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I think I have voiced my opinion regarding your query quite lucidly.

To go back to your example of upper GI bleed, my first and most important priority would be Resuscitate the patient well (mind you, it is just not fluid resuscitation!!!). This itself could take a good amount of time. Based on your assessment you may consider other options like 'terlipressin/vasopressin/octreotide' etc. You also have the choice of using a 'Sengstaken tube'. Possibly a 'gastro-enterologist' is enough rather than Surgical Gastro. All he may need is an Upper GI scope and a sclerosing injection.

The point I am trying to make is that, there are a lot of things you could do as part of resuscitation and patient stabilisation. And also, there are a lot of things you wish you could do but are not humanly possible. It is good to be firmly in touch with reality.

In Major Trauma Centres say in South Africa/Aus/UK, they have Trauma Surgeons as part of the 'Trauma Team', who are trained in emergency surgical procedures. Usually these are vascular surgeons. They are incorporated into the roster and are available 24/7 at a very short notice. Mind you, not all centres have them. One has to improvise the system to meet the local demands.

Coming to the specifics, even if, say you are trained in surgical gastroenterology/urology/CT surgery/Neurosurgery/Obs-Gyn etc etc as part of your curriculum, you need to still see and perform these procedures on a fairly frequent basis to keep up your skill levels. Being able to do a procedure does not mean you are competent in it. Being able to do it consistently well, time and again on par with a specialist in that field would be close to being competent. Anything less than this could amount to negligence. This is the reason that I suggested in my earlier response that you learn to do a procedure only if you see such patients frequently and can keep up with the skills.

If you work in a hospital that calls itself a Trauma Centre, then you / your managers should ensure that the relevant specialists/facilities are available at very short notices. It needs a certain rigor to enforce this. Unless this discipline and commitment exists, your centre shouldn't even be called or accredited as a trauma centre.

At this point of time in the evolution of EM, I would certainly say that it is totally unnecessary for a EM specialist to be trained in 'all' the surgical specialties. On the contrary, it may prove to be detrimental to patient care. The core skills have to be defined by the governing body (hopefully SEMI) based on feasibility and necessity. I am aware that the 'goal-posts' keep shifting and I may be totally wrong twenty years hence!!!

Having talked about trauma scenarios and surgery for so long, let us not forget that EM is not all about cutting and doing fancy interventions. Majority of the emergencies (more than 70%) happen to be medical emergencies.

These are only my opinions. What do other members feel?