An AOA critical issue. Access to emergent musculoskeletal care: Resuscitating orthopaedic emergency-department coverage

Presence of Orthopedic Residency Decreases Emergency Physician's Confidence in Orthopedic Procedures

Introduction: At present, there exists no standard orthopedic training for emergency medicine (EM) residency programs. Varying residency environments including but not limited to volume, acuity, and competing residency programs will dictate the number of orthopedic procedures a resident is exposed to, ultimately dictating a graduate’s comfort level with orthopedic procedures. Our study set out to investigate further whether training alongside an orthopedic residency affects an attending physician’s perceived procedural comfort.

Methods: This is a cohort study utilizing a 14-question survey distributed to an online community of EM physicians to examine the relationship between training at a residence program alongside orthopedic residents, the utility of an elective orthopedic rotation, and the overall confidence in managing closed reductions.

Results: EM physicians trained at a program that also hosted an orthopedic residency were more likely to train at large academic tertiary care centers (78%). Forty-two percent of these respondents felt that the presence of an orthopedic residency had a negative impact on their overall orthopedic training. The remaining 58% felt that the orthopedic residency had a positive impact on their procedural skills. In our study, the overall mean comfort level was statistically significant (p-value = 0.0024) higher in those who trained without orthopedic residents (8.78) compared to those who trained alongside an orthopedic residency (7.61). Those who had an elective orthopedic rotation found it to be more beneficial if they did the rotation with an orthopedic residency (p-value = 0.0329). Those who reported a beneficial orthopedic rotation also reported a higher level of confidence in the management of non-fracture reductions (p < 0.011, ρ = .25).

Conclusion: Seeing as though both training and practice environments for emergency physicians vary greatly across the country, every effort should be taken to ensure graduating residents are prepared to perform orthopedic procedures without the assistance of orthopedic surgeons. Irrespective of whether a program has in-house orthopedic residents or not, EM residents should take it upon themselves to maximize their time during residency to focus on these core competencies. Graduates at the greatest risk of having low confidence are trained at academic centers that also host orthopedic programs. One should be cognizant of this while going through their EM residency.

The Dedicated Orthopaedic Trauma Room Model: Adopting a New Standard of Care

The dedicated orthopaedic trauma room (DOTR) has emerged over the last decade as an effective approach to improving workflow while reducing the complications and costs that are associated with musculoskeletal trauma care. We surveyed the top 20 hospitals in the United States and found that 14 (70%) utilize a DOTR. Coupled with recent data on improved outcomes and patient flow, we see evidence that the availability of a DOTR has become a best practice for orthopaedic trauma care.

Should the trauma surgeon do the emergency surgery?

The specialty of trauma surgery is evolving. The continued decline in general surgery operative interventions in trauma patients has led to an exodus of promising young surgeons away from the field. A concurrent decline in the number of burn surgeons, as well as orthopedists and neurosurgeons interested in providing emergency care, led to a pressing need for surgeons able to perform emergency surgical care. In addition, the general surgery workforce has followed a trend of increased specialization, with young surgeons gravitating toward specialties that are perceived to have a more forgiving lifestyle. This development has led to troublesome gaps in the emergency surgery call schedule at many institutions. Several intrepid centers already have begun assimilating acute care surgery into their departments with impressive results for their patients. Increased operative volume, increased reimbursements, and a palatable lifestyle add to the allure of treating these complex and interesting patients. Training future surgeons to staff the ranks of acute care surgery is an important and exciting challenge. It may be that "Should the trauma surgeon do the emergency surgery?" is the wrong question. A better question may be "How best can we train surgeons for this new specialty"?