for your reply. So for rural community ED's... an EM doc would be responsible for things such as a thoracotomy?

 

[Jabbed]

Actually a medical student but no EM rotation yet. Thank you for your reply. So for rural community ED's... an EM doc would be responsible for things such as a thoracotomy?

As an ED physician, if you were the only person in the hospital qualified to perform a thoractomy, you would still NOT be performing a thoractomy.

 

[Gurby]

As an ED physician, if you were the only person in the hospital qualified to perform a thoractomy, you would still NOT be performing a thoractomy.

Found the #ResusWanker

 

[CajunMedic]

Found the #ResusWanker

Was talking about Dr. Hinds last night while watching a documentary on the Isle of Man TT. That's probably my favorite SMACC video of the few I've seen

 

[InternistDO]

As a sort of related note, for the community docs who work at trauma centers, are any of you involved with trauma activations at all? Or is it purely surgery?

 

[KGflyboy]

As a sort of related note, for the community docs who work at trauma centers, are any of you involved with trauma activations at all? Or is it purely surgery?

At most hospitals it is a joint effort. I've never been to a hospital where the EM physician wasn't active in every trauma, but I know there are some places, particularly the mega trauma centers, that do it quite differently.

 

[Zebra Hunter]

Found the #ResusWanker

None of that refutes what Jabbed said. Always know what the next step is. If you are out in middle-of-nowhere Texas, you get a trauma code that meets indications for thoracotomy, but your closest trauma center is 1 hr away by helicopter, meaning 2 hours away if everything goes perfectly, are you really going to crack a chest understanding that you are going to have the aorta cross-clamped for a minimum of two hours? Keep in mind this has a survival rate of somewhere around 1-2% for all comers, and probably even less than that for neurologically intact survival. Also, those stats are from level 1 trauma centers where you don't need to fly someone out. This is not to mention that you would literally deplete your facility of all of its blood products. This is why med students shouldn't be watching FOAMed videos like the one posted without having a full understanding of the procedure being discussed.

 

[RandomChaos]

As an ED physician, if you were the only person in the hospital qualified to perform a thoractomy, you would still NOT be performing a thoractomy.

I agree that thoracotomies are rare. That being said, I have done 2 in cooperation with a general surgeon at a Level 4 Trauma Center. Cooperation meaning he was on the phone, en route about 5-10 minutes away and agreed with the indication. Both were in young patients with single wound penetrating chest trauma, both were flown to the nearest Level 1 facility, 30 minute flight and survived. I trained at a gun and knife urban center where we were doing about 1 a week and am currently in a fellowship at a center that does 1-2 a month. Again, I do agree that they are few and far between in the community with a poor survival rate, but if you have the experience and the back up, it can be done and is still being done, as I am still seeing post thoracotomy patients in the ICU.

 

[Gurby]

None of that refutes what Jabbed said. Always know what the next step is. If you are out in middle-of-nowhere Texas, you get a trauma code that meets indications for thoracotomy, but your closest trauma center is 1 hr away by helicopter, meaning 2 hours away if everything goes perfectly, are you really going to crack a chest understanding that you are going to have the aorta cross-clamped for a minimum of two hours? Keep in mind this has a survival rate of somewhere around 1-2% for all comers, and probably even less than that for neurologically intact survival. Also, those stats are from level 1 trauma centers where you don't need to fly someone out. This is not to mention that you would literally deplete your facility of all of its blood products. This is why med students shouldn't be watching FOAMed videos like the one posted without having a full understanding of the procedure being discussed.

My post was mostly tongue-in-cheek. I just couldn't help myself.

I think the main message of the video is not necessarily specific to thoracotomy - it's about being mentally prepared, knowing the literature cold, and having the confidence to do the best thing for the patient even if it means dealing with fallout after the fact.

 

[Fox800]

I agree that thoracotomies are rare. That being said, I have done 2 in cooperation with a general surgeon at a Level 4 Trauma Center. Cooperation meaning he was on the phone, en route about 5-10 minutes away and agreed with the indication. Both were in young patients with single wound penetrating chest trauma, both were flown to the nearest Level 1 facility, 30 minute flight and survived. I trained at a gun and knife urban center where we were doing about 1 a week and am currently in a fellowship at a center that does 1-2 a month. Again, I do agree that they are few and far between in the community with a poor survival rate, but if you have the experience and the back up, it can be done and is still being done, as I am still seeing post thoracotomy patients in the ICU.

Interesting. Did you fly with the crew? Seems like you'd need a physician to accompany someone with an open chest. Paramedic/RN flight crew can't be responsible for managing all the things that can go haywire en route.

That brings up another problem: leaving your single-coverage ED without a physician for a few hours.

 

[RandomChaos]

Interesting. Did you fly with the crew? Seems like you'd need a physician to accompany someone with an open chest. Paramedic/RN flight crew can't be responsible for managing all the things that can go haywire en route.

That brings up another problem: leaving your single-coverage ED without a physician for a few hours.

I did not fly with them. Again a rare situation, however they are trained to handle the worst train wrecks and having spoken to them pre flight, they were trained for managing this issue, granted it was via other flight crew's stories and textbooks.

 

[alpinism]

We do thoracotomies for stab hearts on a regular basis without any surgeons.

Survival is >50% for patients who arrive with vital signs.

 

[Dr Mantis Toboggan]

You’re in South Africa? Sounds pretty incredible. What led you to practice there?

We do thoracotomies for stab hearts on a regular basis without any surgeons.

Survival is >50% for patients who arrive with vital signs.

 

[Lexdiamondz]

I'm training at a level 1 centre in north america.

Medical codes are always run by the EM senior residents or attendings at my institution. Airway, procedures - all ours

Trauma codes are split between EM and Trauma on alternating days, airway is always EM, thoracotomies however will typically go to surgery.

 

[Perrin]

Who runs the codes in the ED? EM docs or trauma team?

I'm at a lvl 1 trauma hospital. All medical codes are run by me. Trauma codes are joint with the trauma surgeons. They are all <10 minutes out for a trauma activation after hours and in house during the day. For trauma codes, I'm in charge of getting the airway while the surgeon is getting a chest tube, central line, or preparing for thoracotomy. Once the airway is secure, I'm backing up the surgeon by doing a central line, tubing the other side of the chest, and directing resuscitation. Most of the time, I've intubated the pt just as the surgeon arrives. They start putting in a chest tube while I start a central line. It's very fluid based on injuries and needed interventions, but EM is always airway first.

 

[alpinism]

You’re in South Africa? Sounds pretty incredible. What led you to practice there?

Work there for a couple months a year in government hospitals.

Many reasons but essentially get to practice EM without all the metrics and lawsuits here in the states.

Theres also a huge shortage of EM physicians since its a brand new specialty with only a few residency programs in the whole country.

 

[littlejuan]

In residency EM always had airway. We alternated running codes and procedures with Trauma, including thoracotomies and I was in a very high trauma location. Now as an attending I don’t work in a trauma center but we get a decent amount of walk in traumas or sometimes MVCs that should have gone to the local trauma center. Our surgeons don’t want to touch the traumas so it’s all us until they get transferred out.

 

[jwk]

I'm at a lvl 1 trauma hospital. All medical codes are run by me. Trauma codes are joint with the trauma surgeons. They are all <10 minutes out for a trauma activation after hours and in house during the day. For trauma codes, I'm in charge of getting the airway while the surgeon is getting a chest tube, central line, or preparing for thoracotomy. Once the airway is secure, I'm backing up the surgeon by doing a central line, tubing the other side of the chest, and directing resuscitation. Most of the time, I've intubated the pt just as the surgeon arrives. They start putting in a chest tube while I start a central line. It's very fluid based on injuries and needed interventions, but EM is always airway first.

Just curious - by definition, a level 1 trauma center has in-house surgeons. Yet yours are on call?

 

[BoardingDoc]

Just curious - by definition, a level 1 trauma center has in-house surgeons. Yet yours are on call?

I agree the criteria is 24 hour in house coverage by a general surgeon. I don't know that it stipulates that it must be an attending and I wonder if this is being used as a loophole.

 

[TheComebacKid]

As stated earlier, you should not being a resuscitative thoracotomy unless you have an OR ready to go and a surgeon willing to operate.

ED docs run all the medical codes in the ED. At some hospitals, ED docs run all the medical codes on the floor (especially overnight). At many hospitals that are non-trauma centers, ED docs run all the traumas (usually minor traumas, although I'm sure you get the occasional sick trauma).

At a level 1 trauma center the relationship with trauma surgery varies. For us, EM leads all the traumas and we do all the airways. Procedures (including thoracotomies) are split with primary/secondary survey on odd/even days.

 

[thegenius]

I work at a community hospital, level 2 trauma center.

I run all medical codes in the ED. I also run them all in the hospital. I've run codes in inpatient beds, MRI, on the cath table, even called to the OR during a c-section.

Trauma codes are run in conjunction with the trauma surgeon. We don't argue over what to do. The trauma surgeons usually are not gowned, initially, and give general orders, like "put in bilateral chest tubes, a central line, tube the patient." Sometimes they help out. I generally defer to them on when to stop running the code.

 

[Perrin]

Just curious - by definition, a level 1 trauma center has in-house surgeons. Yet yours are on call?

We are designated a lvl 1 trauma center. Our trauma surgeons are required to live no more than 10 min away. Their NP/PA is always in house. Perhaps that's how they work around it.

 

[DeadCactus]

Work there for a couple months a year in government hospitals.

Many reasons but essentially get to practice EM without all the metrics and lawsuits here in the states.

Theres also a huge shortage of EM physicians since its a brand new specialty with only a few residency programs in the whole country.

What are the logistics in terms of licensing? I assume a large pay cut?

 

[alpinism]

What are the logistics in terms of licensing? I assume a large pay cut?

Takes about 6-12 months to get a license and most jobs pay around 100K per year US dollars.

 

[The White Coat Investor]

As a sort of related note, for the community docs who work at trauma centers, are any of you involved with trauma activations at all? Or is it purely surgery?

I am a community emergency doc. I work at two level 3 trauma centers. I am the trauma team, or at least the only physician on said team. Technically the general surgeon has to be there within 30 minutes if I call it a "trauma one." Most are trauma twos.

It's always been interesting that very few emergency physicians out of training are all that interested in a practice heavy on trauma. There's a reason for that.

 

[frosted2]

I work at a community hospital, level 2 trauma center.

I run all medical codes in the ED. I also run them all in the hospital. I've run codes in inpatient beds, MRI, on the cath table, even called to the OR during a c-section.

Trauma codes are run in conjunction with the trauma surgeon. We don't argue over what to do. The trauma surgeons usually are not gowned, initially, and give general orders, like "put in bilateral chest tubes, a central line, tube the patient." Sometimes they help out. I generally defer to them on when to stop running the code.

Just out of curiosity, where was anesthesia for the code during the c-section?? I was under the impression that anesthesia ran codes in the OR (obviously there are always exceptions).

 

[InternistDO]

I am a community emergency doc. I work at two level 3 trauma centers. I am the trauma team, or at least the only physician on said team. Technically the general surgeon has to be there within 30 minutes if I call it a "trauma one." Most are trauma twos.

It's always been interesting that very few emergency physicians out of training are all that interested in a practice heavy on trauma. There's a reason for that.

Yeah, I know trauma is mostly sexy to laypeople and students, I was just generally curious since I don't really have a lot of experience with non-academic trauma centers and how that dynamic works. Thanks!

 

[GeneralVeers]

In my level 3 places I run all of the traumas. Trauma surgeon ONLY gets called in for a Level 1 patient, and even then I'm still managing for 20-30 minutes until they get there. I love when trauma surgeons second guess my CT-ordering (typically they want pan-scan) without the understanding that I actually manage more trauma patients on a daily basis of ALL acuities than they do.

 

[GonnaBeADoc2222]

I WISH someone else ran the medical codes.

They are generally time sucks with extremely rare good outcomes. Mostly because they way the local EMS system runs these is counter to all science. Instead of staying on site and doing good compressions (aka the only thing that we know works) until there is either ROSC or not, they transport and come rolling in with no one bagging the patient and doing weak, one-handed compressions. All the while, it pulls me and half the nursing / techs in the department away from what they could otherwise be more useful doing. When I come out of the resus room, there are generally 4 or more new patients impatiently waiting to be seen.

 

[frosted2]

I WISH someone else ran the medical codes.

They are generally time sucks with extremely rare good outcomes. Mostly because they way the local EMS system runs these is counter to all science. Instead of staying on site and doing good compressions (aka the only thing that we know works) until there is either ROSC or not, they transport and come rolling in with no one bagging the patient and doing weak, one-handed compressions. All the while, it pulls me and half the nursing / techs in the department away from what they could otherwise be more useful doing. When I come out of the resus room, there are generally 4 or more new patients impatiently waiting to be seen.

Sorry (from a medic) that some EMS providers still do that crap. We are slowly phasing out the older medics who are corpse snatchers. Most of the younger medics at my service work on scene for 20 minutes and call if no ROSC. Still tough for some to do with kids though (working and or pronouncing on scene).

 

[deleted547339]

We are designated a lvl 1 trauma center. Our trauma surgeons are required to live no more than 10 min away. Their NP/PA is always in house. Perhaps that's how they work around it.

That doesn’t meet the criteria for ACS level one trauma center. My suspicion is that ACS is unaware of this fact with some semi-intentional deception on the surgeons’ behalf.

 

[SterlingMaloryArcher]

That doesn’t meet the criteria for ACS level one trauma center. My suspicion is that ACS is unaware of this fact with some semi-intentional deception on the surgeons’ behalf.

Wrong. Level I trauma centers are allowed to have a resident or midlevel in house in the place of an attending specialist for the first 10-15 minutes of work-up. You are correct in that this is how centers get around it.

 

[Angry Birds]

There is no trauma team where I work, so I’m it. But we’re not a trauma center so we don’t get too many serious traumas. That’s good. I don’t enjoy traumas. I don’t HATE them but I’m certainly not upset if I don’t get enough trauma. I did my residency at a level 1 and all I can say is, good riddance!

 

[BoardingDoc]

Wrong. Level I trauma centers are allowed to have a resident or midlevel in house in the place of an attending specialist for the first 10-15 minutes of work-up. You are correct in that this is how centers get around it.

Just looked this up at the american college of surgeons.

Top of page 2 talks about this.

The rule isn't actually that you need a midlevel in house, it stipulates that a PGY 4 or 5 RESIDENT surgeon can fill in until the attending arrives. So can the ED attending provided they are "part of the trauma team." It doesn't appear that a midlevel can fulfill this requirement. That said, it also says in the next block that a surgeon is expected to be in the ED on patient arrival, however, a delay of up to 15 minutes is permitted in level I and II trauma centers. Furthermore, they only have to meet this target 80% of the time.

 

[GeneralVeers]

There is no trauma team where I work, so I’m it. But we’re not a trauma center so we don’t get too many serious traumas. That’s good. I don’t enjoy traumas. I don’t HATE them but I’m certainly not upset if I don’t get enough trauma. I did my residency at a level 1 and all I can say is, good riddance!

Agreed. Trauma is a nuisance to me. Either having to deal with a know-it-all trauma surgeon or having to rush over to every trip and fall that we are now calling a "trauma activation". Seriously it's out of control. They are calling traumas on every old person who falls and hits their head, and on completely un-injured people due to "mechanism". I used to be on the trauma committee of a hospital, and I've definitely noticed creep as far as minimal crap being labelled "trauma" to buff the hospital's numbers. It's not benign to do this, as every time a trauma is called, everyone from myself, to the lab tech, to the X-ray tech has to stop all other work in the department and rush over to a usually perfectly fine patient.

 

[theseeker4]

Just looked this up at the american college of surgeons.

Top of page 2 talks about this.

The rule isn't actually that you need a midlevel in house, it stipulates that a PGY 4 or 5 RESIDENT surgeon can fill in until the attending arrives. So can the ED attending provided they are "part of the trauma team." It doesn't appear that a midlevel can fulfill this requirement. That said, it also says in the next block that a surgeon is expected to be in the ED on patient arrival, however, a delay of up to 15 minutes is permitted in level I and II trauma centers. Furthermore, they only have to meet this target 80% of the time.

Pretty loophole there. Just declare all ED attendings "part of the trauma team" and you are set. Nice.

 

[BoardingDoc]

It's not benign to do this, as every time a trauma is called, everyone from myself, to the lab tech, to the X-ray tech has to stop all other work in the department and rush over to a usually perfectly fine patient.

Plus the patient gets an additional enormous bill (at least they do at the lvl 1 where I trained) from the hospital as a trauma team facility fee.

 

[KGflyboy]

Just curious - by definition, a level 1 trauma center has in-house surgeons. Yet yours are on call?

I agree the criteria is 24 hour in house coverage by a general surgeon. I don't know that it stipulates that it must be an attending and I wonder if this is being used as a loophole.

That doesn’t meet the criteria for ACS level one trauma center. My suspicion is that ACS is unaware of this fact with some semi-intentional deception on the surgeons’ behalf.

Wrong. Level I trauma centers are allowed to have a resident or midlevel in house in the place of an attending specialist for the first 10-15 minutes of work-up. You are correct in that this is how centers get around it.

Boarding doc hit the nail on the head in a subsequent post. ACS allows 4th or 5th year residents to meet the in house requirement.

Also equally important to note... ACS doesn't write regulations or even designate trauma centers as level 1 or 2 or whatever. It offers a voluntary verification that a trauma center can undergo which basically serves as a merit badge. A ton of trauma centers don't undergo this verification process. States can be more or less strict than ACS. Some states only designate trauma centers as level 1 or 2, some have many more levels. The criteria for each level varies from state to state.

Discussing trauma center requirements online when everyone practices in different states is an apples to astronauts comparison.