Acuity of the NICU vs ER

[PrideOrPanthers]

Hi,

3rd year student thinking of going into peds because I love working with kids. I got to rotate through the peds ER but with COVID it’s hard to get into the NICU(understandably so). Just wondering how the acuity of the NICU compares to that of the ED, and if someone could compare/contrast the typical month of these two subspecialties, I would greatly appreciate it.

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[NurWollen]

Hi,

3rd year student thinking of going into peds because I love working with kids. I got to rotate through the peds ER but with COVID it’s hard to get into the NICU(understandably so). Just wondering how the acuity of the NICU compares to that of the ED, and if someone could compare/contrast the typical month of these two subspecialties, I would greatly appreciate it.

They both have high acuity, but in different ways. Peds EM is lots of very routine, non-acute peds stuff, like URIs, rashes, minor lacs, viral gastro, but punctuated with the occasional really, really sick kid. Sepsis, trauma, etc.

While NICU does have some bread and butter, feeder-grower type babies, I would say the percentage of really sick patients is much, much higher in NICU. I'm a first-year NICU fellow, obviously I love the NICU, but I'm still blown away by how critical some of these patients are. It's not for the faint of heart.

 

[FrkyBgStok]

and I am in ER which I love, but I agree with nurwollen. it is a different kind of acuity. I would say they are very similar in a sense that a good chunk of what we do is probably not "super high" acuity. but while nurwollen has to think of all the things affected in this super sick baby after stabilization, I have to think very fast about what this child needs right now, get them to the picu, and then move onto the next patient. Not saying that it is better than NICU, but I never follow gasses every 2 hours or make a decision between conventional mechanical ventilation, oscillation, or a hybrid vent.

the nicu is high acuity and there are times when one infant will take 5-6 hours of dedicated brain power. that just doesn't happen in the ED.

And maybe my words did a bad job explaining. I absolutely respect the work that the NICU does. i don't want to start an argument and hopefully people read that as an illustration and not an attack.

 

[PrideOrPanthers]

They both have high acuity, but in different ways. Peds EM is lots of very routine, non-acute peds stuff, like URIs, rashes, minor lacs, viral gastro, but punctuated with the occasional really, really sick kid. Sepsis, trauma, etc.

While NICU does have some bread and butter, feeder-grower type babies, I would say the percentage of really sick patients is much, much higher in NICU. I'm a first-year NICU fellow, obviously I love the NICU, but I'm still blown away by how critical some of these patients are. It's not for the faint of heart.

Thanks for responding ! What is a typical month like for you and for the attendings?

 

[PrideOrPanthers]

and I am in ER which I love, but I agree with nurwollen. it is a different kind of acuity. I would say they are very similar in a sense that a good chunk of what we do is probably not "super high" acuity. but while nurwollen has to think of all the things affected in this super sick baby after stabilization, I have to think very fast about what this child needs right now, get them to the picu, and then move onto the next patient. Not saying that it is better than NICU, but I never follow gasses every 2 hours or make a decision between conventional mechanical ventilation, oscillation, or a hybrid vent.

the nicu is high acuity and there are times when one infant will take 5-6 hours of dedicated brain power. that just doesn't happen in the ED.

And maybe my words did a bad job explaining. I absolutely respect the work that the NICU does. i don't want to start an argument and hopefully people read that as an illustration and not an attack.

I can’t speak for anyone else but I didn’t read that as you throwing shade at the NICU or anything just highlighting differences, I appreciate the response !

 

[oldbearprofessor]

and I am in ER which I love, but I agree with nurwollen. it is a different kind of acuity. I would say they are very similar in a sense that a good chunk of what we do is probably not "super high" acuity. but while nurwollen has to think of all the things affected in this super sick baby after stabilization, I have to think very fast about what this child needs right now, get them to the picu, and then move onto the next patient. Not saying that it is better than NICU, but I never follow gasses every 2 hours or make a decision between conventional mechanical ventilation, oscillation, or a hybrid vent.

the nicu is high acuity and there are times when one infant will take 5-6 hours of dedicated brain power. that just doesn't happen in the ED.

And maybe my words did a bad job explaining. I absolutely respect the work that the NICU does. i don't want to start an argument and hopefully people read that as an illustration and not an attack.

I didn't see any attack in this, I think it's a fair description. A huge difference is that NICU work includes rounding and chronic care as well as the occasional (well, sometimes frequent) high drama moments. Some folks don't like that, others do. Also, remember that we are caring for different populations of children.

As far as the usual NICU day, it's like any other ward environment except compared to a general ward the patients are sicker and there are more interruptions for emergencies/deliveries. So, it's prerounds (less so for attendings, but we sign in and check labs too...), rounds, admissions, family meetings, educational conferences and that gets us to about 2 pm! Then it's note writing, dealing with problems, checking back in on sick babies and teaching (if in a teaching environment) before sign-out.

 

[PrideOrPanthers]

I didn't see any attack in this, I think it's a fair description. A huge difference is that NICU work includes rounding and chronic care as well as the occasional (well, sometimes frequent) high drama moments. Some folks don't like that, others do. Also, remember that we are caring for different populations of children.

As far as the usual NICU day, it's like any other ward environment except compared to a general ward the patients are sicker and there are more interruptions for emergencies/deliveries. So, it's prerounds (less so for attendings, but we sign in and check labs too...), rounds, admissions, family meetings, educational conferences and that gets us to about 2 pm! Then it's note writing, dealing with problems, checking back in on sick babies and teaching (if in a teaching environment) before sign-out.

Thank you for the response. I like working with the little ones that are sicker, provided we can make them better. Especially with neonates , I feel like the gratification you get from helping them is almost unmatched by any field. Would you see a majority of the little ones in your NICU, you are able to help get better?

 

[oldbearprofessor]

Thank you for the response. I like working with the little ones that are sicker, provided we can make them better. Especially with neonates , I feel like the gratification you get from helping them is almost unmatched by any field. Would you see a majority of the little ones in your NICU, you are able to help get better?

Well, we certainly have our share of bad outcomes, but most of our patients i'd like to think do fairly well. Certainly those over 26 weeks or so gestation do very well, with poorer outcomes as you get in the smallest groups (esp < 24 weeks). Some thing like congenital anomalies aren't things we can make "better" but we can help get the families the resources they need. Overall, it is a very satisfying career but certainly has some bad outcomes.

 

[Stone Cold]

They both have high acuity, but in different ways. Peds EM is lots of very routine, non-acute peds stuff, like URIs, rashes, minor lacs, viral gastro, but punctuated with the occasional really, really sick kid. Sepsis, trauma, etc.

While NICU does have some bread and butter, feeder-grower type babies, I would say the percentage of really sick patients is much, much higher in NICU. I'm a first-year NICU fellow, obviously I love the NICU, but I'm still blown away by how critical some of these patients are. It's not for the faint of heart.

Might be slightly off-topic but what made you choose NICU over others? I'll be applying for fellowships next year but still having a hard time trying to decide NICU vs PICU since I liked both except that NICU has more bread&butter stuff over PICU

Secondly, there a way more NICU fellowship programs out there over PICU but what I'm hearing from attendings is NICU market is kinda getting saturated similar to Peds Cards. Compensation doesn't matter since PICU, NICU & P-Cards almost pay on a similar level

 

[Step Up]

Might be slightly off-topic but what made you choose NICU over others? I'll be applying for fellowships next year but still having a hard time trying to decide NICU vs PICU since I liked both except that NICU has more bread&butter stuff over PICU

Secondly, there a way more NICU fellowship programs out there over PICU but what I'm hearing from attendings is NICU market is kinda getting saturated similar to Peds Cards. Compensation doesn't matter since PICU, NICU & P-Cards almost pay on a similar level

One factor that swayed me towards neonatology is the job market. There are more neonatologists than any other pediatric subspecialty. With my spouse having a job with significant location restrictions, that factor was worth considering highly for me. I also liked the balance of acuity and periods where it's not that busy. I grew to like the physiology. The schedule/lifestyle. The relatively simple notes/charting. The outcomes. The procedures...

 

[FrkyBgStok]

I would agree with the above. In the ED, there may be some minor differences between volumes and institutional styles, but most EDs are very similar and the jobs are very similar, as in every place has 8 or 12 hour shifts, every place has rotating schedules, every place sees the same pathology generally speaking. there is no variety in practices like NICU. I am not in it, but I have personally seen 3 completely different practice styles where there is a scheduled rotation, a hospitalist type model with random days here and there, and a 6a-5p rotation with NNPs overnight. I have also heard of countless other practice models where each neonatologist follows their own patients as long as they are there and there a many practice situations. you can get a job in a quaternary type hospital or you can be the neo in a small hospital only dealing with 32 weeks and later. there are so many practice options available for NICU that even if you moderately liked the field, you could find a practice model that would make you love it.

 

[Stone Cold]

One factor that swayed me towards neonatology is the job market. There are more neonatologists than any other pediatric subspecialty

Doesn't having more neos saturate the market which is what the current situation looks like! While cards attendings advised against a cards fellowship unless I feel I can't pursue anything other than cards, NICU folks only talked about saturation with more NICU fellows graduating every year

I'm an IMG currently in a community based residency but I intend to get into a major university based fellowship. How competitive do you think NICU is when compared to PICU despite the later having fewer fellowship programs, particularly when you're aiming for a top notch one?

Lastly, how is the compensation for both fields be it in academic centers, major hospital systems like Kaiser/Sutter, PP groups and if you're comfortable sharing yours (be as specific or non-specific as you'd like). Do most opportunities have a base salary until you meet the minimum requirement and then goes on to "eat what you kill", RVU based etc

 

[Step Up]

Doesn't having more neos saturate the market which is what the current situation looks like! While cards attendings advised against a cards fellowship unless I feel I can't pursue anything other than cards, NICU folks only talked about saturation with more NICU fellows graduating every year

I wasn't aware of this, but perhaps it is true. I just meant there is a NEED for more neonatologists than any other peds subspecialist. As FrkyBgStok described, as a neonatologist, you have the flexibility to work in smaller hospitals if interested.

 

[NurWollen]

Might be slightly off-topic but what made you choose NICU over others? I'll be applying for fellowships next year but still having a hard time trying to decide NICU vs PICU since I liked both except that NICU has more bread&butter stuff over PICU

Secondly, there a way more NICU fellowship programs out there over PICU but what I'm hearing from attendings is NICU market is kinda getting saturated similar to Peds Cards. Compensation doesn't matter since PICU, NICU & P-Cards almost pay on a similar level

I choose NICU for a few reasons. I went in to medicine partly for the intellectual challenge, the critical care aspects of the NICU really do that for me. I also like that on one hand, I get to apply complex physiology to patient care with the really sick patients, while at the same time getting to enjoy caring for the less-sick patients who need a little breathing or feeding help but who are most likely going to do just fine.

I hadn't heard that about the market getting saturated. None of my mentors gave me any warnings about that. I'm not saying it's not true, but I still know of plenty of places that are hiring, even in fairly desirable places. That said, the market could be totally tanked by the time I'm looking for a job in 2+ years, as far as I know, so I'm going to be focusing on making myself as competitive as I can to potential employers. Also, remember, while there are a lot more NICU spots than there are, say, PICU spots or peds cardiology spots, there are also a lot of NICUs out there. Pick a random community hospital, and there's a good chance they have at least a level II nursery there. Unless it's a large academic center or large regional center, there's probably not a PICU or peds CVICU or peds subspecialty services.

Lastly, as far as choosing PICU, it's a great field and PICU attendings are amazing, but don't think there's no bread and butter. You'll have bronchiolitis and asthma patients every single day for much of the year there.