Creating a Trauma Fellowship for Canadian emergency physicians

Resident Issues

CJEM 2000;2(1):41-42

Résumé

Both the specialty of emergency medicine (EM) and the care of the traumatized patient have developed and flourished over the last few decades. As disciplines evolve, practitioners often desire further training in subspecialty areas of interest. This type of interest and commitment improves patient care and advances research in the specified field. In this paper, I review the rationale and suggest directions for the development of a traumatology subspecialty in Canadian EM.

The rationale

Emergency medicine is a new specialty that incorporates many aspects of other disciplines. Our specialty has matured over the years, and throughout the country we have legitimized our rightful place in patient care; however EM fellowship training has been slow to evolve. Formal training is available in toxicology, EMS and clinical epidemiology, but there are few such opportunities in Canada. The time has come to begin training EM subspecialists, and a particular opportunity exists to create emergency physicians (EPs) with special expertise in trauma care.

Trauma is traditionally considered a surgical disease, yet most injury victims do not require surgery, and it would be a waste of our surgeons’ time to have them evaluate every trauma patient. Therefore, while trauma is a variable component of surgical practice, it is an unavoidable part of emergency medicine. In spite of this, an expanded EP role in trauma remains controversial. The ongoing debate about our involvement in trauma can only be seen as a “turf war.”

EPs are uniquely positioned and educated to address all aspects of trauma care. Trained emergency physicians have a good grasp of the medical and surgical issues central to adult and pediatric trauma resuscitation. We provide initial care for all trauma patients in the ED and definitive care for minor trauma victims (e.g., low-speed vehicle collisions, industrial injuries) whose injuries do not warrant trauma team activation. In tertiary centres, we often act as telephone consultants to our rural colleagues on emergent care and transportation issues. Many EPs are involved in the transport process, leading teams that stabilize and transfer trauma victims from other hospitals into regional trauma centres. Traumatology is a logical extension of everyday emergency medicine.

In some Canadian centres, emergency physicians serve as regional trauma directors. This trend should be encouraged, since most of the duties of a trauma director do not require surgical skills. The responsibilities of a trauma director include injury prevention, EMS management, outcomes research, maintenance of a trauma registry, clinical epidemiology and quality assurance. These skills are already included in the curriculum of many FRCPC Emergency Medicine training programs. Furthermore, the prehospital environment, where trauma care begins, falls under the realm of emergency medicine. Here, EPs participate in education, quality assurance and prehospital care research.

A trauma fellowship

An EM trauma fellowship would focus on clinical, research and administrative expertise. A proposed curriculum would involve 1 year of dedicated trauma training in addition to or incorporated into the 5-year FRCPC program. Currently, many residency programs include a flexible “elective” year, which allows enrichment in specific areas of interest. With a formal fellowship curriculum and adequate “elective” time, it becomes feasible to train emergency physicians with subspecialty expertise.

This proposed trauma curriculum would include

• Mentorship with an existing regional trauma director, to learn administrative duties;
• Learning how to evaluate existing trauma systems and ensure community needs are met;
• At least 2 months of EMS training focusing on ground and air transport issues, EMS quality assurance and prehospital trauma management;
• Completion of basic trauma life support, advanced trauma life support and pediatric advanced life support courses;
• 8 months of trauma team membership and adequate experience as trauma team leader;
• Penetrating trauma experience in a US training centre;
• Pediatric trauma experience in a high volume centre;
• Completion of a scholarly activity or research project, which might be basic science, outcome-based research, or the creation of an educational package.

The creation of subspecialties is a priority for EM, and trauma care is an aspect of emergency medicine where we should take a leadership role. EM trauma fellowships will advance Canadian trauma care and help emergency physicians secure our rightful place in the care of traumatized patients.