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 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?
Does the trauma/general surgeon at your institution take call from home or in house?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?
Where I am which is an academic institute and a level 1, trauma attending takes home call while in house surgical junior and senior along with Ed staff respond first.
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.
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....
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....
Ah then you are not at a US based Level 1 center. Some clarification would have been in order.The trauma attending must live within 20 minutes from the hospital. Our attendings include emergency physicians, trauma surgeons, anethesiologists and 1 orthopedic surgeon.
CanadaAh then you are not at a US based Level 1 center. Some clarification would have been in order.
Since SDN is largely US based, it would be interesting for us to know how YOU or Canadians handle trauma.Canada
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.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.
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 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.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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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.
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.....
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.
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.
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).
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.
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.
thats definitely their thingWhat's with EM and "shop"?
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)their website even claim as much
What's with EM and "shop"?
It really is funny to see the disconnect between academia and the way trauma is handled in every other hospital in the country.
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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Yes. Because the same patients come into any ER.
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
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.
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.
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
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.
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.
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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