Em/ccm

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TrumpetDoc

TrumpetDoc

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For those familiar with programs that take EM residency grads.
Any advice as to how someone who ha been out for 2-3 yrs gets into a program?
Obviously can't do a rotation at a program. Anyone gone this route?
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There are a few places that have been historically friendly to EM docs: UPitt, Shock Trauma, U of Florida anesthesia CCM. Now that medicine, surgery, and anesthesia are opening their boards, you will start to see more places becoming more receptive to EM.
 
I would agree and that is awesome!

Anyone out there do a cCM fellowship (or any FS for that matter) having been out as an attending for 2-3 yrs?
 
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MD Dreams said:
What do you mean by they are opening their boards? Thanks.
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Meant that they are allowing EM grads to become board certified in critical care through their respective boards. For example, the recent IM-CC board cert option that as of 12/11 if you complete a medicine CC fellowship you can sit for their board exam and get certified.
 
ORL10 said:
Officially anesthesia has Created a cosponsorship.

Word is surgery is to follow, with some strange caveats.

http://theaba.org/pdf/ABA-ABEM-ACCM.pdf
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Very exciting! The anesthesia pathway is going to open up a lot more programs for EM people. How many CC fellows does the average anesthesia CC fellowship take a year? Any idea what the Surgery caveats are? Last I heard they wanted EM grads to do a surgery internship first.
 
What ICU would an EM trained doc run? SICU = surgery. Neuro = some anesthesia, some medicine, rest NS. MICU= medicine. I suppose one would be forced to be a consultant (vent, line, airway, drip jockey as most anesthesia is). medicine will not be friendly to having non IM-pulm-icu trained physicians run MICUs. Personally i try and minimise interactions with my surgical colleagues.
 
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Honestly though, I don't know what it is about EM peeps that causes them to think they shouldn't have to to do some IN patient time in order to qualify for critical care.
 
You IM people don't recognize the inherent benefits of being anesthesia or surgical or em trained if u intend on doing Icu.

IM training certainly has its benefits... We all contribute different skills and perspective.



European
 
europeman said:
You IM people don't recognize the inherent benefits of being anesthesia or surgical or em trained if u intend on doing Icu.

IM training certainly has its benefits... We all contribute different skills and perspective.



European
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Bull****. I recognize it all just fine.

My point was that the ICU is IN the hospital. It's an IN-patient service. Why would the EM people who practice (and mostly train) in a completely different environment think that boards wouldn't like to see them have some additional training in IN-patient management. It's like none of it is good enough. All these boards going out of their way to try and accommodate the EM people and all they do is cry about it.

jdh71
 
jdh71 said:
Bull****. I recognize it all just fine.

My point was that the ICU is IN the hospital. It's an IN-patient service. Why would the EM people who practice (and mostly train) in a completely different environment think that boards wouldn't like to see them have some additional training in IN-patient management. It's like none of it is good enough. All these boards going out of their way to try and accommodate the EM people and all they do is cry about it.

jdh71
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Sometimes animosity is based on a lack of understanding. By the end of my emergency medicine training, I had completed 17.5 months of inpatient care (not including EM, anesthesia, etc.). That seems like quite enough to begin training in critical care. Since we hospitalize that majority of inpatients, we do know a thing or two about it.
 
dotcb said:
Sometimes animosity is based on a lack of understanding. By the end of my emergency medicine training, I had completed 17.5 months of inpatient care (not including EM, anesthesia, etc.). That seems like quite enough to begin training in critical care. Since we hospitalize that majority of inpatients, we do know a thing or two about it.
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I don't have any animosity. Why would I have any animosity?

But this is interesting . . . you had 17.5 months where you were on an in-patient service taking care of patients in the hospital? Does this program just hate it's residents? :laugh:
 
europeman said:
You IM people don't recognize the inherent benefits of being anesthesia or surgical or em trained if u intend on doing Icu.

IM training certainly has its benefits... We all contribute different skills and perspective.



European
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No way in hell would i want a surgeon running a micu. Im sure they would feel the same. Glidescope has leveled the playing field for folks with bad dl skills or difficult anatomy. Know how to use an LMA, to bag mask, and when to call for help...not too far fetched for a medicine doc to learn.

Its all good grumpy pants
 
The surgical requirement is not an internship. It is the first year of a two year fellowship. The details are still being worked out, but this is a year that will be integrated into the fellowship and under the control of the surgical critical care program director. That being said, it was clear from the discussion at the CCM section meeting at ACEP yesterday that there is still some uncertainty about what will happen with the surgical option, although it's still great progress that we have gotten this far with it.
 
VentdependenT said:
What ICU would an EM trained doc run? SICU = surgery. Neuro = some anesthesia, some medicine, rest NS. MICU= medicine. I suppose one would be forced to be a consultant (vent, line, airway, drip jockey as most anesthesia is). medicine will not be friendly to having non IM-pulm-icu trained physicians run MICUs. Personally i try and minimise interactions with my surgical colleagues.
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EM is definitely the new kid on the ccm block. However, several EM trained physicians are already trained in CCM. Now that anesthesia and medicine have opened up the doors many of these folks will be able to grandfather in.

Ultimately, EM trained CCM physicians work in whatever unit they feel best suited to their training and interests, this is an advantage of having multiple paths to Critical Care Board Certification. I am EM residency trained and in the midst of my Neurocritical care fellowship. I will likely work in that environment. I have a former residency classmate doing multidisciplinary CCM fellowship in a SICU/MICU who will undoubtably work in either environment. The fellowship is what makes you an intensivist, not the residency.

I do wonder if in general we are not moving to more of a multidisciplinary model of ICU work. In my hospital we have Trauma Crit Care attendings in my NeuroICU; NeuroCrit Care in the CVICU; Pulm/CCM in the SICU...and interestingly, it is working from both a training and patient care perspective.

iride
 
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dotcb said:
Sometimes animosity is based on a lack of understanding. By the end of my emergency medicine training, I had completed 17.5 months of inpatient care (not including EM, anesthesia, etc.). That seems like quite enough to begin training in critical care. Since we hospitalize that majority of inpatients, we do know a thing or two about it.
Click to expand...

17.5 months?!?
Was that an im residency? Pretty close to it!
Define inpatient months please so we can understand what you mean...
 
tartesos said:
17.5 months?!?
Was that an im residency? Pretty close to it!
Define inpatient months please so we can understand what you mean...
Click to expand...

This was my first thought as well. I think his definition of "inpatient" might be broader than mine... and after reading it twice I think his definition of "hospitalize" is broader than mine as well.
 
As a surgeon and future intensivist, I agree that my cup of tea will probably not be a medical ICU


But at lots of hospitals, ICU's are not separated... for example several community hospitals.

I really believe the anesthesia, EM, and surgeons are well-equiped to take care of the multiple patient care types (neuro, medical, surgical, trauma) since, we are the most interactions directly caring for these patients. This is particularly true for the anesthesiologists. Add on that a variety of actual procedural skills, and it's clear that the medical trained people have a lot to learn.

At my hospital, a tertiary care large hospital in New York City, the Medical Intensivists rely the most on consultants compared to the other closed icus in the hospital. At the sicu the intensivists do their own dialysis, their own intubations, their own chest tubes, and their own tracheostomies, to name a few. The MICU does NONE of these (they will, occasionaly, but not routinely, do intubations).

WHat medicine people don't realize is that their training is inherently short. 3 years is a total residency for them. Surgery is 5. Anesthesia and EM are four (granted, there are a few 3 year EM programs, but those are fading). That extra year makes a huge difference in volume/experience.

As a surgeon, I have not had the outpatient medical experience taking care of patients like my medicine colleagues, but I certainly have taken care of just as many,if not more, critically ill patients with a variety of co-morbid medical conditions in the context of their surgical illness.

Ask any ICU nurse generally who are their favorite residents or fellows or attendings in the ICU. In any ICU they generally love the surgeons.
 
europeman said:
As a surgeon and future intensivist, I agree that my cup of tea will probably not be a medical ICU


But at lots of hospitals, ICU's are not separated... for example several community hospitals.

I really believe the anesthesia, EM, and surgeons are well-equiped to take care of the multiple patient care types (neuro, medical, surgical, trauma) since, we are the most interactions directly caring for these patients. This is particularly true for the anesthesiologists. Add on that a variety of actual procedural skills, and it's clear that the medical trained people have a lot to learn.

At my hospital, a tertiary care large hospital in New York City, the Medical Intensivists rely the most on consultants compared to the other closed icus in the hospital. At the sicu the intensivists do their own dialysis, their own intubations, their own chest tubes, and their own tracheostomies, to name a few. The MICU does NONE of these (they will, occasionaly, but not routinely, do intubations).

WHat medicine people don't realize is that their training is inherently short. 3 years is a total residency for them. Surgery is 5. Anesthesia and EM are four (granted, there are a few 3 year EM programs, but those are fading). That extra year makes a huge difference in volume/experience.

As a surgeon, I have not had the outpatient medical experience taking care of patients like my medicine colleagues, but I certainly have taken care of just as many,if not more, critically ill patients with a variety of co-morbid medical conditions in the context of their surgical illness.

Ask any ICU nurse generally who are their favorite residents or fellows or attendings in the ICU. In any ICU they generally love the surgeons.
Click to expand...

You sound like a surgeon
 
europeman said:
At the sicu the intensivists do their own dialysis, their own intubations, their own chest tubes, and their own tracheostomies, to name a few.
Click to expand...

The surgeons do their own dialysis?!? That sounds like a terrible idea.

Anesthesia and EM are four (granted, there are a few 3 year EM programs, but those are fading).
Click to expand...

Not true. The vast majority of EM programs are three years. In addition, most new programs are three years as well.

Ask any ICU nurse generally who are their favorite residents or fellows or attendings in the ICU. In any ICU they generally love the surgeons.
Click to expand...

Are you sure about this? Was this survey done in a SICU?
 
Any EM docs applied this year? If so, how's it going when doing the IM-CC route?
 
europeman said:
..and EM are four (granted, there are a few 3 year EM programs, but those are fading).,.
Click to expand...


Three year EM programs are certainly not fading. At least 50% if not the majority are 3 yr programs
 
europeman said:
As a surgeon and future intensivist, I agree that my cup of tea will probably not be a medical ICU


But at lots of hospitals, ICU's are not separated... for example several community hospitals.

I really believe the anesthesia, EM, and surgeons are well-equiped to take care of the multiple patient care types (neuro, medical, surgical, trauma) since, we are the most interactions directly caring for these patients. This is particularly true for the anesthesiologists. Add on that a variety of actual procedural skills, and it's clear that the medical trained people have a lot to learn.

At my hospital, a tertiary care large hospital in New York City, the Medical Intensivists rely the most on consultants compared to the other closed icus in the hospital. At the sicu the intensivists do their own dialysis, their own intubations, their own chest tubes, and their own tracheostomies, to name a few. The MICU does NONE of these (they will, occasionaly, but not routinely, do intubations).

WHat medicine people don't realize is that their training is inherently short. 3 years is a total residency for them. Surgery is 5. Anesthesia and EM are four (granted, there are a few 3 year EM programs, but those are fading). That extra year makes a huge difference in volume/experience.

As a surgeon, I have not had the outpatient medical experience taking care of patients like my medicine colleagues, but I certainly have taken care of just as many,if not more, critically ill patients with a variety of co-morbid medical conditions in the context of their surgical illness.

Ask any ICU nurse generally who are their favorite residents or fellows or attendings in the ICU. In any ICU they generally love the surgeons.
Click to expand...

Majority of EMs are 3. Furthermore IMs dont work 20 shifts a month. They work 26 days a month and take call and carry pagers at home. :confused: Your IM trained intensivists in the MICU rarely intubate, do chest tubes or trachs?

Surgeons doing dialysis?
What planet are you from? Does plant engineering run ECMO or the clinical documentation specialists manage the cvvhd there? I want to see.
 
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Jagleaso said:
Majority of EMs are 3. Furthermore IMs dont work 20 shifts a month. They work 26 days a month and take call and carry pagers at home. :confused: Your IM trained intensivists in the MICU rarely intubate, do chest tubes or trachs?

Surgeons doing dialysis?
What planet are you from? Does plant engineering run ECMO or the clinical documentation specialists manage the cvvhd there? I want to see.
Click to expand...

Agreed. We intubate all of our own pts, put in al the lines, put in our own chest tubes and our own HD catheters/administer HD. And this is as medicine residents under the guise of most often, hospitlaists. Sometimes an actual intensivist. Anestheisa backs up our airways in case they are difficult, surgeons do the trachs, I have not attempted to become profficient in these, Im ok with a doing a cric if needed, the surgeons can deal with the permanent trachs I have no interest in them. I have seen/heard stories of MICUs that farm out all of their procedures to the surgeons and anesthesiologists, but it is on a hospital to hospital basis, surely not the case at my shop.
 
Bostonredsox said:
Agreed. We intubate all of our own pts, put in al the lines, put in our own chest tubes and our own HD catheters/administer HD. And this is as medicine residents under the guise of most often, hospitlaists. Sometimes an actual intensivist. Anestheisa backs up our airways in case they are difficult, surgeons do the trachs, I have not attempted to become profficient in these, Im ok with a doing a cric if needed, the surgeons can deal with the permanent trachs I have no interest in them. I have seen/heard stories of MICUs that farm out all of their procedures to the surgeons and anesthesiologists, but it is on a hospital to hospital basis, surely not the case at my shop.
Click to expand...

At our hospital, gas residents intubate when needed, renal for dialysis, ENT/surgery for routine trachs, Surgery for chest tubes. Not even the pulm fellows do chest tubes.
 
redy said:
At our hospital, gas residents intubate when needed, renal for dialysis, ENT/surgery for routine trachs, Surgery for chest tubes. Not even the pulm fellows do chest tubes.
Click to expand...

wow. that sounds like a horrible place to do Pulm/CC training in my opinon. Atleast in my case. I suppose there are some that are just interested in the medical management and not the procedures.

In my mind, if you put in the lines, you should be the one dealing with the complications and putting in your own chest tubes. If you cannot fix your own PTX, you shouldn't be putting in the line. And yes I know there are more severe complications that require surgical intervention and its ok to not be able to handle those, ill throw in the towel and call the surgeons if an intern loses a wire or dilates/disects a carotid, after I kill the intern.
 
redy said:
At our hospital, gas residents intubate when needed, renal for dialysis, ENT/surgery for routine trachs, Surgery for chest tubes. Not even the pulm fellows do chest tubes.
Click to expand...

sounds like a cushy place for a medicine guy to train. if our patients have decent anatomy we do our own perc trachs otherwise we call ENT. we do NOT write dialysis orders, renal does.
 
VentdependenT said:
sounds like a cushy place for a medicine guy to train. if our patients have decent anatomy we do our own perc trachs otherwise we call ENT. we do NOT write dialysis orders, renal does.
Click to expand...

I guess it is cush but I am sure you will agree that the residents are poorer for it. Having said others might argue what is the necessity to learn how to intubate or perc trach. I mean I don't know numbers but I would guess the majority of hospitalists don't do procedures or do minimal procedures. Personally I want to learn as much as possible. And the fellows not putting in chest tubes bugs me. I guess they end up doing specific CTICU/SICU rotations and learn.
 
redy said:
I guess it is cush but I am sure you will agree that the residents are poorer for it. Having said others might argue what is the necessity to learn how to intubate or perc trach. I mean I don't know numbers but I would guess the majority of hospitalists don't do procedures or do minimal procedures. Personally I want to learn as much as possible. And the fellows not putting in chest tubes bugs me. I guess they end up doing specific CTICU/SICU rotations and learn.
Click to expand...

You would be gravely mistaken if that is your thought. Outside of academia, most hospitalists at community shops have to intubate, put in lines and run their own codes. In a questionare done by "the hospitalist" in like 2010 I think it was, over 75% of responding hospitalists said they had to take care of CC patients as the main provider and of those 75%, another 75% had to do procedures. In my mind, EVERYONE should be able to intubate. paramedics intubate. if you can run a code and are ACLS certified, you should know how to handle an airway. Now, not all will be able to handle difficult airways, use bougies or other equipment they are not familiar with, or cric. But a freaking mac blade and an 8.0 should be something every hospitalist should be comfortable with. I feel the same with lines. Even if all you are comfortable with is throwing in an emergent femoral and not US guided IJs, atleast you can get access for a pressor. Almost every hospitals reads guys can handle your thoras and paras. So I would say minimum for any hospitalist should be airway, CVC and an LP. I am with you, the more you can handle the stronger your arsenal. Procedures are fun. they make me happy when my soul is being sucked out of me by general internal medicine rotations.
 
Bostonredsox said:
You would be gravely mistaken if that is your thought. Outside of academia, most hospitalists at community shops have to intubate, put in lines and run their own codes. In a questionare done by "the hospitalist" in like 2010 I think it was, over 75% of responding hospitalists said they had to take care of CC patients as the main provider and of those 75%, another 75% had to do procedures. In my mind, EVERYONE should be able to intubate. paramedics intubate. if you can run a code and are ACLS certified, you should know how to handle an airway. Now, not all will be able to handle difficult airways, use bougies or other equipment they are not familiar with, or cric. But a freaking mac blade and an 8.0 should be something every hospitalist should be comfortable with. I feel the same with lines. Even if all you are comfortable with is throwing in an emergent femoral and not US guided IJs, atleast you can get access for a pressor. Almost every hospitals reads guys can handle your thoras and paras. So I would say minimum for any hospitalist should be airway, CVC and an LP. I am with you, the more you can handle the stronger your arsenal. Procedures are fun. they make me happy when my soul is being sucked out of me by general internal medicine rotations.
Click to expand...

That makes it 56% or so. I guess half an half. Anyway I was going by what I have mostly seen in job notices, usually saying procedures not needed/not must/preferable etc etc.
 
redy said:
That makes it 56% or so. I guess half an half. Anyway I was going by what I have mostly seen in job notices, usually saying procedures not needed/not must/preferable etc etc.
Click to expand...

When I initially started looking at job offers I took notice to those too, and promptly discarded them lol. But I ran into far more 'must be comfortable with intubations/procedures' jobs than 'no procedures required' jobs. I suppose it all depends on where you are looking. I was looking mainly in the community shops interspersed between the net cast by Wake, Duke, UNC, MCV, UVA and Carillion. I am sure if I centered more in the tertiary care areas it would have been far more 'no procedures required, full intensivist staff on site'. Anyway, the furthur west you go into the midwest, the more rural the areas become and the more procedures you will need to do. IMO, everyone should be comfortable with the airways, lines and LPs during residency and then whether you keep up those skills, expand on them, or lose them, will depend on where you work.
 
Bostonredsox said:
In my mind, EVERYONE should be able to intubate. paramedics intubate. if you can run a code and are ACLS certified, you should know how to handle an airway. Now, not all will be able to handle difficult airways, use bougies or other equipment they are not familiar with, or cric. But a freaking mac blade and an 8.0 should be something every hospitalist should be comfortable with. I feel the same with lines. Even if all you are comfortable with is throwing in an emergent femoral and not US guided IJs, atleast you can get access for a pressor... So I would say minimum for any hospitalist should be airway, CVC and an LP.
Click to expand...

So glad to hear this said. Big thumbs up. Right on.

glorfindel
emergency medicine
 
glorfindel said:
So glad to hear this said. Big thumbs up. Right on.

glorfindel
emergency medicine
Click to expand...

Haha I was actually re-reading the fellowship on my ipad mini today, just got into ebooks.

I feel the same for ED docs. We have some ED docs here who are longtime FPs NOT AT ALL comfortable with procedures. I put in lines for them in tough to stick HD patients frequently, help do LPs if they have trouble. But they can ALL intubate and put in a femoral. Those are basics in my mind. If you can protect an airway and get some sort of cental access, you can handle most everything coming through the door. Atleast until help arrives for other more challenging things. And yes I know you EM guys can do a **** ton more, all 3 of my med school roomates are EM docs now. But alot of places have non Em trained people not comfortable with alot of procedures.
 
Bostonredsox said:
You would be gravely mistaken if that is your thought. Outside of academia, most hospitalists at community shops have to intubate, put in lines and run their own codes. In a questionare done by "the hospitalist" in like 2010 I think it was, over 75% of responding hospitalists said they had to take care of CC patients as the main provider and of those 75%, another 75% had to do procedures. In my mind, EVERYONE should be able to intubate. paramedics intubate. if you can run a code and are ACLS certified, you should know how to handle an airway. Now, not all will be able to handle difficult airways, use bougies or other equipment they are not familiar with, or cric. But a freaking mac blade and an 8.0 should be something every hospitalist should be comfortable with. I feel the same with lines. Even if all you are comfortable with is throwing in an emergent femoral and not US guided IJs, atleast you can get access for a pressor. Almost every hospitals reads guys can handle your thoras and paras. So I would say minimum for any hospitalist should be airway, CVC and an LP. I am with you, the more you can handle the stronger your arsenal. Procedures are fun. they make me happy when my soul is being sucked out of me by general internal medicine rotations.
Click to expand...

Again, there is a difference between placing an endotracheal tube in a trachea and managing an airway.

Ive come to realize that the act of placing a breathing tube is a monkey skill. Its the pharmacology, physiology,and decision making behind managing an airway that requires, skill, study and practice.

What are your plans A,B,C,D etc when you DL that cardiac cripple and see your grade 3 or 4 view. Know what I mean?
 
oh you mean like putting a friggen lma in? its not rocket science but it takes practice. I do NOT think laryngoscopy is a monkey skill any more than knowing how to bag mask with an oral airway is. Using a glidescope is a monkeyskill. you have one of these then the VAST MAJORITY of difficult laryngoscopies and airways are no longer difficult.

difficult airway is cannot ventilate cannot intubate (experienced laryngoscopist fails on 3 attempts), NOT just cannot intubate. people forget all the time that all you have to do is MOVE AIR. even during codes: "hold chest compressions so i can get tube in." thats bull$hit. effective compressions hold trump card. just bag em if you cant see posterior to the epiglottis. if you cant bag em tube em. if you cant tube em LMA em. if you cant LMA em cut em. if you cant cut em then the patient is S.O.L.

The physiology and pharmacology of respiratory arrest is simple: MOVE O2 into alveoli REMOVE co2 from alveoli. get that done anyway you can.
 
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VentdependenT said:
oh you mean like putting a friggen lma in? its not rocket science but it takes practice. I do NOT think laryngoscopy is a monkey skill any more than knowing how to bag mask with an oral airway is. Using a glidescope is a monkeyskill. you have one of these then the VAST MAJORITY of difficult laryngoscopies and airways are no longer difficult.

difficult airway is cannot ventilate cannot intubate (experienced laryngoscopist fails on 3 attempts), NOT just cannot intubate. people forget all the time that all you have to do is MOVE AIR. even during codes: "hold chest compressions so i can get tube in." thats bull$hit. effective compressions hold trump card. just bag em if you cant see posterior to the epiglottis. if you cant bag em tube em. if you cant tube em LMA em. if you cant LMA em cut em. if you cant cut em then the patient is S.O.L.

The physiology and pharmacology of respiratory arrest is simple: MOVE O2 into alveoli REMOVE co2 from alveoli. get that done anyway you can.
Click to expand...

Thank you. this sufficiently supplies my retort to the difficult airway notion without having to type my own. I have encountered 3s and 4s. I have had to put in an LMA. I have had to use a airtract. I have had to use a bougie. I have had to use a glidescope. I have even nasally intubated a patient. I have not cric'd, as the opportunity has not presented itself as of yet, but as those who have read my earlier posts know, I have prepared myself as best as I can for when the cric comes.
 
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