Life of an intensivist?

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DarkProtonics

DarkProtonics

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What's daily life like for an intensivist, compared to a non-CCM hospitalist?

Don't most intensivists have two subspecialties, one is CCM, the other's another IM subspecialty. Like cardiology+CCM, pulmonology+CCM, ID+CCM?
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Depends on the way the physician's practice is run, and how the ICU is run.

Some intensivists do three 12-hour shifts per week.

At one of the ICUs I rotated in, the doc attended in the ICU from 9am to the early afternoon, and spent the rest of the day doing pulmonology consults for the rest of the hospital.

At one of the other hospitals, I gather that the doc spends just enough time in the ICU to round on all the patients, and spends the rest of the day doing consults and pulmonary clinic and PFT lab
 
I'm at a large urban academic hospital. Our intensivists, for the most part, attend 2wks every 2 months and spend the rest of the time in clinical investigation. Some attendings will also attend on the pulmonary consult service, the procedure service, or the advanced lung disease service (transplant stuff). We're moving toward differentiating intensivists from pulmonary doctors.
 
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souljah1 said:
I'm at a large urban academic hospital. Our intensivists, for the most part, attend 2wks every 2 months and spend the rest of the time in clinical investigation. Some attendings will also attend on the pulmonary consult service, the procedure service, or the advanced lung disease service (transplant stuff). We're moving toward differentiating intensivists from pulmonary doctors.
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I meant intensivists who are only intensivists. How are their daily lives, and what can they do that a general hospital-practicing internist can't or won't.
 
An intensivist would work in a "closed" ICU - meaning that the ICU will not allow an internist to manage the patient in that setting which, ipso facto, would mean that an internist can not manage the patient in that setting.

If you're asking what they learn in fellowship in addition to Internal Med, I suppose you could say that they specialize in the "acute whatever" in each organ system.... acute renal failure, acute respiratory failure, acute pulmonary edema, sepsis. These often occur together and are related to one another. The CCM specialist learns to manage each system and keep the big picture in mind. Just like every subspecialty of Internal Med, they study the finer details of a particular part of Internal Med. In this case, they specialize in a disease process rather than an organ system.

They try not to give IV contrast to a fungemia patient on Amphoterrible, with respiratory failure, and blow out their kidneys.
 
howelljolly said:
An intensivist would work in a "closed" ICU - meaning that the ICU will not allow an internist to manage the patient in that setting which, ipso facto, would mean that an internist can not manage the patient in that setting.

If you're asking what they learn in fellowship in addition to Internal Med, I suppose you could say that they specialize in the "acute whatever" in each organ system.... acute renal failure, acute respiratory failure, acute pulmonary edema, sepsis. These often occur together and are related to one another. The CCM specialist learns to manage each system and keep the big picture in mind. Just like every subspecialty of Internal Med, they study the finer details of a particular part of Internal Med. In this case, they specialize in a disease process rather than an organ system.

They try not to give IV contrast to a fungemia patient on Amphoterrible, with respiratory failure, and blow out their kidneys.
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Yeah, if I end up in the MICU, I want an intensivist as my attending, w/ my FP as a consultant, not the other way around --my FP feels the same way--.

They also learn how to effectively ventilate and monitor patients, I suppose.

Would giving MRI contrast to such a pt be less toxic?

Are acute cardiac problems dealt w/ by cardiologists, intensivists, or both?

I heard some intensivists tele-monitor MICU pts for the attending at night.

I wonder why they didn't make House an intensivist? That tends to be what he does.
 
DarkProtonics said:
Yeah, if I end up in the MICU, I want an intensivist as my attending, w/ my FP as a consultant, not the other way around --my FP feels the same way--.

They also learn how to effectively ventilate and monitor patients, I suppose.

Would giving MRI contrast to such a pt be less toxic?

Are acute cardiac problems dealt w/ by cardiologists, intensivists, or both?

I heard some intensivists tele-monitor MICU pts for the attending at night.

I wonder why they didn't make House an intensivist? That tends to be what he does.
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Gadolinium? I suppose its safer. But I think that the radiologist would have a problem with you shoving the ventilator into the MRI along with the patient.

Acute cardiac problems are dealt with by a critical care nurse, and the intensivist, or the resident covering the ICU. ER docs and paramedics do those sorts of things too.

No, the critical care nurse monitors the patient at night.

What House does is nothing like what an intensivist does. And if you must know, Dr Chase is supposed to be an intensivist. And what he does on the show is surgery, not critical care.
 
howelljolly said:
Gadolinium? I suppose its safer. But I think that the radiologist would have a problem with you shoving the ventilator into the MRI along with the patient.

Acute cardiac problems are dealt with by a critical care nurse, and the intensivist, or the resident covering the ICU. ER docs and paramedics do those sorts of things too.

No, the critical care nurse monitors the patient at night.

What House does is nothing like what an intensivist does. And if you must know, Dr Chase is supposed to be an intensivist. And what he does on the show is surgery, not critical care.
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Yeah, House is a lot more like a general internist then an intensivist. And Chase USED to be an intensivist before he was fired; apparently he somehow became a general surgeon now.
 
One other point about the telemetry thing.... we treat patients, not monitors so, that wouldnt fly.

Im a House junkie myself. On the first episode, He says that hes a BORED certified diagnostician, with dual fellowships in nephrology and infectious disease. Somehow, since that episode he's never done any nephrology. I believe that Episode 3 of this season is the first time he ever ordered dialysis. Anyway, theres an old thought that if you can't come to a diagnosis, think of infectious or renal etiology. Ive done a Nephrology elective... a metformin induced acidosis, a poisoning which wasnt responding as expected (turned out to be two separate toxins), 29 year old healthy guy with rhabdo for no apparent reason, cancer patient whos fingers would turn blue every now and again, patient whos turning into stone. It was all figured out by nephrology, during my month-long rotation, in between managing many CRF patients.

If you want a real diagnostic nightmare every day, and twice on Saturday, think about rheumatology. Im usually itching for a puzzle. Rheumatology was even too much for me.

Again, give yourself time. Try new things, dont assume you already know what you are interested in. Thats a mistake I made when I was choosing my undergraduate major. Molecular Bio... what was I thinking?
 
howelljolly said:
One other point about the telemetry thing.... we treat patients, not monitors so, that wouldnt fly.

Im a House junkie myself. On the first episode, He says that hes a BORED certified diagnostician, with dual fellowships in nephrology and infectious disease. Somehow, since that episode he's never done any nephrology. I believe that Episode 3 of this season is the first time he ever ordered dialysis. Anyway, theres an old thought that if you can't come to a diagnosis, think of infectious or renal etiology. Ive done a Nephrology elective... a metformin induced acidosis, a poisoning which wasnt responding as expected (turned out to be two separate toxins), 29 year old healthy guy with rhabdo for no apparent reason, cancer patient whos fingers would turn blue every now and again, patient whos turning into stone. It was all figured out by nephrology, during my month-long rotation, in between managing many CRF patients.

If you want a real diagnostic nightmare every day, and twice on Saturday, think about rheumatology. Im usually itching for a puzzle. Rheumatology was even too much for me.

Again, give yourself time. Try new things, dont assume you already know what you are interested in. Thats a mistake I made when I was choosing my undergraduate major. Molecular Bio... what was I thinking?
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I've already made my decisionto switch from microbiology to chemistry at Cerritos College; I'll make m decision as to my real major when I transfer.

Then them making House an nephrologist and infectious disease specialist might've been an appeal to that line of thinking.

What's your rheumatology rotation like? Isn't the treatment from rheumatological diseases always either aspirin, prednisone, or methotrexate+mycophenolate?

Here's a company that telemonitors MICU pts: http://www.icumedicine.com/

Do MICUs Swan-Ganz catheterize every pt w/ a cardiac problem?
 
DarkProtonics said:
I've already made my decisionto switch from microbiology to chemistry at Cerritos College; I'll make m decision as to my real major when I transfer.

Then them making House an nephrologist and infectious disease specialist might've been an appeal to that line of thinking.

What's your rheumatology rotation like? Isn't the treatment from rheumatological diseases always either aspirin, prednisone, or methotrexate+mycophenolate?

Here's a company that telemonitors MICU pts: http://www.icumedicine.com/

Do MICUs Swan-Ganz catheterize every pt w/ a cardiac problem?
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I didnt do a rheum rotation. My internal med rotation had two or three outstanding rheumatology faculty who gave the field its fair share of attention. Yep, the treatment is usually the same, but the diagnosis was some serious mental gymnastics.

The ESCAPE trial showed that sticking a Swan-Ganz in everyone did nothing to improve outcome in the ICU. So, its not done.
 
howelljolly said:
I didnt do a rheum rotation. My internal med rotation had two or three outstanding rheumatology faculty who gave the field its fair share of attention. Yep, the treatment is usually the same, but the diagnosis was some serious mental gymnastics.

The ESCAPE trial showed that sticking a Swan-Ganz in everyone did nothing to improve outcome in the ICU. So, its not done.
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So, do they Swan-Ganz anyone anymore, and if so, why?
 
DarkProtonics said:
So, do they Swan-Ganz anyone anymore, and if so, why?
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This is one of the 3rd rails of medicine (meaning, there's no consensus).

The data do not support the claim that SG catheters reduce mortality. So, if that's your only factor in choosing an intervention or therapy (more on this below), then that would be that.

But, of course, there's more to the story. Many folks question the validity of applying the "benefit of reduced mortality" litmus test to something that is a monitoring device rather than a therapy. Others point out that a SG catheter might have more utility in the hands of an experienced operator, or at least someone who knows what to DO with the data.

There is no doubt that we use SG less now in my era (I'm a critical care fellow) then in times gone past (say, 10 years ago) at least in this country.

But I would also say that I do use them, and I feel like I have made clinical decisions based on the data. I work in multiple units stratified by specialty (SICU, MICU, CT ICU, Neuro ICU). I use them in the CT ICU commonly, the SICU occasionally, and the MICU and Neuro ICU rarely (in these last two units, almost exclusively in septic patients when I'm trying to make fluid balance decisions in the face of someone who might have the sepsis-associated transient decrease in cardiac function and I'm trying to decide if I need more resuscitation or more cardiac squeeze). Of course, I use them in pulm hypertensive patients if I'm actively titrating vasodilatory medications.

I think there is still a role for them. I'm using the LiDCO a lot, too.

Like most things in medicine, I feel the truth is somewhere in the middle: The catheter itself doesn't necessarily reduce mortality, but just because that has been the apparent result in academic studies, it shouldn't preclude an experienced (with SG catheters) intensivist using them in certain circumstances in certain patients. To be dogmatic about them one way or the other, I think, is the only mistake.
 
emergiQ said:
This is one of the 3rd rails of medicine (meaning, there's no consensus).

The data do not support the claim that SG catheters reduce mortality. So, if that's your only factor in choosing an intervention or therapy (more on this below), then that would be that.

But, of course, there's more to the story. Many folks question the validity of applying the "benefit of reduced mortality" litmus test to something that is a monitoring device rather than a therapy. Others point out that a SG catheter might have more utility in the hands of an experienced operator, or at least someone who knows what to DO with the data.
.
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I actually was of the opinion that using mortality as the outcome was not the appropriate endpoint. But what do I know? Im surprized that you brought that up in your argument.

I had also heard the specific point that clinicians don't really know what to do with the data, so clinical decisions are made on faulty interpretation or current understanding of the physiology. The next step to that line of thinking was to throw the baby out with the bath water, and not use swans at all... to stop clnicians from treating the swan-ganz rather than the patient. Obviously, I think we need to refine our understanding of its use.
 
howelljolly said:
I actually was of the opinion that using mortality as the outcome was not the appropriate endpoint. But what do I know? Im surprized that you brought that up in your argument.
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I brought it up just to point out the controversial part. Personally, I don't think mortality is a relevant end point for a monitoring device. But others would argue with me, so I bring it up to point out its contentious, and to try and be objective.

howelljolly said:
I had also heard the specific point that clinicians don't really know what to do with the data, so clinical decisions are made on faulty interpretation or current understanding of the physiology. The next step to that line of thinking was to throw the baby out with the bath water, and not use swans at all... to stop clnicians from treating the swan-ganz rather than the patient. Obviously, I think we need to refine our understanding of its use.
Click to expand...

It's tough to "re"-define something when it has never been, well... defined :) That's the point -- there is no definition as to when to use it. I would like to see the study that examines its use and controls for experienced operators (say, clinicians who do at least 20 per year). I think then we would see some surrogate markers improve (such as time off pressors, volume and timing of resuscitive fluids, etc.).

I don't think that experienced-with-its-use clinicians make faulty interpretation of this data any more or less then most other data we get in medicine including data from monitoring devices (pressure from A-lines, ICP pressures from intracranial monitoring) as well as laboratory tests (what to do with a high white count in someone not acting infected? What to do with renal insufficiency?).

This is the 'art' of medicine. Personally, I am *GLAD* that there are issues, tests, and monitoring devices that cause controversy. I loathe cook-book medicine -- I like when we have to interpret data and use judgement when the obvious choice is not apparent. It's one of the things that pulled me to ICU and ER medicine, since those are two of the most common areas where you have to make a judgement call without all the information. It also puts you at risk of being scrutinized by the retrospectoscope from your colleagues, but I have a pretty thick skin :)
 
With this new age of evidence based medicine, I see the logical, though far-off endpoint to be cookbook medicine. It takes clinical intuition, judgement, and anecdotal experience out of the equation. Take a look at the Paramedic protocols for Canada. (search SDN for evidence based medicine AND paramedics) They have advanced autonomous protocols like we have in Manhattan, but they can quote every RCT thats ever been done off the top of their head.

Are you an EM/CCM? If so, Ive got a question that Ill PM to you.
 
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