Peds CC vs IM CC

[DeadCactus]

Kind of random, but how different is the actual critical care portion of the knowledge base between those two fields? Do you think someone who did an IM/Peds combined residency and a CC fellowship through either specialty would be qualified to work in both?

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[jdh71]

Kind of random, but how different is the actual critical care portion of the knowledge base between those two fields? Do you think someone who did an IM/Peds combined residency and a CC fellowship through either specialty would be qualified to work in both?

no

 

[DeadCactus]

No as in you don't think they would be qualified or no you don't think they'd be able to find work without the pedigree?

 

[jdh71]

No as in you don't think they would be qualified or no you don't think they'd be able to find work without the pedigree?

Not qualified to work in both

 

[Hernandez]

god no.....and who'd want to do both?

 

[PMPMD]

I believe one would have to do med-peds (5) + BOTH fellowships (2 + 3, if you omitted the pulm component) = a decade of GME training

 

[J-Rad]

Mostly no. That said, you may bump into people who work in areas in which they did not have the "traditional" training. These days, that typically someone who trained in days of yore. My two examples are a pediatric intensivist in my fellowship hospital who initially trained as a pediatric cardiologist (in years past it was common for the cardiologists to attend in the PICU. He just happened to stay in the field. These days cardiologists who are intensivists have either done a 4th year CVICU fellowship or double boarded in Peds CCM by completing reqs for both fellowships). Another example, more closely related to your OP is this person: http://findadoc.mmc.org/page.asp?phyID=6273. When I was a medical student rotating at this hospital I knew of her attending in both the pediatric and adult ICUs. She was med-peds trained, but adult Pulm/CC trained (MMC only has that fellowship, not Peds CCM). I suspect it would be very hard to do that these days and her example is an artifact of the time when she trained (and, now, experience obtained). Aside from hospital priviledging, though, you might be able to make the argument that the critical care portion of the knowledge base is similar, but that the pediatric intensivist needs to know the critical care knowledge as it relates to not only sick, really sick, and oh, $h** sick, but those at neonate, small child, child, and adult ages and physiologies and that in a philosophical (not practical) sense they could more easily work in an adult ICU than an adult intensivist could work in a peds ICU. The military is always a funny one to use as an example (because of their love of archaic systems), but to my knowledge, when a peds intensivist deploys to a war zone, they're considered game for all-age CCM.

 

[Stitch]

The two practices are really quite different. The differential diagnoses and even the interventions for similar disease processes will be different. Even leaving out congenital heart disease we manage patients a bit differently. Some is style, some is data. In peds we use a lot more ECMO and HFOV for example. Kids physiology and response to critical illness is often different than an adult's. I think we can all learn from one another and share data/experience, but actually practicing in both places? No.

 

[DeadCactus]

Thank you all. Was just curious because I recall reading that smaller hospitals with only a generalized ICU will occasionally admit a pediatric patient under an Adult ICU attending. Seemed reasonable that an adult/peds + adult cc trained physician could work in a pediatric ICU at small community hospital.

 

[jdh71]

Thank you all. Was just curious because I recall reading that smaller hospitals with only a generalized ICU will occasionally admit a pediatric patient under an Adult ICU attending. Seemed reasonable that an adult/peds + adult cc trained physician could work in a pediatric ICU at small community hospital.

Well, it all depends on how "peds" the patient is. I'd probably be comfortable enough taking care of a 16 or 17 y/o, you know patients on the cusp, but anything pre-pubescent for sure would be outside of my comfort zone, especially the little ones.

There's a lot of cross-over in the abstract, but for all practical purposes it wouldn't be a good idea for the patients.

 

[Hamhock]

r

 

[Stitch]

Well, it all depends on how "peds" the patient is. I'd probably be comfortable enough taking care of a 16 or 17 y/o, you know patients on the cusp, but anything pre-pubescent for sure would be outside of my comfort zone, especially the little ones.

There's a lot of cross-over in the abstract, but for all practical purposes it wouldn't be a good idea for the patients.

From my end we get some cross over on the 19-21 year olds, which can still come into the unit. To be honest though, the adult guys do a better job of taking care of this population than we do, and the nursing staff is more comfortable dealing with sedation issues, traching earlier, that sort of thing.

Another exception might be some of the childhood diseases such as cystic fibrosis, congenital heart disease (single ventricle physiology), that sort of thing. We actually had a 22 year old, 115 kg down's patient in last week. It was tough for everyone, and I really think he would have done better in a MICU. How do you adult guys feel about the above patients? Are you seeing some come through the MICU? How can we transition care now that they are living longer?

 

[Hernandez]

From my end we get some cross over on the 19-21 year olds, which can still come into the unit. To be honest though, the adult guys do a better job of taking care of this population than we do, and the nursing staff is more comfortable dealing with sedation issues, traching earlier, that sort of thing.

Another exception might be some of the childhood diseases such as cystic fibrosis, congenital heart disease (single ventricle physiology), that sort of thing. We actually had a 22 year old, 115 kg down's patient in last week. It was tough for everyone, and I really think he would have done better in a MICU. How do you adult guys feel about the above patients? Are you seeing some come through the MICU? How can we transition care now that they are living longer?

in general 2 pof these ts wouldn't be much of an issue for an acute issue in MICU, the CF pts acute issues they typically happen is more than appropriate.....and my MICU population has a large number of MRDD pts. the congenitle hearts, would be tough just due to lack of familiarity.

 

[Socrates25]

Thank you all. Was just curious because I recall reading that smaller hospitals with only a generalized ICU will occasionally admit a pediatric patient under an Adult ICU attending. Seemed reasonable that an adult/peds + adult cc trained physician could work in a pediatric ICU at small community hospital.

I've never heard of a "small community hospital" that happens to have a PICU.

I could see older teenagers 15 or older being treated in an adult ICU, but anything younger than that I imaging would get shipped off to the nearest large academic medical center PICU.

 

[jdh71]

From my end we get some cross over on the 19-21 year olds, which can still come into the unit. To be honest though, the adult guys do a better job of taking care of this population than we do, and the nursing staff is more comfortable dealing with sedation issues, traching earlier, that sort of thing.

Another exception might be some of the childhood diseases such as cystic fibrosis, congenital heart disease (single ventricle physiology), that sort of thing. We actually had a 22 year old, 115 kg down's patient in last week. It was tough for everyone, and I really think he would have done better in a MICU. How do you adult guys feel about the above patients? Are you seeing some come through the MICU? How can we transition care now that they are living longer?

We've kept the CFers alive for so long now they're coming into the adult ICUs, but we usually deal with their issues on the pulmonary firm service at the University. I think there is enough experience with that population now that it's not considered way "out there".

Now congenital hearts on the other hand . . . I've seen one tetralogy of fellot (immigrant) adult survivor and that was pretty outside of my current comfort zone. I don't see much of this population.

 

[J-Rad]

From my end we get some cross over on the 19-21 year olds, which can still come into the unit. To be honest though, the adult guys do a better job of taking care of this population than we do, and the nursing staff is more comfortable dealing with sedation issues, traching earlier, that sort of thing.

Another exception might be some of the childhood diseases such as cystic fibrosis, congenital heart disease (single ventricle physiology), that sort of thing. We actually had a 22 year old, 115 kg down's patient in last week. It was tough for everyone, and I really think he would have done better in a MICU. How do you adult guys feel about the above patients? Are you seeing some come through the MICU? How can we transition care now that they are living longer?

We've kept the CFers alive for so long now they're coming into the adult ICUs, but we usually deal with their issues on the pulmonary firm service at the University. I think there is enough experience with that population now that it's not considered way "out there".

Now congenital hearts on the other hand . . . I've seen one tetralogy of fellot (immigrant) adult survivor and that was pretty outside of my current comfort zone. I don't see much of this population.

Sometimes it just may be a matter of where you are. Where I trained for fellowship, I felt like the PICU was very comfortable with the age group mentioned by Stitch and I would rather they be taken care of in the PICU. They were much more comfortable with complex CHD, especially single ventricles, and actually, after a little back and forth, a soft policy was made that all single ventricle patients would go to the PICU, regardless of age. We sent a mid 30s Fontan conversion there (in addition to some others) and they did well. Honestly, I think in some ways they liked being in the PICU better than being on the medicine floor (which is where they went later in recovery). As for the 22yo Downs patient, you might also argue that sometimes, for social and familiarity reasons, they might be better off in the PICU. Many of them are still very much children cognitively and young adults really are just big kids. I am in no way saying that adult intensivists do a bad job, but depending on the system in which you are in, it may alter your views on fuzzy age "boundaries". Back to Stitch's comment on ECMO and HFOV, this is a fascinating area. I know when I was a medical student (and I believe Stitch was one at the same time) ECMO and HFOV were seen as modalities only used in peds. There has been an incredible upswing in their use (esp. ECMO) in the adult population since that time. IIRC one of our ECMO nurses was actually saying they were doing more ECMO in the adult unit than the PICU since our peds CT surgeon came on board (not many of his patients came back from the OR on ECMO). This is where my admittedly abstract thoughts earlier came from.