Who should run traumas and who does at your institution? Does one specialty do a better job than the other? How does in house vs home call effect your outcomes?
Who should and who does run traumas?
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1)GS
2)GS
3) is this an attempt to pit EM against GS? I'm biased of course but I think surgeons run the traumas better and can offer definitive treatment if needed.
4) it's not as simple as that. Hospitals that allow home call for the trauma team also tend to have less acuity, fewer traumas and also fewer sub-specialists available all of which can affect outcomes.
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Does the trauma/general surgeon at your institution take call from home or in house?
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Surgery for sure. Trauma is a surgeon's disease to manage. I think they do a better job, but also, they are the ones who are going to manage the patient in-house. The trauma team is also going to be the one to manage any issues missed by the ED on the initial assessment.
I still think ED doctors can be involved and their residents should learn trauma stabilization, but, particularly at a level I center, it should be surgeon driven.
In house coverage by a PGY-4 or above is required for level I accreditation.
I still think ED doctors can be involved and their residents should learn trauma stabilization, but, particularly at a level I center, it should be surgeon driven.
In house coverage by a PGY-4 or above is required for level I accreditation.
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I wonder what would happen if you posed this question in the ER forum?
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deleted547339
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Ours is run by surgery with ED rotators. I don't really understand the point of ever having a ED-run service. If the patient is going to be admitted or need any kind of surgical intervention, then the trauma team is going to have to re-examine the patient anyway right? Seems redundant and easier to just have surgery see it. Unless the ED is willing to see patients on the floor or trauma ICU.
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What is the required response time for those attendings on level one traumas? I believe that they must live and respond within 15 minutes; often they're given a heads up before the alert is even called in my experience.
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deleted547339
You really don't understand the point, or are you just being facetious? Because if you don't see the point in that, we should simply do away with ER docs and just have 20 sub specialists sitting in the ED - have a cardiologist sitting in the ED to deal with all chest pain, a surgeon for all abdominal pain, OB/gyn for all vag bleeds, pediatrician for all children....well, you get the point - a very small subset of patients that come to the ED need to be admitted or need a consult. Even your highest acuity ERs send home 70% of all patients.
Only a small subset of traumatic injuries are managed surgically and an even smaller subset is managed by emergent surgery. The overwhelming majority of trauma in this country is seen by ER docs initially. Residency training skews a lot of people's perspective because they assume that the ivory tower is the only way to do things.
One thing that a lot of my colleagues don't understand is that a working at a non-trauma center doesn't mean you don't see trauma, it means you don't have backup. Go to the country where there's no surgeon in the county and you will see some nasty tractor injuries, hunting misadventures and all around redneck-thought-it-was-a-good-idea tricks. I've seen some truly horrific traumas outside of the trauma center.
I just don't understand the way traumas are run in most academic centers. Most surgeons love operating and hate being called to the ER, especially when the odds of going to the OR are low. I don't understand why trauma at academic centers is the exception where surgeons would rather hang out in the ER and see patients that end up not going to the OR instead of operating....
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I agree with you that ED residents must learn trauma - for exactly the reasons you mention. The fact of the matter is that most hospitals are not level I academic trauma centers. These hospitals will still see trauma patients and it is the ED doctors who will be doing the stabilization and initial management.
The reason it should be primarily surgeon run at the level I centers is that although most trauma patients do not need surgery, especially not emergently, a reasonable percentage of them will get admitted. Typically, it will be the trauma team admitting them. Even if it is another service, it will be the trauma team called for trauma related issues that arise.
Of course, not all patients with injuries rise to the level of trauma activation and each level I hospital will have its own criteria. However, for those that are activations - that is, those that are most likely to have injuries requiring admission with or without surgery - the trauma team should be in charge from the get-go.
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Basically everything ProfMD said above. I don't have much to add. A large majority of traumas get admitted and theres no ED doc thats going to manage them on the floor, and I don't think medicine is the proper place for those patients.
And trust me, I know how annoying trauma is and how few actually need surgery. I'm speaking from a good patient care perspective. Yeah, I'd rather just be in the OR all the time and have a midlevel see clinic patients and postops, but I don't think that's the best patient care either. I'm not ****ting on ED docs in this instance, I just don't think the standard ED model of stabilize and turf makes a lot of sense for trauma patients.
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Ah then you are not at a US based Level 1 center. Some clarification would have been in order.
I'not sure if you added the poll or I just didn't see it on my phone but how is an Orthopedic surgeon helpful outside of the context of pure orthopedic injuries? How are you expecting the anesthesiologist to run the trauma from the position at the head of the bed? "ICU intensivist" is not specific enough as it can encompass a number of specialties and "trauma surgeon" = general surgeon +/- additional training so is a bit redundant unless you are claiming that one must be fellowship trained to do trauma.
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Since SDN is largely US based, it would be interesting for us to know how YOU or Canadians handle trauma.
The team is lead by an attending or fellow, junior and senior surgical residents secure airway and conduct the survey.
The team may be lead by a surgeon or by emergency physician/er trauma fellow while trauma surgeon may stand at the side and observe.
The team may be lead by a surgeon or by emergency physician/er trauma fellow while trauma surgeon may stand at the side and observe.
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I'd add to this discussion that the specialty likely matters less than the type of trauma-specific knowledge/skills of the provider in question. And some of that knowledge and skill will have to do with training and the amount of trauma they manage.
That being said, I think general surgery residency (+/- trauma fellowship) best equips someone to function as the trauma team leader. Not to say an EM physician couldn't reach the same level, but it would take some effort post-residency to get there.
That being said, I think general surgery residency (+/- trauma fellowship) best equips someone to function as the trauma team leader. Not to say an EM physician couldn't reach the same level, but it would take some effort post-residency to get there.
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My academic center with a major trauma center (and president of Eastern trauma society), priority 1 and 2 trauma (the ones likely to be operative or admitted) are responded primarily by the in house trauma team. Priority 3 are fielded by er and upgraded if there's something needing admission/operation.
All surgeons are required to have ATLS certification to be board certified. I hope all er doctors are also thusly required. But I think that er doctors, especially for the minor bs, should be seen by er. But I'm biased
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Where I trained (level 2 trauma center but the only trauma center in the entire county) who ran the trauma depends on who you asked. EM claimed they ran it because we gave them the airway, but the surg senior was directing things from the foot of the bed and had final say on stuff like imaging and procedures (no chests getting opened without surg approval). Attending was at home with a 30 min max response time (which was the same as OR home call response time so that was fine) but could be reached by phone in case the EM attending disagreed with our plan (a rare event and our attendings often sided with us which would be accepted by the EM attending or we would just admit the patient to our service if they didn't accept it taking them out of the equation). This was only for activations. Anything that didn't meet criteria or any activation that the ER decided to deactivate we let them work up and only call us if admit was needed (so lots of low speed mva's, trip and falls, and similar stuff we didn't have to waste our time on).
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I didn't mean ATLS protocol but rather since you seem to be interested in who's running the trauma, I was just interested in whether it's mostly EM or surgically "run" in Canada.
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The majority of traumas are run by em and many of the em docs also have trauma fellowships where they spend months as a team leader while a surgeon stands by (sometimes the surgeon is physically standing behind everyone else) and acts as a second opinion.
To answer your question, the majority of traumas are run by em.
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deleted547339
Although I disagree that general surgery residency makes someone more competent to handle acute traumatic resuscitations (I think this is likely institution driven, not speciality specific), I think you hit the nail on the head when you state that there is a specific knowledge base and skill set that must be mastered to care for sick trauma patients. To be an expert in any field (particularly involving sick patients), you need to work for it. Essentially, all knowledge and all skills initially involved in trauma resuscitations (rapid IV access by PIV, IO or CVL, chest tubes, intubation, surgical airways, pelvic stabilization, ordering blood, calling IR for embolizations, shipping when appropriate, etc) can be done by either specialty, while either background leaves you unable to entirely care for trauma patients (we both still need neurosurgeons, orthopods, anesthesiologist, etc). The thing that sets a surgeon apart from an ER doc in trauma is the ex-lap and thoracotomy. Conversely, I don't know many (any?) surgeons who feel comfortable intubating. I am also a lot more comfortable reducing fractures and dislocations than the general surgeons at my center. It really comes down to knowledge, ability to perform a handful of bedside procedures, decisiveness and, most importantly, leadership ability. The world's smartest doc with amazing hands that can't calm and organize a room full of scared nurses, a screaming patient and a cadre of spectators has no place in the trauma bay.
I'm not trying to wax poetic on the field of EM - we have plenty of our own problems. I simply think either system can work with competent, motivated physicians. I've seen times/places where surgery runs the show and it runs like clockwork and times where it's been a complete cluster. I've seen times/places where EM runs the show at it runs like clockwork and a complete cluster.
I've also seen times when a moonlighting family practice doc or neurosurgeon manages trauma, but that's a whole different discussion.....
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I agree with you 90%. Any properly trained physician (EM or surgery) can perform the evaluation and stabilization. However, there are two other important things that set the surgeon apart from the EM physician:
1) Deciding when surgery is necessary. Non-surgeons, at least where I work, have a tendency to tell me when surgery is indicated. They are often wrong. Only a surgeon can really decide when an operation may benefit a patient.
2) Inpatient / admitting privileges. While it is true that either specialty can perform in the trauma bay, once the patient hits the floor or the ICU, the EM doctor says "peace out" while the surgery team continues to care for the patient.
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The surgeon's second opinion is more like the final opinion. It's like saying residents take care of patients and go to the attendings for a second opinion. We run trauma as a partnership between surgery and EM but surgery has the final say regardless which team is captain that week.
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I can't emphasize enough the significance of admitting patients and following them longitudinally. Surgeons admit most trauma patients, even those with ortho/face/neuro needs. As a result, we are less like to miss something during the initial eval. And if we do miss something, we have the privilege of learning from our mistakes because we follow those patients.
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Yes. Follow a well run trauma service and see the value of repeated tertiary surveys.
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their website even claim as much
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As has been mentioned, at academic centers GS runs trauma. This is as it should be, mainly for educational reasons. Much of the confidence I currently carry in the management of the sick patient was earned as an R2 running trauma hall and covering the ICU.
At community based trauma programs, even ACS level 1 and 2 programs, the ED runs level 2 activations and below and calls the trauma surgeon once workup is complete if the patient requires admission. We examine the patient and order any additional workup if needed. We are in house. For level 1 activations we have 15 minutes to arrive at the bedside and take over management of the patient. Frequently, level 1 activations are paged out as soon as the EMS calls with an in transit report so we are usually at the bedside when the patient arrives. If we are in the OR then our backup is notified. If it is safe to do so, we may even scrub out to run down to the ER and get things started. Out of necessity, trauma in the community is quite a bit different when you don't have residents to do everything.
At community based trauma programs, even ACS level 1 and 2 programs, the ED runs level 2 activations and below and calls the trauma surgeon once workup is complete if the patient requires admission. We examine the patient and order any additional workup if needed. We are in house. For level 1 activations we have 15 minutes to arrive at the bedside and take over management of the patient. Frequently, level 1 activations are paged out as soon as the EMS calls with an in transit report so we are usually at the bedside when the patient arrives. If we are in the OR then our backup is notified. If it is safe to do so, we may even scrub out to run down to the ER and get things started. Out of necessity, trauma in the community is quite a bit different when you don't have residents to do everything.
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deleted451730
Many times, by the time the GS/trauma surgeon arrived into the ED for a Level 1 (community hospital), even though being X minutes away, the EM physician already stabilized the patient or almost finished doing so--chest tubes, intubation, scans, labs, central lines, etc. Because...well...the EM doc is already right there.
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Of the 20 or so ED docs that I work with there are probably only 1 or 2 that I wouldn't trust to do the things that you listed. But those are not the things that concern me about your facility. If your surgeons are habitually showing up late for unstable and hemorrhaging level 1 trauma patients then I bet those patients are getting either a ton of crystalloid or a bunch of PRBC and no FFP, platelets or cryo and going to the operating room late for hemorrhage control and consequently having more MOF and mortality in the ICU postop. If you are at a designated trauma facility and I was your site reviewer I wouldn't just hand out a simple deficiency--I would drop the hammer. We have fired a few trauma surgeons in my group for that sort of thing. If you are at a nondesignated trauma facility and EMS just shows up with these patients then you just have to do the best with what you have.
If on the other hand your ED docs resuscitate closer to a 1:1 ratio and start the OR mobilization process as the surgeon is coming in then they deserve a gold star. That is not the expectation around here. BTW, I consider a central line, especially a triple lumen, in a trauma patient with 2 large bore IVs to be a waste of time and likely not clean in the ED. If needed, I place it after hemorrhage control.
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Essentially any EM physician works with the understanding that, no matter how podunk or quiet their shop, they will at some point have to deal with trauma patients. Plenty of surgeons, once they leave residency, can choose to never see one again. At my current non-trauma center, when I get someone who needs admission or OR, I look at the GS call schedule and if it's one of the two or three old surgeons who like to deal with it, I call them. If it's the bariatric surgeon, or the breast surgeon, or the endocrine surgeon, etc., I just ship them out without even calling, since I know if I call them I won't get past 25 yo M GSW to abdomen before they say we're not a trauma center.
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What's with EM and "shop"?
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thats definitely their thing
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Yeah, thats how i know they claim they run it. It isn't like any of the residents said that to me (we got along great and i am more than happy to let them run all the minor mva's and ground level falls without getting involved at all so if the trade off is letting them think they are in charge for a while for the activations but the patient is stil getting the assessment and management i want because of a nicely choreographed ballet of med students, interns, and residents from both services i see no reason to quibble over words on a website)
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I am not in GS but see plenty of trauma patients after/during the primary survey.
It should be GS that runs it, hands down.
It should be GS that runs it, hands down.
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deleted547339
It really is funny to see the disconnect between academia and the way trauma is handled in every other hospital in the country.
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Gretchen, stop trying to make shop happen! It's not going to happen!
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The difference you are seeing is the difference between a level 1 trauma center and level 2-3... Is there something funny about that?
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deleted547339
Yes. Because the same patients come into any ER.
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If you have a well run state trauma system, the same patients should not be coming to any ED. The patients should be triaged by a central call center to the most appropriate trauma center.
If a seriously injured trauma patient who belongs at a level 1 center does show up at your level 2-3 center then the goals are also different - stabilize and ship rather than stabilize and admit/fix.
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No reason to argue. The ER guys provide a valuable service. They are probably less important than they think they are and probably more important than most of us think they are
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I agree with you but any ED doc that thinks they have any business running the primary on a real trauma patient at a real level 1 trauma center truly is delusional. There is a reason there must be Surgeons in house at the level 1 trauma center.
I would have to ask if that person actually rotated through or trained at a level 1 trauma center with that line of thinking tbh.
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deleted547339
Alright man, you don't get it and that's fine. People hop in the back or a pick up and drive until they see the red sign that says "ER." And a lot of the rural EMS systems aren't well-developed.
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Yes, I get that people hop in the truck and drive to the closes ED. I also get that there are areas without well-developed trauma systems. Although even some rural states have good trauma systems. It is not limited to cities.
That is the purpose of my second point - that if a major trauma does end up in a level 2 or level 3 center, the goal of care is to stabilize and ship the patient. This is what the ED doctor needs to do. This is why I absolutely advocate for ED residents to learn trauma and learn it well (I have posted this opinion on this thread, in fact).
However, when a trauma patient arrives at that level 1 center, surgery should run it, especially for trauma activations. General surgery / trauma surgery manages nonoperative trauma on the inpatient side, the ED does not. Therefore, surgery needs to be involved early. I get that most trauma is nonoperative, and I get that most surgeons want to operate. However, until ED doctors start admitting patients to their own services, rounding on the floor, responding to inpatient pages, etc the surgeons should still be in charge, at least for trauma activations.
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This holds true for all areas of medicine, not just the ED.
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The ED doesn't manage anything on the inpatient side. If someone has chest pain, should cardiology be called immediately? If they have vaginal bleeding, should OBGYN be called immediately? If there's a headache, should they just get at CT and call neurosurgery if there's a bleed and neurology if there isn't?
As an EM resident, I definitely prefer running just about everything in the ED by emergency medicine. Fewer people shouting over each other, and things happen in a much more orderly fashion. I appreciate trauma when the patient is really unstable and needs to go immediately to the operating room, but our guys tend to get CTs in just about everyone except those so critical that even the most uninformed layman could recognize they need an OR now, so that's pretty uncommon.
Meanwhile, much of my state is at least an hour by helicopter to a surgeon, and they're lucky if their "ER doc" is even a doctor at all, much less an emergency medicine trained one, so I see the value in getting good experience with managing trauma.
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To start with the last paragraph first, that is irrelevant since I specifically referenced level 1 trauma centers.
As for your other questions, trauma is a diagnosis that is generally managed by surgeons. Chest pain, vaginal bleeding, headaches are all symptoms. If a patient is having an MI, you will call cardiology, an ectopic pregnancy, you will call on/gyn, an intracranial hemorrhage, you will cal neurosurgery. You will not try and figure out if they hemorrhage is from amyloid, hypertension, AVM, tumor, etc - you will leave that to the neurosurgeon.
Once you identify a problem that is best managed by a particular specialist (assuming the problem requires acute care, as trauma does) you will contact that specialist.
Like I said, I am all in favor of ED doctors learning trauma and learning it well. Many level 2 and level 3 centers will rely on them. However, once trauma activation arrives at the level 1 center, surgery should be in charge.
You may not agree with me, and that's ok, but in my experience patient care is improved this way.
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Who do you think runs the traumas at the busiest level 1 trauma centers in LA and NYC? I'll give you a hint, its not surgery.
I'd also ask if you've ever actually rotated through a real ED, not those at ivory tower academic centers where surgery runs everything.
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