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After the Match

After the Match

The Last Time You Walk into a Trauma Bay

Cook, Thomas MD

doi: 10.1097/01.EEM.0000697732.95405.74
    emergency medicine residency, attending, career

    If you are a senior resident right now, you are approaching the end of your 11-plus-year journey to a career as an emergency physician. It's an incredibly exciting time as you contemplate job offers for the following summer. Next spring, you will slowly lose interest in your work as a resident, a natural process near the end of a long professional engagement.

    You will start to shut down your emotional connection to your current endeavor in anticipation of your next adventure. Before you take for granted the experiences of your last year of residency, however, it is essential to understand that you are rapidly approaching the last time you will encounter several different clinical scenarios that are now routine. Residents naturally take it for granted that their careers will mirror what they have done during residency. After all, what is the point of practicing something in residency that they would not replicate in the future?

    For more than two years, senior residents enter a trauma bay with a group of providers charged with caring for severely injured people. They see the kind of stuff their friends ask about at parties. Everyone dressed in blue, arms and legs contorted at bizarre angles, cut-off clothes on the floor, holes in bodies, and blood everywhere provoke intense anxiety during the first few shifts of internship. But as senior residents, they are desensitized to the bloodshed and focus instead on their specific task as a member of the trauma team.

    Once they graduate, however, most of this will not be part of their future practice. Most emergency medicine residency graduates end up working in community hospitals without a fully integrated trauma service, and severely injured patients will bypass their hospital for the nearest trauma center. The trauma patients they see will be more of the fender-bender type than the multiple-rollovers-and-ejected type. Even if they wanted to take care of trauma patients, their new employer has no interest in them doing so. A substantial percentage of these patients are not insured, their care is typically costly, their eventual disposition is often complicated, and their boss would rather just let the trauma center have them.

    And it's not just trauma. If their new hospital does not have a cath lab, all those STEMI patients who came through the ED during residency will bypass them to go to another facility. Will their new EMS service perform 12-lead ECGs in the field? If they do, the STEMIs they identify are not coming to their shop.

    No STEMIs, No Strokes

    What about strokes? There has been a revolution in the management of acute CVAs over the past decade. When I was in residency, we would see someone with a stroke and tell them, “Yup, you are having a stroke,” and that was it. Nothing left to do but to admit them for monitoring before going to rehab. Now, these patients are aggressively managed at stroke centers with increasingly sophisticated algorithms related to the onset of symptoms and the results of a variety of imaging studies. Anyone with a little slurred speech or extremity weakness is triaged to a stroke center.

    The point of telling you this is that your last year of training may be the last opportunity to hone your skills in various critical illnesses that you may only see occasionally in the future. A seriously ill trauma patient might sneak into your ED every once in a while, and you will need to conjure up memories of how you cared for them in the elite trauma setting of residency. Managing a difficult airway, getting IV access, putting in a chest tube, and packaging the patient for transfer are hard to do and will fall entirely on you. Can you do this now? If not, focus on what you need to learn.

    You might also miss the challenge these diseases bring. Like most large emergency departments with EM residency programs, mine is divided into an area where we care for critically ill patients (red zone) and another where we care for less serious and even barely ill patients (yellow zone). Residents as a rule really like working in the red zone. It's more interesting; there are more procedures, fewer patients per hour, and the dispositions are usually easier because most of the patients clearly need admission.

    Residents frequently groan when they have to work in the yellow zone—the patients are more manipulative and socially challenging, and it is much trickier to get consultants to admit them. Nonetheless, this clinical environment is more representative of what graduates will encounter in community hospitals. It's not going to be rollovers and gunshots but dementia and dizziness. If you think this type of clinical setting will ultimately make you professionally unhappy, consider this a warning about what job to look for after graduation.

    Treat each shift of your last year of residency, particularly in your ED's high-acuity areas, as a precious opportunity to temper the steel of your clinical skills. Also, consider whether it is something you can live without for the next 30 years of your professional life.

    Dr. Cookis the program director of the emergency medicine residency at Prisma Health in Columbia, SC. He is also the founder of 3rd Rock Ultrasound ( Friend him, follow him on Twitter@3rdRockUS, and read his past columns at

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