Emergency Medicine Residency (Part 1.75 A Parable About Trauma and Perception)


Consider two separate rooms in the same Emergency Department. In one lies a young man who has been shot in the chest and arrived in full cardiac arrest with the paramedics frantically giving CPR. Red frothy bubbles come out of the gaping hole over his heart whenever the bag attached to his endotracheal tube is squeezed. A Full court press ensues and the trauma bay fills with interested bystanders watching the action as the patient is prepped for an emergent thoracotomy; a procedure where the chest is cut open to expose the heart and allow the repair of any obvious holes (as well as manual compression of the left ventricle to circulate blood).

In another room sits a sixteen-year-old girl, two weeks out from a tonsillectomy, with an emesis basin by her mouth and over which she has coughed or vomitted enough blood to cover the front of her dress. The room is empty except for the Emergency Physician, the nurse, and the anxious family.

Which case is more important? Surely the gunshot wound in the trauma bay is getting the most attention. It is an exciting case after all. It has everything one could possibly want. Blood, gore, violence, the cops, good guys, bad guys, and a young man whose life is hanging by such a fine thread that the Emergency Physician who is not in any way, shape or form a trained cardiothoracic surgeons is preparing to make a very large hole in a chest to perform rudimentary open-heart surgery. This is the stuff of which legends are made.
“Say, Bob, remember that chest we cracked last month. Man. What a mess that was!”

The young girl in the other room? It’s just a post-tonsillectomy hemorrhage. Not exactly riveting stuff but I submit that this girl is the more important of the two cases. The guy in the trauma bay, after all, is dead and not likely to improve. He’s been shot through the heart or a great vessel and has been without oxygen to his brain for all but the first minute (the time it takes for his heart to pump most of his blood onto the street) of the last official twenty minutes of his life. There is probably nothing left upstairs to save even if circulation is restored. There is literally nothing to lose so everything possible is done and the trauma bay hums with frenzied activity even though the chances of even restoring spontaneous circulation with an emergent thoracotomy in a patient who arrives without vital signs is less than one percent. And only a small fraction of that less-than-one-percent ever leave the ICU except feet first for that last ride to the basement.

And yet this kind of thing defines Emergency Medicine as a specialty. The sixteen-year-old girl? How many of you contemplating Emergency Medicine as a career have ever though about this kind of patient? She seems pretty mundane and yet a patient like this is in mortal danger unless something is done and done quickly.

Everybody knows what to do in an exciting trauma. Big Things. Big Procedures. Lines, tubes, fluids, ventilators. Futile but extremely gratifying. How many of you have even considered how you’d handle a frightened sixteen-year-old rapidly bleeding to death and periodically vomitting another half-pint or two of blood. And no, it’s not as easy as you think. The girl could die. She’s sixteen. She isn’t supposed to die just yet. It’s just a tonsillectomy for which her otolaryngologist humorously prescribed ice-cream to make her throat feel better. If you let her die how will you explain it to the family?

“We did everything we could…I’m sorry,” doesn’t quite cut it in this case.

The moral? Emergency Medicine is not what you think. For every major trauma you are going to see a hundred garden-variety gastrointestinal bleeds, overdoses, strokes, heart attacks, ectopic pregnacies, sepsis and a large variety of other potentially life-threatening presentations. These will be woven into a day mostly spent dealing with relatively minor stuff like vague abdominal pain, headaches, and whatever complaint can be used to access the bounty of The Man. That’s just the way it is.

18 thoughts on “Emergency Medicine Residency (Part 1.75 A Parable About Trauma and Perception)

  1. You, sir, speak the truth. It seems that we enjoy doing a whole lot of excitingly hopeless things just because it makes for a much cooler story. It’s not just in the ER, either: I see this same phenomenon on a different level in the ICU every single day.

  2. All the ER’s I worked in were places were we payed equal attention to people in mortal danger of losing their life.

    How did we manage to do this, you must be asking?

    Two ways:

    Frist, aLL staff helped—NOT just the doctor. Every single staff member in an ER, whether doctor, nurse, RT, or lingering paramedic is trained to do the basics.

    Second: When a Code Blue is called, eerybody else in the hospital comes to help, and they’re not just “interested bystanders watching the action”. They are trained professionals who can help out; i.e. doctors, nurses, RT’s, House Supervisor, etc.

    An ER treats more than one person at a time. Nobody bleeding to death gets neglected simply because a chest trauma is in the next room.

    At least, that’s the way it was in the ER’s I worked in.

  3. I didn’t say the young girl with the post-tonsilectomy bleed was being ignored, just that this is not the kind of case that generates much excitement for the specialty even though this is the kind of thing that you are more likely to see.

    Once again you are reading my blog on a hair-trigger, waiting to find something with which to disagree or to demonstrate some moral or intellectual superiority.

    And there are plenty of interested bystanders in every trauma bay unless the attending expressly orders people out.

  4. Well, this is every specialty. Interesting case and importance to the patient have little connection to each other. Bread and butter in every specialty becomes boring, even chest cracking – just ask those CABGing fools in CT.

  5. The tonsillar bleeds are frustrating because there really isn’t much we can do about them in the ER.

    Establish IV access. Type and Cross. Call the ENT. Wait for the ENT to call back. Wait for the ENT to finally arrive. Deal with the family’s frustration as they perceive that we aren’t doing anything for their poor daughter. Watch the ENT finally take the patient to the OR as we pat her on the shoulder and give her our best wishes as she is wheeled away.

    At least with the futile GSW we can feel like we are actually doing something.

  6. I am really enjoying the discussion re: the “excitement” of trauma. The very word sends orgastic shivers up the spines of medical students. I have a classmate who consistently says she is “going into ER because I LOVE trauma.”

    I’m apply for EM this year, am I allowed to say that I don’t really like trauma? It’s stressful, tiring, and the only time during my clinical years when I consistently ended up with blood/bodily fluids on my clothes.

  7. Well look, I like trauma. A lot. It is exciting and fun. But I also like medical codes, critical care, and acute but not necessarily emergent medical problems.

    You need to know how to manage trauma but if you really don’t care for it, I’d suggest you not match at places like Detroit Receiving or any of the big trauma shops.

  8. Thanks for laying out the difference between the Trauma service (SURGERY) and EM. Lots of med students don’t have the slightest clue about what actually goes on the the ED and sadly, some of those same folks are the ones that are all hyped about the specialty and will end up burning out after 5 years in a small level-2 center someplace in the suburbs pulling splinters and passing out narcotics to bored housewives.

    Personally, I like the idea of getting people stable, making the dx and shipping them off to the appropriate service or out the door…I’d rather do that than spend the rest of my life asking the same group of patients if they’ve passed gas every morning at 5am for weeks on end.

  9. Gee, Panda, I’m shocked. That doesn’t sound like you at all.


    (It’s not even worth enabling comment moderation-PB)

  10. I gotta say that there are SOME comments that warrant enabling comment moderation. One using the N-word while pretending to be you would surely be such an example.

  11. Although I heartily disliked my EM rotation in med school I have to agree that these medical patients with “hidden” emergent etiologies require much more intricacy than the poly-trauma mva.

    My sister almost died in college after the family doc at the college clinic sent her home with abx twice for a sore throat. When she had unbearable pain and went to the ED, the doc there lanced her retropharyngeal abcess that was threatening to close off her airway.

    EM has a different perspective and really does require its own residency to develop this unique insight.

  12. I’ve worked the ER for about 15 years. I’ve seen “mundane” patients come close to crashing because of the “big” trauma in the next room.

    I’ve seen the girl with the bleed from a T&A, I’ve seen the boy with a simple bee sting arrest in front of my eyes as we moved him from the EMT cart to one of our own carts.

    I’ve seen the vaginal bleeds come in that nobody bothered to check to see how much bleeding has occurred.

    I’ve seen the room full of people in the trauma room. I can do traumas as good as the next person, but if there is already 10 people in the room, they sure as hell don’t need me.

    I have to admit Panda, I’ve been pretty darn proud of myself (even a little haughty) when I caught something that was just not right, but didn’t present as a trauma. Maybe it’s that nurse’s intuition.

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