Emergency Medicine Residency (Part 1.5: Answering an Important Reader Question)

Whenever you get a major trauma, do you get your fair share of procedures (chest tubes, central lines, etc..) or do the surgical residents tend to take them?
At our program, because it is a Level I trauma center, trauma surgery is in charge of most of the traumas. The EM residents manage the airway and do the initial assesment and stabilization in theory but in practice it is a joint effort with trauma surgery doing most of the heavy lifting. Trauma is not that complicated at our program. Unstable patients are stabilzed and taken to the OR. Stable patients are “pan-scanned” and trauma surgery elects to either operate, admit, or send home. We just sort of take their lead.

And we don’t get that much major trauma. We get a lot of trauma codes but they usually turn out to be nothing much. A lot of the level 1 trauma patients are actually discharged from the department. Determining the level of a trauma is a judgement call and any high speed rollover, for example, is often called at the highest level (level I) even if everybody was in seatbelts and walking on the scene (They still arrive on a back board, you understand.) It’s also a little bit political because to justify your funding as a Level I trauma center you have to see a certain number of Level I traumas. In other words, trauma patients are often upgraded to the next highest level but they are rarely downgraded.
I have done some chest tubes but only one on a trauma patient. The rest were on medical codes of which my program sees plenty. Same with central lines and the like. Very few trauma patients get anything more than quick femoral lines which are not hard to place. I have done all of my many internal jugular and subclavian lines on critical medical patients both in the department and the ICU as well as most of the rest of my procedures. The only surgical airway I was in on (and I was just helping) was in the ICU. To date, I intubate more patients in the ICU than I do in the department. I probably intubated two or three times a night when on call in the ICU. A lot of the trauma patients arrive pre-intubated for our convenience as our city has superlative paramedics.
It’s the medical codes that are difficult. Managing a decompensating dialysis patients with an exacerbation of his congestive heart failure secondary to his smoking crack is a lot more challenging than putting in a chest tube. Sorry. It is. We see a lot of this kind of patient and worse at my program.
I confess that I am not yet very good at managing trauma patients. There are usually two or three attendings in the trauma bay along with every single surgery resident in the hospital so I’m afraid I am somewhat intimidated…what, after all, do I have to add to the high level brainpower there assembled? It’s a case of too many pimps, not enough hoes. Paradoxically, in the ICU where there are seldom any attendings or other residents around except those standing around waiting for somebody to take charge, I am completely comfortable managing a critical care patient running south for the border. And occasionally when I go up there (the EM residents are on the hospital code team) the ICU nurses take me aside and ask me to put in the lines because they really need access and they’re not that confident that the family medicine and internal medicine residents on call are up to the task of getting them in quickly.

ICU nurses like Emergency Medicine residents because we like to aggressively manage patients and are not afraid of procedures. They don’t like sitting on a dangerously unstable patient with only tenuous peripheral access and a shoddy airway. It makes their already difficult job even more difficult.

Trauma for Emergency Medicine is easy and somewhat over-rated (uh, once you get the hang of it, I mean). It’s just ATLS and that’s about it. Besides, if it’s serious there is nothing to manage as they are quickly taken to the operating room where they become surgery patients. They do not come back to the Emergency Department. The exit is one-way only.

The critical skills (other than not losing your cool) in trauma are managing the airway, recognizing the causes of your patients respiratory and hemodynamic instability, and correcting them. So if you know your ABCs, the skills you need are intubation, needle decompression, chest tube, FAST exam, pericaridocentesis, and central venous access. That will cover you for 99 percent of what you see and then the patient will go to the OR or the morgue.
We rotate on the trauma service, by the way.
One of my favorite television programs is “Trauma: Life in the ER.” But to be fair the show should be called “Trauma: Life in the ER as a Trauma Sugery Resident” as that’s who they are usually following. Emergency medicine, except at the big urban war zones, is not really that trauma-intensive. Everybody likes a really goopy gore-fest of course (we’re only human) but most Emergency Medicine residents will see many, many more massive GI bleeds than they will gunshot wounds. Panda’s Axiom Number Two: Blood coming out of a hole in the chest is cool. Out of the rectum not so much.

And a massive upper-GI bleed of which I have seen two in the last week is a lot more unsettling than most traumas.

4 thoughts on “Emergency Medicine Residency (Part 1.5: Answering an Important Reader Question)

  1. I echo you sentiments on major trauma.

    Granted, I only work at a Level III center, but in our hospital, we’re the trauma team. Yeah, we have the house surgeon come down to help, but we do our own lines, chest tubes, etc. And I’ve had to do exactly none of those on our traumas.

    We tend to keep our major adult traumas in house, but rarely do they ever materialize into something. If they’re that horrible, we fly them to the Level I in the city (since we’re in suburbia). Once, the night resident told me they had a lady who fell down the flight of stairs while sleep-walking who had a grade 4 splenic lac, who proceeded to central line and the OR. I recently had a 12 year old who went over her handlebars on her bike and had a brain bleed and free fluid in her pelvis (we flew her out).

    The medical resuscitations tend to be much more fun and interesting, as it’s much more challenging to bring back septic shock or hemorrhagic CVA than your standard MVC or fall from height. You test your skills as a doctor by stopping massive GI bleeding and the like, because so much of trauma is cookbook medicine in terms of ATLS protocols, etc.

    And, I agree with you on the TV show Trauma, Life in the ER. It’s a show about trauma surgery…not anything about what it’s like to be in the ER. If they had a TV show about what it’s really like in the ER, then nobody’d watch because it’s usually a bunch of primary care mumbo jumbo with a bit of excitement when your critical care patients roll in. The real fun in EM is using your skills to tease out the differential.

  2. My advice: Pay attention and get as good at trauma as you can. Trauma care is becoming more and more regionalized. I am a general surgeon at a 150 bed community hospital. I do not do trauma any more, nor do my surgeon colleagues. Major trauma, and we do get a few each month, are managed by the ED docs, stabilized and transferred to the level I center an hour away. Most of the time surgeons are not involved in the care of the trauma patient at all. Lines, tubes, and intubation all done by the ED physician while transport is being arranged. I was once an ATLS instructor, but having done no trauma in a decade, I acknowledge that the docs in the ED are much better at managing acute trauma. Rarely, they call me for assistance, but usually I find out about “the great trauma case” the next day in the doctors’ lounge.

  3. I love the ‘too-many pimps and not enough hoes.’ I always feel bad for the two ED nurses getting instructions barked at them by six different doctors who are all sure what they are doing is the most important.

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