Bedside trach and bronch

[Ttan]

Hi!

Question regarding these two. Do purely IM/CC boarded physicians have opportunities to become proficient in bronch and bedside trach? Or are these reserved for the pulm and surgery types?

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[CCM-MD]

Hi!

Question regarding these two. Do purely IM/CC boarded physicians have opportunities to become proficient in bronch and bedside trach? Or are these reserved for the pulm and surgery types?

Bronchoscopy proficiency is an ACGME requirement for critical care medicine. But ICU bronch indications are different from outpatient bronchs. For example, you won't be doing tumor biopsies. How many you do will depend on the program you go to. Fellows at my program graduate with plenty (hundreds).

Perc trachs also depends on the program you go to. A few of the super large academic places I interviewed at had less procedural opportunity. We do bedside precutaneous trachs and even some PEGs depending on how interested someone is in doing that. Where I did residency the pulm/cc fellows did not do any perc trachs.

 

[Nephro critical care]

Totally depends on your level of interest . Sometimes helps if you get close to an interventional pulm guy during fellowship . I did a 2 year pure CC fellowship and did between 15 and 20 trachs and 100s of bronchoscopies. Did about a month of IP ( just because I was interested and ended up with 25 EBUSes and 10 navigational bronchs along with 25 non intubated bronchs with biopsies . That was overkill as I only do intubated bronchs now but my bronch skills are way better than many CC guys .

It's good to learn perc trachs , but only practice as an attending if you have supportive ENT guys who don't want to do them but will bail you out if you have a problem. The more depth you have in procedures you will be better at dealing with emergent stuff like emergency cric/ trach if ENT is not around.

 

[tartesos]

Perc trachs.... ain't nobody got time for that!!



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[Nephro critical care]

Perc trachs.... ain't nobody got time for that!!



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Perc trachs are kind of fun. They are probably the most badass surgical procedure you can get in pulm/cc . I see 10 to 14 critical care pts , dictate 10 minute long progress note 10 times a day, and have 5 goals of care discussion on the chronically ill 97 yr olds but I didn't go into critical care for that. I went into it for the perc trach or the high stress intubation in the pt with a respiratory code.

 

[tartesos]

Perc trachs are kind of fun. They are probably the most badass surgical procedure you can get in pulm/cc . I see 10 to 14 critical care pts , dictate 10 minute long progress note 10 times a day, and have 5 goals of care discussion on the chronically ill 97 yr olds but I didn't go into critical care for that. I went into it for the perc trach or the high stress intubation in the pt with a respiratory code.

That Gets old too... but I hear you, we all do.


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[Ttan]

Totally depends on your level of interest . Sometimes helps if you get close to an interventional pulm guy during fellowship . I did a 2 year pure CC fellowship and did between 15 and 20 trachs and 100s of bronchoscopies. Did about a month of IP ( just because I was interested and ended up with 25 EBUSes and 10 navigational bronchs along with 25 non intubated bronchs with biopsies . That was overkill as I only do intubated bronchs now but my bronch skills are way better than many CC guys .

It's good to learn perc trachs , but only practice as an attending if you have supportive ENT guys who don't want to do them but will bail you out if you have a problem. The more depth you have in procedures you will be better at dealing with emergent stuff like emergency cric/ trach if ENT is not around.

That's cool you did interventional pulm stuff.

With IM/CC, if you managed to do a lot of that with the IP folks during fellowship, is it possible to get hired to do outpatient bronchs as well?

 

[CCM-MD]

That's cool you did interventional pulm stuff.

With IM/CC, if you managed to do a lot of that with the IP folks during fellowship, is it possible to get hired to do outpatient bronchs as well?

Why would you want to? Who would refer patients to you? If you want to do outpatient bronchs do pulm.

 

[jdh71]

I would quibble that a bronch in the icu on a ventilated patients isnt really a real bronch! Ha!

Go through tube. Suck out mucous and or do BAL.

 

[jdh71]

That's cool you did interventional pulm stuff.

With IM/CC, if you managed to do a lot of that with the IP folks during fellowship, is it possible to get hired to do outpatient bronchs as well?

Outpatient bronchs are a very different beast.

 

[CCM-MD]

I would quibble that a bronch in the icu on a ventilated patients isnt really a real bronch! Ha!

Go through tube. Suck out mucous and or do BAL.

Although that's most of it, massive hemoptysis, difficult airway intubation, and foreign body aspiration are some of the more cooler indications.

 

[jdh71]

Although that's most of it, massive hemoptysis, difficult airway intubation, and foreign body aspiration are some of the more cooler indications.

Wasn't aware any of that was done with a bronch . . .

 

[AdmiralChz]

That's cool you did interventional pulm stuff.

With IM/CC, if you managed to do a lot of that with the IP folks during fellowship, is it possible to get hired to do outpatient bronchs as well?

I've done tons of bronchs and awake/asleep intimations as part of Anesthesiology residency. I'd never even dream a hospital would credential me for outpatient bronchs - you go see a pulmonologist for this.

 

[tartesos]

I've done tons of bronchs and awake/asleep intimations as part of Anesthesiology residency. I'd never even dream a hospital would credential me for outpatient bronchs - you go see a pulmonologist for this.

Or a nurse practitioner soon if they can get away with it.



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[Nephro critical care]

Outpatient bronchs are a very different beast.

I did a good number of outpatient bronchs during CC fellowship. There is 1 additional skill to learn that is to intubate the vocal cords with the scope. I won't do it now because I don't do those often but I am sure a could learn it.

I thought biopsies or foreign body extraction were kind of challenging until anesthesia called me to the OR to extract a foreign body on the weekend when pulm was off and it went without issue.

 

[jdh71]

I did a good number of outpatient bronchs during CC fellowship. There is 1 additional skill to learn that is to intubate the vocal cords with the scope. I won't do it now because I don't do those often but I am sure a could learn it.

I thought biopsies or foreign body extraction were kind of challenging until anesthesia called me to the OR to extract a foreign body on the weekend when pulm was off and it went without issue.

Humility is often missing too much in critical care.

Sure. Whatever you say.

 

[Nephro critical care]

EBUS is not a difficult skill to learn. Maybe it's because we as CC docs are already quite skilled in ultrasound. What is the major skill required in biopsying a large station 7 lymph node especially with an ET tube in place ? The PTX risk is also very low some of our pulmonologist didn't get routine CXR after EBUS.

We had a IP guy at fellowship who boasted diagnostic rates with EBUS of 85% while the non IP guys were floundering in the lower 60s or 50s. His secret : have anesthesia intubate with a 8.5 tube all his EBUS pt , take an hour and do a gazillion passses on every node he could see. Everyone else were not using anesthesia or ET tubing their patients.

I could never figure out the navigational scope though. I didn't understand the small airways , the software , that navigational scope was too complicated to manipulate and it took way too much time. But neither did the non IP pulmonologists or the thoracic surgeons who were also trying to get their foot into the IP door. I saw one of the thoracic surgeons struggle for a while on an EBUS and navigational and switch mid procedure to mediastinoscopically biopsy a station 2 / 4 node. At least he got the job done .

 

[jdh71]

I guess it is just *that* easy. My mistake. I am now convinced.

Enough work to go around. I'm not territorial. Good luck.

 

[Laryngophed]

Perc trachs.... ain't nobody got time for that!!



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As a (future) anesthestiologist/intensivist, if I'm putting a hole in a neck it had better be an emergency.

 

[maverickdoc]

A non Pulmonologist should not be doing outpt bronchs independently .
There is more to EBUS than Bx of 2 cm Station 7 .

ICU vent bronchs are a different story and pretty easy to learn.

Thinking of the medico legal aspect of a botched outpt bronchoscopy by a non pulmonary doctor is a nightmarish situation no sane hospital administrator would want to get into.

One thoracic surgery guy used the same monkey analogy for VATS .

Outpt bronch is not a critical care procedure . Period . Let alone EBUS/ Nav

 

[CCM-MD]

A non Pulmonologist should not be doing outpt bronchs independently .
There is more to EBUS than Bx of 2 cm Station 7 .

ICU vent bronchs are a different story and pretty easy to learn.

Thinking of the medico legal aspect of a botched outpt bronchoscopy by a non pulmonary doctor is a nightmarish situation no sane hospital administrator would want to get into.

One thoracic surgery guy used the same monkey analogy for VATS .

Outpt bronch is not a critical care procedure . Period . Let alone EBUS/ Nav

No (sane) person becomes an intensivist to do outpatient bronchs. There's more exciting things to do in life.

That being said, EBUS isn't neurosurgery... I know Pulm fellowships where fellows have a total of 150 bronchs under their belt when they graduate. Not sure how many of those are EBUS but doubt it's that many and they seem to be doing just fine in practice.

Outpatient bronchs aren't that cool and don't reimburse that well anyway.

 

[maverickdoc]

No (sane) person becomes an intensivist to do outpatient bronchs. There's more exciting things to do in life.

That being said, EBUS isn't neurosurgery... I know Pulm fellowships where fellows have a total of 150 bronchs under their belt when they graduate. Not sure how many of those are EBUS but doubt it's that many and they seem to be doing just fine in practice.

Outpatient bronchs aren't that cool and don't reimburse that well anyway.

That is besides the point . I don't go to the OR to administer GA because I think I can or do colonoscopy/ cystoscopy as I know how to handle a scope .

 

[dhavalp]

Error. Accidental post.

 

[tartesos]

No (sane) person becomes an intensivist to do outpatient bronchs. There's more exciting things to do in life.

That being said, EBUS isn't neurosurgery... I know Pulm fellowships where fellows have a total of 150 bronchs under their belt when they graduate. Not sure how many of those are EBUS but doubt it's that many and they seem to be doing just fine in practice.

Outpatient bronchs aren't that cool and don't reimburse that well anyway.

It's not neurosurgery, I know a lot of Pulmonologist and Ct surgeons that do it well all the time.


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[jdh71]

No (sane) person becomes an intensivist to do outpatient bronchs. There's more exciting things to do in life.

That being said, EBUS isn't neurosurgery... I know Pulm fellowships where fellows have a total of 150 bronchs under their belt when they graduate. Not sure how many of those are EBUS but doubt it's that many and they seem to be doing just fine in practice.

Outpatient bronchs aren't that cool and don't reimburse that well anyway.

NAV with EBUS staging actually has reasonable wRVU for the time spent. Not as good as vented patients but definitely better than seeing patients in clinic.

I enjoy the work and think it's pretty cool. In a few years we'll be ablating cancers that can't be cut or radiated.

 

[Nephro critical care]

Is it true that a ICU vented pt bronchoscopy with BAL and outpatient bronchoscopy with biopsy don't pay that much different. The outpt un-intubated patient getting biopsy has considerable risk/ liability and the vent pt BAL takes 5-10 minutes and has little risk if you know what you are doing. At a private hospital where I worked the private pulm groups were always fighting each other for the chance to bronch a vent pt.

I should do more bronch with BALs on vent pts with resp failure would get decent (2.78 RVUs) . But since I am hospital employed and a glutton for punishment I spend a lot of my time on difficult arterial lines which have terrible RVUs and take 30 minutes or more sometimes without success .

 

[tartesos]

Is it true that a ICU vented pt bronchoscopy with BAL and outpatient bronchoscopy with biopsy don't pay that much different. The outpt un-intubated patient getting biopsy has considerable risk/ liability and the vent pt BAL takes 5-10 minutes and has little risk if you know what you are doing. At a private hospital where I worked the private pulm groups were always fighting each other for the chance to bronch a vent pt.

I should do more bronch with BALs on vent pts with resp failure would get decent (2.78 RVUs) . But since I am hospital employed and a glutton for punishment I spend a lot of my time on difficult arterial lines which have terrible RVUs and take 30 minutes or more sometimes without success .

Bronching someone that does not need to be bronched( mucus plug) is wrong and bad karma.
No matter how good it may $eem


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[jdh71]

Is it true that a ICU vented pt bronchoscopy with BAL and outpatient bronchoscopy with biopsy don't pay that much different. The outpt un-intubated patient getting biopsy has considerable risk/ liability and the vent pt BAL takes 5-10 minutes and has little risk if you know what you are doing. At a private hospital where I worked the private pulm groups were always fighting each other for the chance to bronch a vent pt.

I should do more bronch with BALs on vent pts with resp failure would get decent (2.78 RVUs) . But since I am hospital employed and a glutton for punishment I spend a lot of my time on difficult arterial lines which have terrible RVUs and take 30 minutes or more sometimes without success .

You are incorrect about the the differences in rvu

But based on the ignorance of the entire conversation thus far, I'm not surprised.

 

[jdh71]

Bronching someone that does not need to be bronched( mucus plug) is wrong and bad karma.
No matter how good it may $eem


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Wait for the audit that will eventually come. Then wait for the payback bill.

 

[mochief2000]

IMHO Bronch with EBUS or even navigational bronch is a pretty useless skill to have as a critical care doc. I just can't come up with one scenario where its justified. Why are you trying to sample enlarged lymph nodes or get that peripheral lesion in the ICU? I am not talking about the ability to do it, I am talking more why the need to learn it??

 

[CCM-MD]

IMHO Bronch with EBUS or even navigational bronch is a pretty useless skill to have as a critical care doc. I just can't come up with one scenario where its justified. Why are you trying to sample enlarged lymph nodes or get that peripheral lesion in the ICU? I am not talking about the ability to do it, I am talking more why the need to learn it??

Completely unnecessary, just like this whole thread.

 

[Nephro critical care]

As a CC doc I don't intubated every vented patient only the immunocompromised or if I am not sure what bug is in there . But there are some private pulmonary groups that do bronch almost all vented pts with respiratory issues. Why I bothered to do EBUS , outpt bronchs , perc tracheostomy or even the occasional percutaneous gastrostomy is just to build hand -eye coordination and get more experience with dealing with complications like bleeding, PTX which I won't get that often with regular ICU procedures .
Of course I am ignorant about RVUs of bronch with biopsy. I heard from a pulmonologist it's not greatly more but I don't know the numbers. I know we get 2.78 RVU for bronch / BAL .

I am ignorant but not a jerk.

 

[Hernandez]

NAV with EBUS staging actually has reasonable wRVU for the time spent. Not as good as vented patients but definitely better than seeing patients in clinic.

Unless Endo is poorly run

Everything is easy until it isn't. Sometimes the more important skill is to know where not to do a procedure. ive had several calls from er's and hospital admin 1 weekend as they wanted me to do a foriegn body removal in a 15 year old. Yeah I could do that but just imagine the liability if something went wrong.

I'm technically trained to do percent trachs, but I let the skill lapse and now plan on not getting credentials back and let my partners or surgery do them