I might share the joke with the chaplain. Anesthesia, not so much.
Just tell them you heard it from the guy that does a 5 minute stand-up for intensivists on how to get EM to do your work for you.
Anesthesia is pretty good at laughing at themselves. My favorite is this little gem.
http://www.youtube.com/watch?v=xuZl9tRqjoQ
written and performed by one.
(just to show there are no hard feelings I also have "the EDs guide to getting surgery to do their work for them"
I guess we should talk about something serious now...
By the way, there's a great on-going discussion in the EM and trauma worlds about who should be doing the "trauma activations" in the future. While there is a small bit of a turf war going on, the surgeons also realize that the rate of immediate surgical intervention has been dropping for years. Who wants to do in-house call just to write adnission orders for serial CBCs, when you could be well-rested for the 8 cholecytectomies in the morning. Plus, trauma cases tend not to be well-insured...
I have been around the US for this particular turf war, It has been going on at least a decade.
I think the first thing that has to be understood is that probably 99% of all modern surgeons do not like to do trauma. They were trained in an era where ruling out candidates for surgery was more important than actually operating. So much so, I actually have a book detailing that only 20% of an attending surgeon's time in the hospital is in theatre. (not all that much for people who claim to love operating)
Of the remaining "old school" surgeons, many of them haven't adapted with modern techniques in surgery. So much so, they create studies that demonstrate effectiveness of what they are doing in order to keep getting paid for them. How many studies on vascular stenting have you seen where the conclusion is either:
a. This is just as good as open repair.
or
b. in select populations intravascular repair is showing to be superior in the short term, but more studies are needed.
As the perfect example I like to use pelvic fracture. The threat in pelvic fracture is bleeding from the various illiac vessles. They are large caliber vessles that are easily accessed intravascularly. So why not take these people to fluro and fix it that way?
The reason I hear most is: "because they we have to get an interventional radiologist or vascular surgeon."
Why do only a few trauma surgeons learn these techniques? Isn't a majority of life threatening trauma vascular or are patients bleeding from a location different from a blood vessel?
Modern surgery lags behind its medical counterparts in insisting that surgery is divided by location instead of pathophysiology. Surgeons are not usually big picture people so you have to give them some time to catch on. You also have to let a few Master's of the Universe die off or retire so the young guys can actually affect some change because of the hierarchal nature of surgery. Remember surgeons have only been doctors for about 150 years and there is still a lot of technical labor culture to them. (if it wasn't for them medical residencies would not exist)
Another key aspect of trauma is who it affects. It affects poor people disproportionally and is a recurring disease. That is why we see more trauma in developing nations, war zones, austere environments, and refugees. It is also why a majority of 1st world trauma patients are from lower socioeconomic status. They share the same environment.
If somebody became a trauma surgeon to save the lives of the upper middle class family guy, they picked the wrong profession. That guy is in bed by 9pm and his idea of "living on the edge" is mowing the lawn every 9 days instead of every 7 like his homeowners association demands.
The town drunks, drug abusers, roofers, treecutters, factory workers, unskilled labor, and criminals are the patient population. 99% of their injuries are preventable. Especially when highly educated people see them all suffer from the same things again and again.
This population is also the very definition of charity care. I am not sure how any fee for service provider thought they were going to take the poorest population who requires the most medicine the most often and make big dollars.
It is obvious why hospitals don't like this population.
To say the solutions are simple. Putting them in effect... an entirely different matter.
Since trauma is charity care, there needs to be a larger pool of trauma providers so that they all have less time exposure to this nonpaying population.
Either that or trauma facilities will have to salary these people at a rate that makes it lucrative not to have to hold over the next day to do paid operation. Fat chance of this though. (heavy sarcasm)
During a visit to the trauma surg department of the Royal London Hospital a few years back, I saw what was perhaps the most efficent trauma surgery dept I have ever witnessed. I particularly like their model.
A senior trauma "resident" on staff with a junior trauma "resident." (both of whom were either general or vascular surg) If things were slow, they would take a case off the morning schedule and operate on it during the night shift. If a trauma came in, one of the 2 surgeons would go and evaluate that trauma in the ED. It literally kept the OR in operation 24 hours a day. (talk about optimizing an OR)
If the trauma was bad, they could call another in hospital surgeon to perform a quick closure on what they had or even finish the OP. While attending to it.
During one night, just before shift change of course, an MVA with a partial foot amputation came into A&E. In the closest thing I have ever seen to the civilian implementation of damage control surgery, they restored vascular flow to the distal foot and then medicated and left the guy to be definitively repaired by the day shift. When we left, the pt. was still in A&E.
Another interesting component of non-US trauma surgery I have seen is keeping traumatology in ortho. (I don't really like it, but it works) There is an orthopod in the building 24/7. Since most trauma is ortho, rather than a temporary splint and an ortho follow-up, Orhto is directly given the case. The medical providers don't even see or touch the patient. If the patient is life threatening, The specif surgeon, or in multi-system cases, surgeons, and anesthesia saunter over and create a plan and take the pt away from the ED.
Unless it is life threatening by presentation, not by criteria or mechanism, these providers never know the patient exists.
In the US, ATLS, and a host of other trauma initiatives have been instituted based on mechanism and "what if" as you notice, "what if" and "holy $**T" are rare and on the decline.
As I have noticed, most of trauma care is actually intensive care. I am also starting to think the best place for the surgical trauma provider is closer to the action and farther from the ivory tower. The seriously bleeding patient in the community ED needs surgical control of bleeding. They do not need water or blood poured into an open circuit and a transfer yet.
In my not always humble opinion, the ideal trauma provider is a surgeon, and intensivist, and learns a variety of total body procedures from multiple disciplines for the sole purpose of temporizing the patient for resuscitation and later definitive repair by somebody more specialized. It is in effect the only real use for a general surgeon.
Consequently, the procedures needed are the same for any emergency surgery patient. So whether it is PCI, aneurysm repair, acute pancreatitis, appendicitis, etc, this surgeon is in effect an "emergency" surgeon, who primarily works nights, weekends, and holidays because there are ample dayshift specialsts about making nonintesivist services of this provider superfulous.
edit: I got a strong sense of deja-vu writing this response. This topic doesn't come up often, does it?
Perhaps not here, but this topic has existed as long as I can remember.
h34r:
