IM advantage to surgical critical care?

[europeman]

Anyone from a medicine background who has done or is currently training in SURGICAL critical care feel/think their background somehow gives them an advantage to surgeons who do critical care or anesthesiologists that do surgical critical care?

Obviously one can imagine someone from a medicine background would have a lot of disadvantages not being familiar with the surgeries, procedures, etc. I'm just wondering the other way around.

Thanks!

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[PMPMD]

Patients don't always fit neatly into medical or surgical categories. Many pts going to the OR have complex comorbidities. Your strengths in medicine will help you with these patients, who are becoming more common in SICUs I believe that CCM is truly multidisciplinary, and that the distinctions between the units are often blurry.

 

[europeman]

With all due respect, I disagree.

SICU patients are patients that recently had an OPERATION. period.

MICU patients do not.

Now do patients go from one unit to another because of this and that bedding/staffing... sure. That's not the point of my question.

Does the patient's hypercholesteralemia, hx of CABG and MI 10 years ago, type 2 diabetes, and COPD, however, make a post operative perf'd septic diverticulitis who just had a sigmoidectomy any more appropriate for a MICU than a SICU? Of course not.

That said, the point to my question you may indirectly be answering. Perhaps you feel, somehow, that physicians with a backgrounnd in INTERNAL MEDICINE and then critical care have an advantage with patients, (perhaps the elderly or frail?) with multiple MEDICAL comorbidies in the ICU setting? That seems reasonable at first glance, though I don't really agree. You mind expanding?

Thanks!

thanks for the response.

 

[Hamhock]

Patients don't always fit neatly into medical or surgical categories. Many pts going to the OR have complex comorbidities. Your strengths in medicine will help you with these patients, who are becoming more common in SICUs I believe that CCM is truly multidisciplinary, and that the distinctions between the units are often blurry.

I am really a believer that there isn't - or shouldn't be - a distinction between the units, blurry or otherwise.

I eagerly anticipate the day when CCM is a specialty unto it's own, accessible from multiple base specialties (surgery, IM, EM, anesthesiology, etc.). This will benefit patients and providers alike.

Of course, I also think that CCM fellowship should be two years for everyone and should require advanced ultrasound (including TEE), bronchoscopic, anesthesia, vent mgt, advanced CV support, and renal replacement skills.

...probably not going to happen soon, though. Given that CCM is still dominated by IM folks in the US, I doubt such a progressive view of CCM will develop soon.

HH

 

[PMPMD]

My point was that there are patients who straddle the medical surgical divide. If a patient has major medical problems, and undergoes a minor surgery (cysto, etc), what are the patients main issues going to be? Are they going to have the same post-surgical stress response as someone who had a Whipple? I think we have to consider the magnitude of the procedure and not just a binary yes/no variable.

Very much agree with HH's post.

 

[Xerxes1729]

I agree that an MI ten years ago is not a really major medical issue and that you don't need a bunch of training in IM to handle a patient who had one. But what about your non-operative trauma patient who also has ALL? Pulmonary HTN from scleroderma in a post-op appy? Mastectomy with critical aortic stenosis?

Obviously, you'll be better off with someone who has more experience with whatever your main problem is. If your main problem is a wound infection, the surgeon has more experience. If you had a v-fib arrest on induction, I think the cardiologist will do more for you than your urologist.

I'm a big fan of multidisciplinary critical care, like the other posters. Really sick patients don't always fit into nice little boxes

 

[jdh71]

Multidisciplinary critical care is the wave of the future, and I don't know if we'll ever see a single "critical care" board or not, but you definitely would be at an advantage to go multidisciplinary for training. Sick patient are sick patients, generally . . . I personally think neuro critical care is a bit of different beast, but not so much so.

 

[europeman]

I don't know where you guys are coming from, but I don't see multidisplinary critical are anywhere in the future!

perhaps in training/fellowship.. .fine.... but not in actual critical care practice. it just doesn't make sense. you have post op cardiac patients, transplant patients, post op general surgery/vascaulr patients, medical icu patients, trauma patients, etc. these are generally very different patient populations.

i'm at a tertiary institution where we have a tranplant ICU, a surgical ICU, a post cardiac surgery ICU (including patients on echmo, etc), a neonatal icu, a neurosurgery ICU, a pediatric ICU, a medical ICU, and a coronary care (non surgery cardiac) icu, and a trauma ICU THEY FUNCTION VERY DIFFERENTLY.

Why in god's name would anyone want to stick all these patients in the same unit?

Now.... perhaps you guys are referring to multidiscplinary training, whereby, theoretically, a fellow rotates through all those things and has a fair amount of facility managing all those patients. In reality, I think the differences between patient populations is too big though.

I mean, the trauma surgeon ICU guys also cover the surgical ICU (makes sense). The anesthesia ICU guys cover the SICU as well as the cardiac (most of the anesthesia critical care guys here are also specifically cardiac trained). There is an ER intensivist that only covers the SICU. The medical guys cover mostly the MICU, but a few also cover the neuro ICU (though most are neurologists with ICU fellowship). So... obviously you guys see the overlap... but, it doesn't make ANY SENSE FOR A TRAUMA SURGEON intensivist to be covering the post cardiac ICU patients unless that trauma surgeon has some specific interest in those patients and gets additional training/experience in it. Otherwise, leave it to the CT surgeon intensivists or anesthesia CT intensivists. cmon!

 

[jdh71]

I don't know where you guys are coming from, but I don't see multidisplinary critical are anywhere in the future!

perhaps in training/fellowship.. .fine.... but not in actual critical care practice. it just doesn't make sense. you have post op cardiac patients, transplant patients, post op general surgery/vascaulr patients, medical icu patients, trauma patients, etc. these are generally very different patient populations.

i'm at a tertiary institution where we have a tranplant ICU, a surgical ICU, a post cardiac surgery ICU (including patients on echmo, etc), a neonatal icu, a neurosurgery ICU, a pediatric ICU, a medical ICU, and a coronary care (non surgery cardiac) icu, and a trauma ICU THEY FUNCTION VERY DIFFERENTLY.

Why in god's name would anyone want to stick all these patients in the same unit?

Now.... perhaps you guys are referring to multidiscplinary training, whereby, theoretically, a fellow rotates through all those things and has a fair amount of facility managing all those patients. In reality, I think the differences between patient populations is too big though.

I mean, the trauma surgeon ICU guys also cover the surgical ICU (makes sense). The anesthesia ICU guys cover the SICU as well as the cardiac (most of the anesthesia critical care guys here are also specifically cardiac trained). There is an ER intensivist that only covers the SICU. The medical guys cover mostly the MICU, but a few also cover the neuro ICU (though most are neurologists with ICU fellowship). So... obviously you guys see the overlap... but, it doesn't make ANY SENSE FOR A TRAUMA SURGEON intensivist to be covering the post cardiac ICU patients unless that trauma surgeon has some specific interest in those patients and gets additional training/experience in it. Otherwise, leave it to the CT surgeon intensivists or anesthesia CT intensivists. cmon!

Of course they are all different a nuanced, but there no reason why an intensivist couldn't do them all if trained so. The only advantage the surgeons have is the option of taking a patient to the OR themselves, outside of that it's not that much different except for nuances and degrees.

 

[europeman]

i mean, sure, anyone can be trained to take care of any unit.... but it goes only so far. i don't think it's possible to have an intensivist be able to take care of ALL types of units and effectively keep up with the literature in ALL the patient populations. That said, sure, anyone could care for any unit.

That said, I think the anesthesia and surgery guys have an advantage w/the surgery patients because they inherently understand what happens in the OR. makes a difference lots of times in decision making.

 

[KYTNOH]

I don't know where you guys are coming from, but I don't see multidisplinary critical are anywhere in the future!

perhaps in training/fellowship.. .fine.... but not in actual critical care practice. it just doesn't make sense. you have post op cardiac patients, transplant patients, post op general surgery/vascaulr patients, medical icu patients, trauma patients, etc. these are generally very different patient populations.

i'm at a tertiary institution where we have a tranplant ICU, a surgical ICU, a post cardiac surgery ICU (including patients on echmo, etc), a neonatal icu, a neurosurgery ICU, a pediatric ICU, a medical ICU, and a coronary care (non surgery cardiac) icu, and a trauma ICU THEY FUNCTION VERY DIFFERENTLY.

Why in god's name would anyone want to stick all these patients in the same unit?

Now.... perhaps you guys are referring to multidiscplinary training, whereby, theoretically, a fellow rotates through all those things and has a fair amount of facility managing all those patients. In reality, I think the differences between patient populations is too big though.

I mean, the trauma surgeon ICU guys also cover the surgical ICU (makes sense). The anesthesia ICU guys cover the SICU as well as the cardiac (most of the anesthesia critical care guys here are also specifically cardiac trained). There is an ER intensivist that only covers the SICU. The medical guys cover mostly the MICU, but a few also cover the neuro ICU (though most are neurologists with ICU fellowship). So... obviously you guys see the overlap... but, it doesn't make ANY SENSE FOR A TRAUMA SURGEON intensivist to be covering the post cardiac ICU patients unless that trauma surgeon has some specific interest in those patients and gets additional training/experience in it. Otherwise, leave it to the CT surgeon intensivists or anesthesia CT intensivists. cmon!

Multidisciplinary critical care doesn't mean you put all the patients in the same unit. From what I have seen, multidisciplinary refers to the breadth of training that someone receives while in fellowship and seems like it applies very well to the Emergency Medicine and Anesthesia trained fellows since they straddle the medical-surgical divide. Instead of doing just a surgical critical care fellowship someone would rotate through the Trauma ICU, the CCU, the MICU, the SICU, the CTICU, etc.

Where I'm at currently, pulmonary/critical care is a combined fellowship, and with the exception of a couple months they are exclusively in the adult medical ICU. That would not be a multidisciplinary critical care fellowship. Likewise, the trauma/critical care fellows only rotate through the trauma/surgical critical care service. That would not be multidisciplinary either. A good example of a multidisciplinary CC fellowship would be the Pitt EM or Anesthesia tracks that have you rotate through MICU, Neuro ICU, CTICU, transplant ICU, trauma ICU, Surgical ICU, and CCU. The second year of the fellowship would then be available for a niche if that's what the fellow wanted.

 

[Intensivist]

@europeman - have you ever worked in two different ICUs? the way you present things, it seems you aren't all that well introduced to icu problems.

 

[europeman]

Hi Intensivist.

I'm a surgery PGY-3 (i.e. will be PGY-4 in July) at in a large tertiary hospital in NYC. I spend most of my free time in the surgical ICU (when i'm not operating), which, in this hospital, has no trauma, a lot of transplant, and lots of gen surg...and all the attendings are either medicine or anesthesia trained. No surgeons (this is a function of the hospital not being a trauma center, and hence no surgeons who are ICU trained since they most come from the trauma/acute-care route). I've also rotated on the cardiac ICU service, which is run by mostly by anesthesia intensivists and they have one CT-sugeon who is also ICU trained who attends there.

At our community hospital rotation, whereby it is a trauma center, the majority of the SICU patients are trauma.


I went to medical school at Yale, and did 2 ICU electives 4th year, one in the MICU and on in the SICU (micu was medicine/pulm run... the sicu was mostly surgeons, and one anesthesiologist and on ER trained intensivist). I then did a

 

[Intensivist]

and still think that critical care for all sorts of patients has many things in common, and can be thought in single speciality or to think that multimodal approach isn't apropriate one?

 

[Hernandez]

I agree with the others, eventually CCM will be Multidisciplinary critical care in training. I don't see IM fully desgregating it from Pulm, but it would not surprise me if everyone finally got stop the political fighting and combined gas/surg/IM/EM into a single board and possibly fellowships.

as far as advantage, not really, unless you were one of the gas/surgeons who dumped all the medical issues on the fleas and somehow manage to make it through your training without learning your basic medicine. then yes, I'd have a huge advantage over you.

 

[jdh71]

as far as advantage, not really, unless you were one of the gas/surgeons who dumped all the medical issues on the fleas and somehow manage to make it through your training without learning your basic medicine. Then yes, i'd have a huge advantage over you.

qft

 

[deuist]

and still think that critical care for all sorts of patients has many things in common, and can be thought in single speciality or to think that multimodal approach isn't apropriate one?

Where I did my gen surg internship, all of hospital's ICU's where run by medical intensivists as closed units. That includes the burn ICU and the SICU. The surgeons rounded everyday to write notes, but all of the orders were handled by the pulm/medical crit guys. The fellows rotated through all of the ICU's, even the PICU.

 

[europeman]

Yeah, most SICU's in the country are run by medicine trained intensivists. There is a low supply of surgeon/anesthesia/ER trained intensivists nationally. In europe, my understanding is, though i've never worked there, it's different - mostly anesthesiologists. Anyway, in this country, the SICU's without surgeon/anesthesia trained intensivists tend to be more prevalent in smaller, community and/or non-trauma non-tertiary hospitals. That's not to say there aren't large tertiary hospitals w/o them, i'm just saying prevalent wise, the phenomenon of a medicine-trained intensivists running a closed SICU is relatively less common.

As far as Hernandez's comment who thought medicine trained intensivists don't have an advantage in SICU's compared their anesthesia/surgery trained colleagues, thank you.

I'm a surgeon - but, I am partial to non-medicine trained intensivists for surgerical patients in my experience, in general (not always), simply because they just aren't as familiar with the procedures that happen in the OR, and aren't as procedure-oriented. In fact, in my experience of like n=3 ER trained intensivists, I was pleasantly surprised how adept and comfortable they were at bedside procedures compared to their medicine colleauges.

Of course, SICU is more than just procedures.

Anyone else have thoughts?

thanks!

 

[bulgethetwine]

Wow. Couldn't have figured out you were a surgeon without reading your post.

Are you going for that vascular or CT fellowship?

Hi Intensivist.

I'm a surgery PGY-3 (i.e. will be PGY-4 in July) at in a large tertiary hospital in NYC. I spend most of my free time in the surgical ICU (when i'm not operating), which, in this hospital, has no trauma, a lot of transplant, and lots of gen surg...and all the attendings are either medicine or anesthesia trained. No surgeons (this is a function of the hospital not being a trauma center, and hence no surgeons who are ICU trained since they most come from the trauma/acute-care route). I've also rotated on the cardiac ICU service, which is run by mostly by anesthesia intensivists and they have one CT-sugeon who is also ICU trained who attends there.

At our community hospital rotation, whereby it is a trauma center, the majority of the SICU patients are trauma.


I went to medical school at Yale, and did 2 ICU electives 4th year, one in the MICU and on in the SICU (micu was medicine/pulm run... the sicu was mostly surgeons, and one anesthesiologist and on ER trained intensivist). I then did a

 

[europeman]

no, i'm a general surgery resident. i'll be going into a trauma/critica-care/acute-care-surgery fellowship.