Who should and who does run traumas?

[Apollyon]

Chest pain, vaginal bleeding, headaches are all symptoms.

Actually, vag bleeding is a sign (provided there is blood there). It's not a symptom.
/quibble

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[Druggernaut]

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.

[...]

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.

"Trauma" really isn't a diagnosis, either.

And there's the rub: EM needs to learn to manage trauma, and do it well. Meanwhile, all the surgeons feel they should be the ones managing it at the level 1 center, where most of the EM residencies are. Is watching someone else do something the best way to learn to do it? We're also the ones who will be managing it our entire careers, and see it just about every shift of every month of residency, while the majority of surgeons will gladly leave it behind forever once they graduate.

 

[ProfMD]

"Trauma" really isn't a diagnosis, either.

And there's the rub: EM needs to learn to manage trauma, and do it well. Meanwhile, all the surgeons feel they should be the ones managing it at the level 1 center, where most of the EM residencies are. Is watching someone else do something the best way to learn to do it? We're also the ones who will be managing it our entire careers, and see it just about every shift of every month of residency, while the majority of surgeons will gladly leave it behind forever once they graduate.

Yup, that is the rub isn't it.

Participate in trauma stabilization. Rotate with the trauma service.

Leave the surgeons in charge at the level 1 centers.

 

[thedrjojo]

I've done more trauma as a resident than I care for (and I'm on 4th of July trauma call tomorrow, fml), and the workup and eval is very algorithmic and I honestly don't see what is so special about it that a surgeon has to run the initial trauma... Someone should be ATLS certified, but doing the abcde of the primary survey and following the algorithm for the appropriate workup doesn't require a surgeon, and on the inpatient world, the surgeon that does the initial eval is hardly the person providing the inpt care (that's the interns, apn's, and the rounding attending)... As the chief resident I'm responsible for all the in pts, not just the ones I admitted. I can get a turnover /sign-out from anyone and then assume the care.

 

[ACSurgeon]

I've done more trauma as a resident than I care for (and I'm on 4th of July trauma call tomorrow, fml), and the workup and eval is very algorithmic and I honestly don't see what is so special about it that a surgeon has to run the initial trauma... Someone should be ATLS certified, but doing the abcde of the primary survey and following the algorithm for the appropriate workup doesn't require a surgeon, and on the inpatient world, the surgeon that does the initial eval is hardly the person providing the inpt care (that's the interns, apn's, and the rounding attending)... As the chief resident I'm responsible for all the in pts, not just the ones I admitted. I can get a turnover /sign-out from anyone and then assume the care.

The point about continuity is that when you take care of trauma patients in the hospital you become familiar with complications/missed injuries that ED doctors never learn about.

Most initial traumas can be done by anyone. The difficult level one traumas need someone proficient at thinking quickly and acting quickly (i.e. lines, chest tube, pounding blood, etc). I've never seen a non-surgeon do that well except for an occasional anesthesiologist here and there. Otherwise, even medicine and anesthesia CC people are not as capable of massive resuscitation the way trauma surgeons are. I'm clearly biased.

 

[thedrjojo]

The point about continuity is that when you take care of trauma patients in the hospital you become familiar with complications/missed injuries that ED doctors never learn about.

Most initial traumas can be done by anyone. The difficult level one traumas need someone proficient at thinking quickly and acting quickly (i.e. lines, chest tube, pounding blood, etc). I've never seen a non-surgeon do that well except for an occasional anesthesiologist here and there. Otherwise, even medicine and anesthesia CC people are not as capable of massive resuscitation the way trauma surgeons are. I'm clearly biased.

We just ran a trauma (july 1st at 3am) that ended up with 80u prbc, 60 ffp, 30 platelets, fiba, cryo, at one point an ffp and fibrinogen drip. I get the value in those, that those even 5 minutes that would be delayed to get the surgeon involved would mean the pt wouldn't have made it out of the ed to the or (where we had to ligated the portal vein among other things... Im so jealous I didn't get in on that case). Last I checked pt was still alive too. But priority 2 traumas, even those don't REALLY need a surgeon to workup... But I'm also biased and jaded and hopeful I can sleep tomorrow night

 

[deleted547339]

The point about continuity is that when you take care of trauma patients in the hospital you become familiar with complications/missed injuries that ED doctors never learn about.

Most initial traumas can be done by anyone. The difficult level one traumas need someone proficient at thinking quickly and acting quickly (i.e. lines, chest tube, pounding blood, etc). I've never seen a non-surgeon do that well except for an occasional anesthesiologist here and there. Otherwise, even medicine and anesthesia CC people are not as capable of massive resuscitation the way trauma surgeons are. I'm clearly biased.

If you're working with EM folks who can't get a line and chest tube in quick, the problem is with youre EM folks, not EM.

 

[NWwildcat2013]

Didn't fully appreciate this argument until I witnessed the issue in action.

Trauma surgeon hands down.

 

[tiedyeddog]

But priority 2 traumas, even those don't REALLY need a surgeon to workup... But I'm also biased and jaded and hopeful I can sleep tomorrow night

I agree, level 2's don't need a surgeon.

 

[neusu]

As a member of the SONOS (Society of Non-Operative Surgeons), we intend to blur the lines between trauma surgeon and EM trauma attending.

 

[ACSurgeon]

As a member of the SONOS (Society of Non-Operative Surgeons), we intend to blur the lines between trauma surgeon and EM trauma attending.

By making trauma surgeons train and work less (with trauma patients) or make the EM attending train and work more?

 

[Slack3r]

By making trauma surgeons train and work less (with trauma patients) or make the EM attending train and work more?

By using the word "shop" a lot and wearing scrub tops tucked into khakis/cargo pants.

 

[Apollyon]

By using the word "shop" a lot and wearing scrub tops tucked into khakis/cargo pants.

I'll take "Things I don't say or do as an EM attending" for $200, Alex.

 

[Winged Scapula]

I'll take "Things I don't say or do as an EM attending" for $200, Alex.

Ha!

But you can't deny that a lot of your colleagues do use the word "shop" to refer to the physical place they work.

 

[Apollyon]

Ha!

But you can't deny that a lot of your colleagues do use the word "shop" to refer to the physical place they work.

Only here on SDN. True story. I have never once heard it anywhere in the "real world". Now, granted, that may be the "fallacy of anecdote" ("I've never seen it, so it doesn't exist"), but, as I say, IRL, nah.

 

[Slack3r]

Only here on SDN. True story. I have never once heard it anywhere in the "real world". Now, granted, that may be the "fallacy of anecdote" ("I've never seen it, so it doesn't exist"), but, as I say, IRL, nah.

How about scrub tops tucked into pants?

 

[Apollyon]

How about scrub tops tucked into pants?

That is the "ER mullet". I put a percentage on that of about 80%, if not wearing scrubs. I am one of the 20%. Dress pants, subtle aloha ("Hawai'ian", for you haole mainlanders) shirt, and white coat.

Oh, but the scrub top not tucked in! I don't have an estimate on that.

 

[tiedyeddog]

How about scrub tops tucked into pants?

I actually very rarely see that in the emergency department at my institution. Most of the residents or attendings just wear scrubs. Seems like that is more of a radiologist thing where I am at.


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[dr zaius]

I actually very rarely see that in the emergency department at my institution. Most of the residents or attendings just wear scrubs. Seems like that is more of a radiologist thing where I am at.


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I saw it a ton in medical school in The South (go figure). Not once during residency in the mid-Atlantic. I reckon they're fancier up here.

 

[filhodeinferno]

Doesn't really matter who runs the initial "resus" in the trauma bay. Just follow the algorithm.

In a Level 2/3 community ED, is usually the EM doc who runs it and calls trauma in as needed.
In Level I center, should be collaborative affair. EM residents need to learn it for when they're working at the above, GS residents need to definitively treat it, as needed.

In my short career, I have found that the surgeons are obviously better at identifying an operative vs non-operative problem. The EM docs seem to be better able to understand and manage an airway (minus a cric). I guess if surgery wants to bring their anesthesiologists down with them to every activation, then they could cut EM docs out of the traumas completely. I'd be ok with that...trauma patients are usually boring to one who is not going to take them to the OR. Not to mention, they're generally the dregs of society and are the most difficult patients to deal with, at least at my....'shop' .

 

[JayDoc06]

Busy referral community (read: non-residency) hospital with Level-1 state trauma status (in house Gen Surg/Trauma 24-7).

Similar to my busy urban academic county type hospital residency, EM works up all traumas Level 2 or less. They call the surgeon when work up complete or situation changes (sudden hypotension, intubation, deterioration, etc...). Surgeon beside immediately for all Level-1 (expanded criteria compared to residency). I feel this is the best balance. In our current hospital it does depend on the ability of a nurse to stratify patient injuries based on field info or transferring info- which is sometimes wrong, fortunately usually OVER triaged, which while annoying at 2 am, prevents delays in care/dispo. For the severely injured, surgeons are better at deciding what to do next. The sooner the physician who is ultimately going to care for patient gets involved, the better, nowhere is the more true than trauma. Decisions of ICU for ongoing resuscitation, OR, angio for embolization for a pelvic fracture, for instance, is very complex and should happen early but may not meet Level 1 criteria strictly.

 

[Arcan57]

Only here on SDN. True story. I have never once heard it anywhere in the "real world". Now, granted, that may be the "fallacy of anecdote" ("I've never seen it, so it doesn't exist"), but, as I say, IRL, nah.

We use it all the time. I understand some people get riled by the idea of our workplace being compared to a blue-collar vs. professional workplace but that's never bothered me. On the other hand I still get irrationally bothered by it being referred to as an emergency "room". The contagiousness of your attendings' cultural pathology is impressive.

I confess to being guilty of the ER mullet in residency. It's a good look on exactly no one. I would say that most of my colleagues wear plain scrubs with some occasional white coat+scrub or the ubiquitous "night shift female doc apparel" of scrubs+hoodie.

 

[deleted547339]

We use it all the time. I understand some people get riled by the idea of our workplace being compared to a blue-collar vs. professional workplace but that's never bothered me. On the other hand I still get irrationally bothered by it being referred to as an emergency "room". The contagiousness of your attendings' cultural pathology is impressive.

I confess to being guilty of the ER mullet in residency. It's a good look on exactly no one. I would say that most of my colleagues wear plain scrubs with some occasional white coat+scrub or the ubiquitous "night shift female doc apparel" of scrubs+hoodie.

That's scrubs with a hospital blanket around both shoulders in my neck of the woods.