Options for IM/CCM without Pulmonary?

[Chrismander]

Hi--I know that you can do a 2 year fellowship for pure CCM after IM without doing pulmonary, but how viable is that for getting a job afterwards? Do most hospitals prefer you to be pulmonary boarded too? I assume a lot of the smaller units might not need a full-time intensivist, would they be effectively excluded from your job hunt after?

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[psychbender]

I don't see why a hospital would toss out your job application if you were CCM only, without pulmonary. Other specialties can go CCM without doing pulm (surgery, anesthesia, EM), and the American medical system seems to be hurting for trained intensivists, period. Others actually in the system may have other (more informed) opinions, and I defer to them.

 

[augmel]

I was talking to one of our private practice pulmonologists and he was saying that they envision the practices growth being dominated by the need for 24/7 ICU coverage as that becomes the expectation at bigger hospitals. So for them, hiring some CCM only people is entirely possible. Unfortunately, it is not here yet so the actual need is hard to predict.

 

[Pulm2B]

What's one more year anyway? CCM through IM is 2 years, Pulm/CCM is 3. I am interested more in CCM than Pulm but with fewer and fewer programs offering just CCM via IM, Pulm/CCM is the standard. Also, with Sleep Med training through Pulm/CCM, you can sit back and relax from your ICU shifts and make bank doing sleep studies.

 

[Henle]

1) Jobs: there are clearly LESS jobs for CCM only, 90 % need the combo. Hard to find job in University setting with pure CCM only because most depts have either Anesth or Pulm/CC
2) Income: 160- 250 with usually 15 12H-shifts per month. Every state has job offers for CCM. see nejm.org job section
3) Overall Pulm/CC combo better choice

This is from an insiders first hand experience

 

[proman]

Also inside knowledge for a large university medical center:

starting IM teaching hospitalist: 120K
starting PCCM asst prof: 140K
starting CCM night attending: 180K for 3 10 hour nights per week.

I've seen several hospitals with CCM only. This is likely the wave of the future. Hospitals will subsidize the CCM practice to have 24 hour in house coverage. The pulmonologists will like it because they can spend more time on sleep and outpatient. I don't see any job shortages for the IM CCM only trained people. Don't do pulm if you don't like it or want to practice it.

 

[Henle]

I was referring to the private sector with above income figures.
Agree with above post that there will be jobs in pure CCM.
I personally would not like to do outpatient pulmonary med (Asthma, COPD and incurable intersititial lung dz).
Overall, there is a huge difference in income potential if you take the money+ benefits and break it into hourly wage. Typically it is around 100$/h in non-university hospitals. South pays best (as usual).
Again, one negative aspect of pure CCM is the small number of academic jobs in the big university hospitals after training (for those interested). However, plenty of jobs in teaching hospitals all over the country, if you enjoy interacting with housestaff.

 

[Apollyon]

A flipside is competition for the fellowships: the combined CCM/Pulm fellowships are a harder "get" than straight CCM (I don't know why, but the money thing might be part of it - EM types frequently say that "I don't want to be doing bronchs all day" when they say why they want to do CCM). I don't know if there are specific Pulm only fellowships (as I would think, for that angle, CC is part and parcel).

 

[Eidolon6]

Inpatient pulmonary consultation practice and billing in addition to critical care practice can be a drive. Also, unlike GI, bronching all day is unlikely even in busy practices.

Pulmonary only fellowships exist but are less popular. Some are tied with allery/immunology. They tend to be less competitive.

 

[Apollyon]

The "bronchs all day" is hyperbole by EM types. I guess it equates to "I don't want to do it at all".

 

[augmel]

Inpatient pulmonary consultation practice and billing in addition to critical care practice can be a drive. Also, unlike GI, bronching all day is unlikely even in busy practices.

Pulmonary only fellowships exist but are less popular. Some are tied with allery/immunology. They tend to be less competitive.

What institutions have pulm fellowship tied to allergy?

 

[Eidolon6]

Until recently, Vandy had a Pulmonary/Allergy fellowship consisting of 3 years. This was probably possible because the Allergy/Immunology division is tied in with Pulmonary/CCM. You will not find formal listings for combined Allergy/Pulmonary but some fellowships can be flexible and training tailored if there is significant crossover amongst subject matter.

 

[viscera]

Hi--I know that you can do a 2 year fellowship for pure CCM after IM without doing pulmonary, but how viable is that for getting a job afterwards? Do most hospitals prefer you to be pulmonary boarded too? I assume a lot of the smaller units might not need a full-time intensivist, would they be effectively excluded from your job hunt after?

Eight years later... has anything changed? Has anyone noticed an increased interest on the part of hospitals for hiring intensivists (IM/CC) for ICU coverage?

 

[ORL10]

there are lots of jobs for straight CCM. Most hospitals are moving to a shift based model and there are several groups hiring specifically for CCM only (i.e; intensivist group...)

The CCM fellowships are easier to obtain for IM residents, getting harder to obtain for EM applicants. This is because of the ridiculous quota of 25% of past 5 years can be EM in a CC-IM fellowship. This is because IM is the board certifying body and they think that IM residents are going to be the work force for CCM, which is totally BS. The reality is anesthesia makes more money in OR, less incentive to do ICU, IM tend to not gravitate towards CCM in general (and most do PCCM when they are interested), while EM interests grows each year and the best applicants I have seen this year are coming from EM.

So if you are IM interested in pure CCM you are in a good spot to secure a position and get a job when you are finished. If you are EM it's getting tougher to get a spot and finding a dual job in the same hospital after graduation has proven to be a challenge.

 

[deleted547339]

there are lots of jobs for straight CCM. Most hospitals are moving to a shift based model and there are several groups hiring specifically for CCM only (i.e; intensivist group...)

The CCM fellowships are easier to obtain for IM residents, getting harder to obtain for EM applicants. This is because of the ridiculous quota of 25% of past 5 years can be EM in a CC-IM fellowship. This is because IM is the board certifying body and they think that IM residents are going to be the work force for CCM, which is totally BS. The reality is anesthesia makes more money in OR, less incentive to do ICU, IM tend to not gravitate towards CCM in general (and most do PCCM when they are interested), while EM interests grows each year and the best applicants I have seen this year are coming from EM.

So if you are IM interested in pure CCM you are in a good spot to secure a position and get a job when you are finished. If you are EM it's getting tougher to get a spot and finding a dual job in the same hospital after graduation has proven to be a challenge.

I've been hearing the same...how 'tough' is 'tough'? I'm EM planning on applying to IM-based CCM.

 

[mochief2000]

there are lots of jobs for straight CCM. Most hospitals are moving to a shift based model and there are several groups hiring specifically for CCM only (i.e; intensivist group...)

The CCM fellowships are easier to obtain for IM residents, getting harder to obtain for EM applicants. This is because of the ridiculous quota of 25% of past 5 years can be EM in a CC-IM fellowship. This is because IM is the board certifying body and they think that IM residents are going to be the work force for CCM, which is totally BS. The reality is anesthesia makes more money in OR, less incentive to do ICU, IM tend to not gravitate towards CCM in general (and most do PCCM when they are interested), while EM interests grows each year and the best applicants I have seen this year are coming from EM.

So if you are IM interested in pure CCM you are in a good spot to secure a position and get a job when you are finished. If you are EM it's getting tougher to get a spot and finding a dual job in the same hospital after graduation has proven to be a challenge.

haha EM being the best applicants huh...... biased are we?? EM people always complaining about how it is not fair about not being boarded in CCM or the 25% rule. Yet, when they refuse to allow FM to be boarded in EM even if they do a fellowship. Politics.....

btw I actually agree with you that EM should be boarded in CCM without the 25% rule. Just thought your post was funny.

 

[sylvanthus]

haha EM being the best applicants huh...... biased are we?? EM people always complaining about how it is not fair about not being boarded in CCM or the 25% rule. Yet, when they refuse to allow FM to be boarded in EM even if they do a fellowship. Politics.....

btw I actually agree with you that EM should be boarded in CCM without the 25% rule. Just thought your post was funny.

No that actually makes sense, critical care starts in the ED and for those EM graduates pursuing CC fellowship they are required to do a certain number of critical care months during residency and a 2 year fellowship to be boarded. Realistically how much EM are you doing in a FM residency where you think you deserve to be boarded after a 1 year EM fellowship?

 

[ORL10]

I'm not saying em people are smarter, or more prepared or make better intensivists. What I am saying is the applicants for pure ccm positions from em are stronger than im applicants this year based on research and board scores which is the only objective data I can use that isn't "biased". Also this is a very broad generalization but the most motivated em residents tend to go into ccm and this tends to be more of the exception than the rule for IM (I.e; PCCM, cards, endo, gi, heme/onc are the obvious more popular choices)

The 25% rule is ridiculous, there is a shortage of intensivists of which we are seeing dramatic increases in interested em applicants yet many programs have limited spots for em because of this rule. I have spoken with several pd's who have said they are taking less polished IM applicants over em apps because of this rule and they do not want to be cited by acgme. I would think you would want the best man for the job not based on some arbitrary percentage set by ABIM.

How tough is tough? Don't know for sure, no one does, but some programs have 0 spots others have one or two. Anesthesia ccm is opening some doors ( lots of programs, many very good) but the application cycle seems to throw residents off.

 

[jdh71]

Eight years later... has anything changed? Has anyone noticed an increased interest on the part of hospitals for hiring intensivists (IM/CC) for ICU coverage?

Private practice pulmonary groups covering hospital ICUs is quickly going away. Hospitals are hiring to staff the ICU and don't care as much about the pulmonary clinic, so there is a market for just critical care only folks. But be prepared to 1/3 to 1/4 nights, week on, week off, 12 hour days, and you WORK for every freaking thin dime. If you're ok being the last house on the block dumping ground for every ED, hospitalist, surgical sub-specialist, and basically any non-trauma trained general surgeon, then you'll find work.

 

[jdh71]

No that actually makes sense, critical care starts in the ED and for those EM graduates pursuing CC fellowship they are required to do a certain number of critical care months during residency and a 2 year fellowship to be boarded. Realistically how much EM are you doing in a FM residency where you think you deserve to be boarded after a 1 year EM fellowship?

It's nuanced but I don't think the ED does much "critical care" - and this may be a matter of semantics - but the ED does "stuff" to people to keep from from dying very acute and gets the initial resuscitation going when needed. The critical care happens in the unit keeping people alive who would die if you didn't keep doing whatever it is you happen to be doing.

I suppose that EDs that end up "boarding" MICU patients then end up doing some critical care, but it's been my experience, based on my definition, that critical care does not begin in an ED. Patients get pulled just from the brink and then the ED wants them the hell out and fast.

 

[sylvanthus]

"Critical Care has been defined as the delivery of medical care to "any patient who is physiologically unstable, requiring constant and minute-to-minute titration of therapy according to the evolution of the disease process." It has not defined by location..."

I still stand by critical care starting in the ED. If you truly believe that its "emergency care" in the ED or whatever you want to call it and the moment they step foot in the ICU it becomes "critical care" and want to use that as your definition, fine, we agree to disagree.

Regardless, the point of my post is that ED residents pursuing a CC fellowship get way more experience in "critical care" than FM residents pursuing a one year EM fellowship get in EM.

 

[deleted547339]

It's nuanced but I don't think the ED does much "critical care" - and this may be a matter of semantics - but the ED does "stuff" to people to keep from from dying very acute and gets the initial resuscitation going when needed. The critical care happens in the unit keeping people alive who would die if you didn't keep doing whatever it is you happen to be doing.

I suppose that EDs that end up "boarding" MICU patients then end up doing some critical care, but it's been my experience, based on my definition, that critical care does not begin in an ED. Patients get pulled just from the brink and then the ED wants them the hell out and fast.

So when I recognize that my patient has septic shock, fluid resuscitate, get cultures and get broad spec abx on board early, put in a cvl and start pressors, intubate, get the lactic headed in the right direction, titrate pressors, etc, I'm just "doing stuff" to people? But when a patient on the floor with pneumonia decompensates and comes to the unit, you do the same thing and that's critical care?

 

[jdh71]

So when I recognize that my patient has septic shock, fluid resuscitate, get cultures and get broad spec abx on board early, put in a cvl and start pressors, intubate, get the lactic headed in the right direction, titrate pressors, etc, I'm just "doing stuff" to people? But when a patient on the floor with pneumonia decompensates and comes to the unit, you do the same thing and that's critical care?

Nope. Initial resus isn't "critical care" the way I'm defining here. I already mentioned this is a semantic argument here.

You get cookies for doing the right things BEFORE they get sent up.

You have a right to he offended but I don't really think you should. I wasn't trying to hurt any sensitive feels.

 

[jdh71]

"Critical Care has been defined as the delivery of medical care to "any patient who is physiologically unstable, requiring constant and minute-to-minute titration of therapy according to the evolution of the disease process." It has not defined by location..."

I still stand by critical care starting in the ED. If you truly believe that its "emergency care" in the ED or whatever you want to call it and the moment they step foot in the ICU it becomes "critical care" and want to use that as your definition, fine, we agree to disagree.

Regardless, the point of my post is that ED residents pursuing a CC fellowship get way more experience in "critical care" than FM residents pursuing a one year EM fellowship get in EM.

Definitions are like buttholes.

 

[deleted547339]

Definitions are like buttholes.

So are opinions

 

[jdh71]

So are opinions

Yup.

The only truth in the universe is math.

 

[namethatsmell]

It's nuanced but I don't think the ED does much "critical care" - and this may be a matter of semantics - but the ED does "stuff" to people to keep from from dying very acute and gets the initial resuscitation going when needed. The critical care happens in the unit keeping people alive who would die if you didn't keep doing whatever it is you happen to be doing.

I suppose that EDs that end up "boarding" MICU patients then end up doing some critical care, but it's been my experience, based on my definition, that critical care does not begin in an ED. Patients get pulled just from the brink and then the ED wants them the hell out and fast.

So, assuming appropriately aggressive ED care, you're saying that critical care docs basically just shepherd the patient across the river after the ED doc has pulled the drowning patient to shore, built them a boat, and set them back on the right course?

I actually agree with you in that most EDs aren't staffed/set up right now for "ICU" care that's identical to the unit. At the same time, EDs are probably better staffed/equipped to safely "take over" a critically-ill patient's physiology compared to many ICUs...especially regarding airway control and many invasive procedures.

I got lots of respect for CC docs and what they do, but probably a little more respect for semantics .

 

[jdh71]

So, assuming appropriately aggressive ED care, you're saying that critical care docs basically just shepherd the patient across the river after the ED doc has pulled the drowning patient to shore, built them a boat, and set them back on the right course?

I actually agree with you in that most EDs aren't staffed/set up right now for "ICU" care that's identical to the unit. At the same time, EDs are probably better staffed/equipped to safely "take over" a critically-ill patient's physiology compared to many ICUs...especially regarding airway control and many invasive procedures.

I got lots of respect for CC docs and what they do, but probably a little more respect for semantics .

Not exactly. And this is the problem with you folks in the ED you don't appreciate the nuance of what really occurs in the unit. You think that the initial resus and initial procedures are "critical care". And they are not really.

A better analogy if you like the pulling the drowning man analogy, and even if I beg the question about "building a boat" (which doesn't really happen very often - most lines are put in upstairs, thank you kindly for the airway, I suppose), it's more like pulling a man from the ocean and the critical care doc captains the ship through the rough seas, around the coral reefs, past the pirates and to another continent.

I disagree that the ED is the "better" spot for procedures. Every time I've needed to do anything in an ED it takes longer and the nurses are less helpful. If you wanna call shenanigans on my anecdote, ok, but that's been my experience on 8 EDs across all of residency, fellowship, and time as an attending.

The same reason why a pulmonary and critical care doc cannot just step into the same role as an emergency doc is the same reason an emergency doc cannot step into the role as a critical care doc.

There is some overlap. Mostly as it pertains to procedures but it mostly ends there.

You don't have to take offense. But you can if you want. It's a free country.

I have a lot of respect of emergency docs and what they do but you're not going to convince me it's critical care the way I'm defining it. <insert emoticon here>

 

[namethatsmell]

Not exactly. And this is the problem with you folks in the ED you don't appreciate the nuance of what really occurs in the unit. You think that the initial resus and initial procedures are "critical care". And they are not really.

A better analogy if you like the pulling the drowning man analogy, and even if I beg the question about "building a boat" (which doesn't really happen very often - most lines are put in upstairs, thank you kindly for the airway, I suppose), it's more like pulling a man from the ocean and the critical care doc captains the ship through the rough seas, around the coral reefs, past the pirates and to another continent.

Don't totally agree with your analogy, although my initial one was maybe too playful and borders on snarky I suppose--no offense intended. I give credit for working in the pirates.

I think who puts in the lines varies greatly based on what shop you happen to be in (my experience in around 7 EDs between a former career and med stud/resident rotations)--at two of my current shops the ED lines essentially every unit-bound pt per request of the ICU team (for better or worse). At another shop this is far more variable as some of the ED attendings don't want it to disrupt department flow if pt has good enough access to get the line in the unit.

I disagree that the ED is the "better" spot for procedures. Every time I've needed to do anything in an ED it takes longer and the nurses are less helpful. If you wanna call shenanigans on my anecdote, ok, but that's been my experience on 8 EDs across all of residency, fellowship, and time as an attending.

We have very different experiences here, but it's probably because of where we call "home." I know where everything is in my EDs and the nurses know me and will help me out with anything. When I'm off-service in the ICU the nurses don't know me from a hole in the wall and I have no clue where stuff is. I'm sure the reverse situation could be true.

I'll concede that lines should be pretty similar to do in both spots (bigger ICU rooms are really nice for this), but in my experience intubating in the ED goes far, far smoother than in the ICU as we do it more (at least where I've worked) and we have easy access and familiarity with more drugs and toys. Just my anecdotal experience.
I respect the way you guys work the vent and always try to learn as much as possible about this when I'm in the unit.

The same reason why a pulmonary and critical care doc cannot just step into the same role as an emergency doc is the same reason an emergency doc cannot step into the role as a critical care doc.

There is some overlap. Mostly as it pertains to procedures but it mostly ends there.

You don't have to take offense. But you can if you want. It's a free country.

I have a lot of respect of emergency docs and what they do but you're not going to convince me it's critical care the way I'm defining it. <insert emoticon here>

I take no offense as I think we play different, but equally necessary, roles in the game. I also think we have more overlap than you feel but I'm really not out to change your mind (I've read enough of your posts and I respect your training). Rather, just adding my own point of view for any students who may be following this thread.

 

[viscera]

Private practice pulmonary groups covering hospital ICUs is quickly going away. Hospitals are hiring to staff the ICU and don't care as much about the pulmonary clinic, so there is a market for just critical care only folks. But be prepared to 1/3 to 1/4 nights, week on, week off, 12 hour days, and you WORK for every freaking thin dime. If you're ok being the last house on the block dumping ground for every ED, hospitalist, surgical sub-specialist, and basically any non-trauma trained general surgeon, then you'll find work.

Would it be reasonable to assume that most hospitals are staffed with pulmonary groups covering the ICU in the more desirable areas? Reason being that these locales have less difficulty finding abled bodies and, given the choice between a pulm/cc vs. cc trained doc, the pulm doc has a bit more to offer in ways of procedures and clinic/consult coverage.

 

[jdh71]

Would it be reasonable to assume that most hospitals are staffed with pulmonary groups covering the ICU in the more desirable areas? Reason being that these locales have less difficulty finding abled bodies and, given the choice between a pulm/cc vs. cc trained doc, the pulm doc has a bit more to offer in ways of procedures and clinic/consult coverage.

Hm. Yeah. Kind of. Though mostly these days the hospitals want their units covered first. If they can get both then it's a bit of a bonus but their priority is covering the ICU so I'm not so convinced it matters to the hospitals themselves as much. Now to PP groups it will make a bit of a difference. And there will probably be a preference to have pulm and critical care.

 

[ORL10]

as an ED doc and an ICU doc I agree with both of you, but I do think the ED scope of CC is very narrow. The initial resus is fun lots of prcoedures and keeping the patient alive, which is why you went into ED in the first place. ICU is more about being OCD about everything: riding out AKI (should we start CVVH), hypoxemic respiratory failure on high FiO2/PEEP, MODS, VAP, DVT/PE from immobility, poor nutrition or intolerance, GIB, line infections, delirium, weakness/debility, when to stop antibiotics or restart for that matter is the daily grind of critical care. ED docs have no desire to do this, and ICU docs have no desire to sift through low risk chest pain, low risk abdominal pain and social complaints. We both like to do resuscitation which is where the venn diagram overlaps and both specialties are excellent at this, unfortunately it represents a small portion of both practices.

The ED at most places is NOT set up to take care of critically ill patients for any prolonged period of time. If you do not have a cc pod with excellent protocols in place, dedicated nursing ratios of atleast 1:2, after the initial resus that patients excellent care you just gave over the initial 1-2 hours is likely to dramatically decline. This isn't because the ED is incompetent (no matter what the admitting team says) it's because you have a thousand other things to do, and the busy ed is not the place to be OCD about ICU patients.

 

[jdh71]

Don't totally agree with your analogy, although my initial one was maybe too playful and borders on snarky I suppose--no offense intended. I give credit for working in the pirates.

I think who puts in the lines varies greatly based on what shop you happen to be in (my experience in around 7 EDs between a former career and med stud/resident rotations)--at two of my current shops the ED lines essentially every unit-bound pt per request of the ICU team (for better or worse). At another shop this is far more variable as some of the ED attendings don't want it to disrupt department flow if pt has good enough access to get the line in the unit.



We have very different experiences here, but it's probably because of where we call "home." I know where everything is in my EDs and the nurses know me and will help me out with anything. When I'm off-service in the ICU the nurses don't know me from a hole in the wall and I have no clue where stuff is. I'm sure the reverse situation could be true.

I'll concede that lines should be pretty similar to do in both spots (bigger ICU rooms are really nice for this), but in my experience intubating in the ED goes far, far smoother than in the ICU as we do it more (at least where I've worked) and we have easy access and familiarity with more drugs and toys. Just my anecdotal experience.
I respect the way you guys work the vent and always try to learn as much as possible about this when I'm in the unit.



I take no offense as I think we play different, but equally necessary, roles in the game. I also think we have more overlap than you feel but I'm really not out to change your mind (I've read enough of your posts and I respect your training). Rather, just adding my own point of view for any students who may be following this thread.

I like ending conversations where there is some disagreement like gentlemen. This could have escalated quickly. lol.

Though I think I'm often misunderstood which may partly be my fault.

I don't really disrespect any area of medicine (except those darn radiologists!!! Yuk yuk [I kid]) and I really wasn't trying to be dismissive. I merely think the hour or two (sometimes shorter right? Especially if a bed is available and the patient really needs to be upstairs) down in the ED compared to the days and sometimes weeks I'll spend with a patient in the unit really underline the differences I'm trying to get at but maybe didn't do a good job of presenting.

I can NOT work the way I do without a good doc in the pits at the door. If I had to go down and get all things going BEFORE the patient got upstairs it would be a completely different practice environment and one in which I would not like to work. *In that sense* I will grudgingly concede that critical care cannot begin until you guys have done your work.

 

[jdh71]

as an ED doc and an ICU doc I agree with both of you, but I do think the ED scope of CC is very narrow. The initial resus is fun lots of prcoedures and keeping the patient alive, which is why you went into ED in the first place. ICU is more about being OCD about everything: riding out AKI (should we start CVVH), hypoxemic respiratory failure on high FiO2/PEEP, MODS, VAP, DVT/PE from immobility, poor nutrition or intolerance, GIB, line infections, delirium, weakness/debility, when to stop antibiotics or restart for that matter is the daily grind of critical care. ED docs have no desire to do this, and ICU docs have no desire to sift through low risk chest pain, low risk abdominal pain and social complaints. We both like to do resuscitation which is where the venn diagram overlaps and both specialties are excellent at this, unfortunately it represents a small portion of both practices.

The ED at most places is NOT set up to take care of critically ill patients for any prolonged period of time. If you do not have a cc pod with excellent protocols in place, dedicated nursing ratios of atleast 1:2, after the initial resus that patients excellent care you just gave over the initial 1-2 hours is likely to dramatically decline. This isn't because the ED is incompetent (no matter what the admitting team says) it's because you have a thousand other things to do, and the busy ed is not the place to be OCD about ICU patients.

I think the biggest problem is the nuance required in adjusting things. Which may be what you are getting at with your being "OCD". So much of medicine in an area you normally don't work in is not knowing what you don't know and not because you are an idiot, you simply didn't get that training.

 

[deleted547339]

I like ending conversations where there is some disagreement like gentlemen. This could have escalated quickly. lol.

Though I think I'm often misunderstood which may partly be my fault.

I don't really disrespect any area of medicine (except those darn radiologists!!! Yuk yuk [I kid]) and I really wasn't trying to be dismissive. I merely think the hour or two (sometimes shorter right? Especially if a bed is available and the patient really needs to be upstairs) down in the ED compared to the days and sometimes weeks I'll spend with a patient in the unit really underline the differences I'm trying to get at but maybe didn't do a good job of presenting.

I can NOT work the way I do without a good doc in the pits at the door. If I had to go down and get all things going BEFORE the patient got upstairs it would be a completely different practice environment and one in which I would not like to work. *In that sense* I will grudgingly concede that critical care cannot begin until you guys have done your work.

Agree on the first point. Could have gotten out of hand.

Disagree on the second. I don't think I've ever even made a call to the MICU within the first two hours...My workup is done and I've started my treatment before they get called. In a septic patient, I almost always have a second lactate before calling. I know this isn't how it is everywhere, but that's at least how it is here. We also get a lot of MICU boarding, so having a patient on a vent for 12-24h isn't horribly uncommon. We re-arrange our nursing staff if we know there aren't enough ICU beds - they'll often go 1:1 on the critically ill patients. No, I don't do lovenox or protonix prophylaxis in the ED, but we do a decent bit of management.

Plus, it takes a lot to get a patient into the MICU where I'm at. We have a great relationship with the MICU (except for one fellow - she knows who she is, lol), but there just aren't enough beds. Basically, it's intubated, on pressors or SEVERE metabolic derangement to get a MICU bed.

The only one time I've called the MICU within that 2h mark was on a DKA patient....pH was in the mid 6's with a SBP in the 50s on arrival....her dispo was fairly obvious. Normally we close the gap on our DKA patients, give them sub-cut insulin and feed them in the ED then send to the floor. This pt was obviously not going to get their gap closed in the next 6-8h, lol.

 

[jdh71]

Agree on the first point. Could have gotten out of hand.

Disagree on the second. I don't think I've ever even made a call to the MICU within the first two hours...My workup is done and I've started my treatment before they get called. In a septic patient, I almost always have a second lactate before calling. I know this isn't how it is everywhere, but that's at least how it is here. We also get a lot of MICU boarding, so having a patient on a vent for 12-24h isn't horribly uncommon. We re-arrange our nursing staff if we know there aren't enough ICU beds - they'll often go 1:1 on the critically ill patients. No, I don't do lovenox or protonix prophylaxis in the ED, but we do a decent bit of management.

Plus, it takes a lot to get a patient into the MICU where I'm at. We have a great relationship with the MICU (except for one fellow - she knows who she is, lol), but there just aren't enough beds. Basically, it's intubated, on pressors or SEVERE metabolic derangement to get a MICU bed.

The only one time I've called the MICU within that 2h mark was on a DKA patient....pH was in the mid 6's with a SBP in the 50s on arrival....her dispo was fairly obvious. Normally we close the gap on our DKA patients, give them sub-cut insulin and feed them in the ED then send to the floor. This pt was obviously not going to get their gap closed in the next 6-8h, lol.

You guys in training programs have a horribly skewed view of the world. And I say that without guile.

My med school had an EM residency you'd all know and respect.

No residency where I did my residency and not residents at the main hospital where I did fellowship (because of other residencies in the city) and no residents where I'm working now. And I can promise all that boarding and ICU work you're talking about ends (so does any blocking if admits) and I can pretty much promise that unless you stay in a tracing spot you won't be doing a lot of ICU work in your ED. Regardless. Most of what happens, even when boarded is temporizing measures and not what we are doing upstairs. For instance I've never seen a patient extubated in the ED. It's not the same. Experience will show through at some point. I think Ill fund myself vindicated here.

 

[deleted547339]

You guys in training programs have a horribly skewed view of the world. And I say that without guile.

My med school had an EM residency you'd all know and respect.

No residency where I did my residency and not residents at the main hospital where I did fellowship (because of other residencies in the city) and no residents where I'm working now. And I can promise all that boarding and ICU work you're talking about ends (so does any blocking if admits) and I can pretty much promise that unless you stay in a tracing spot you won't be doing a lot of ICU work in your ED. Regardless. Most of what happens, even when boarded is temporizing measures and not what we are doing upstairs. For instance I've never seen a patient extubated in the ED. It's not the same. Experience will show through at some point. I think Ill fund myself vindicated here.

I agree with most this statement. We do time in a community ED and the ICU players disappear within an hour. We have several attendings who have spent a lot of time in private practice that say the same thing. One of my attendings even jokes about how EGDT is a entirely impossible in the community because you just can't get a good fluid bolus, abx, cultures, pressors, cvl, etc done prior to the patient being taken upstairs.

I've extubated 3 patients in the ED.....none of them were good experiences. I realize that extubation is entirely out of the purview of EM. One was a GHB overdose that was coming around. The ICU fellow did not understand that it's something we aren't comfortable with. I wanted him to come down and he just kept saying "it's fine, just extubate him."

Again, I disagree with you in that I fully believe in the academic setting we provide critical care in the ED, but we disagree on the definition of critical care. I'll let you know if my opinion changes after fellowship.

 

[Bostonredsox]

Also inside knowledge for a large university medical center:

starting IM teaching hospitalist: 120K
starting PCCM asst prof: 140K
starting CCM night attending: 180K for 3 10 hour nights per week.

I've seen several hospitals with CCM only. This is likely the wave of the future. Hospitals will subsidize the CCM practice to have 24 hour in house coverage. The pulmonologists will like it because they can spend more time on sleep and outpatient. I don't see any job shortages for the IM CCM only trained people. Don't do pulm if you don't like it or want to practice it.

Where are you finding these numbers, and more importantly, if they were true, why would anyone do academic cc? I have no cc fellowship, work only nights in smaller 150-250 bed community hospitals, with 10-20 bed ICUs, and have yet to see an offer less than 2000/shift. I cover the house and all er admits in addition to the units but still, 180k for night intensivist work would seriously make me question ever going back for the fellowship I gave up.

 

[ChrisGriffen]

Ok hopping in.

I am starting to look into residency programs. I am pretty dead set on pulm-critical care, and I want to maximize my chances at getting a fellowship. Would it be a good idea to pursue a combined IM/EM residency, or is that overkill?

 

[jdh71]

Ok hopping in.

I am starting to look into residency programs. I am pretty dead set on pulm-critical care, and I want to maximize my chances at getting a fellowship. Would it be a good idea to pursue a combined IM/EM residency, or is that overkill?

Could be, could be not. That's a long road. Do you like the ED?

 

[Kahreek]

No that actually makes sense, critical care starts in the ED and for those EM graduates pursuing CC fellowship they are required to do a certain number of critical care months during residency and a 2 year fellowship to be boarded. Realistically how much EM are you doing in a FM residency where you think you deserve to be boarded after a 1 year EM fellowship?

no, most of the critical care does not start in ED.

 

[deleted547339]

no, most of the critical care does not start in ED.

That's cute...

 

[sylvanthus]

no, most of the critical care does not start in ED.

Thank you for your analysis medical student, I will defer to your vast knowledge in the matter.

 

[Kahreek]

Thank you for your analysis medical student, I will defer to your vast knowledge in the matter.

Much obliged.

 

[NontradICUdoc]

The purpose of the ED for the critically ill,is to appropriately identify these patients, start management, contact the ICU and get them to it as soon as possible. In my experience what limited there is at this time is that the ED will start resuscitation and should be able to identify the septic patient and ensure that they at least get the appropriate treatment started. I have also found that they have dropped the ball in several instances. This may be because the department had a large influx of patients or multiple critical patients, I do not know. What I also found, is that thr ED is not equipt to handle certain aspects of what th ICU needs. No cvp measurements, no a line setup, delay in getting studies, etc.

That is because the ED is set up as a stationary triage. Does the patient get admitted, more often than not yes. If so, where.

The treatment of the critically I'll needs to be done in the ICU. not the ED.

 

[Mad Jack]

no, most of the critical care does not start in ED.

Yeah, I've never, ever seen a patient end up on a vent in the ER. That's like some unicorn stuff right there, most docs go their whole life having without seeing such a case

 

[Hernandez]

. What I also found, is that thr ED is not equipt to handle certain aspects of what th ICU needs. No cvp measurements,

Paul Marik smiled a little a that thought.

 

[deleted547339]

Does the patient get admitted, more often than not yes.

lol. no.

 

[tartesos]

The purpose of the ED for the critically ill,is to appropriately identify these patients, start management, contact the ICU and get them to it as soon as possible. In my experience what limited there is at this time is that the ED will start resuscitation and should be able to identify the septic patient and ensure that they at least get the appropriate treatment started. I have also found that they have dropped the ball in several instances. This may be because the department had a large influx of patients or multiple critical patients, I do not know. What I also found, is that thr ED is not equipt to handle certain aspects of what th ICU needs. No cvp measurements, no a line setup, delay in getting studies, etc.

That is because the ED is set up as a stationary triage. Does the patient get admitted, more often than not yes. If so, where.

The treatment of the critically I'll needs to be done in the ICU. not the ED.

Sometimes I hate my er colleagues ( figure of speech).
Like: she had a saddle pe was a little hypotensive so we gave tpa...
Now she's hypotensive( maxed on levo and vasopressin through a peripheral line) and we can't get a cvp line, just put her in the Icu.
I felt like bitch slapping some one.
But I just put a femoral line in the patient in the er in front of all of them and took her in.
I lost a lot of respect for them that day.
But In reality
Ed gets bombarded with crap left and right and ends up making stupid mistakes. I feel sorry for them sometimes.

 

[ORL10]

Look I've played on both fences. The ed completes a significant portion of resuscitation at good hospitals (like taking a history, calling the nursing home, getting a line in with abx and fluids to avoid falling out of "core measures" +/- intubation). If they aren't doing that, they aren't doing a good job, is this critical care, in my opinion yes.

But after that first hour or so the quality of care declines for a multitude of reasons. Not because ed doctors "aren't smart enough" or "don't know what they are doing" even though Im sure many of you would argue differently, but they get bombarded with 100 other things to do. If you have time to evaluate VTI, or PLR after initial fluid resus send a repeat lactate, monitor hourly UO, and titrate vasopressors you aren't working in a busy enough ed. Or you're in one of the few eds that have carved out an ED critical care niche to afford you the time to do that. Seeing 2.5-3 pts/hr (average numbers in community jobs) means you need to move on to chest pain, AMS, dizziness/syncope, traumas, low risk abdominal pain and pregnant vaginal bleeders (god I don't miss that.)

The one thing I will say is in medicine we love to blame each other for everything. "The stupid ED missed this, I cannot believe the surgeons had x complication, why did they operate on this disaster, how did he get a transplant, medicine sat on this all night?..."

Hindsight is 20/20, don't be that doctor who complains about his colleagues being incompetent all the time, it gets old.