Anesthesia to Pulm Crit?

[flabbergabber]

Hey all,

MS4 here applying to anesthesia. I loved both SICU and MICU as an MS4, but to be completely honest, MICU beat SICU by miles, the main difference being the sense of ownership being greater in MICU.

I know the ED - > PCCM pathway was recently created. Is there any possibility of there being an anesthesia -> PCCM fellowship pathway being approved in the next 5 or so years? What would the barriers be? I was initially surprised when I learned about the ED->PCCM route (it seems like ED gets to do all sorts of fellowships?!), while I would argue that anesthesiologists would also be similarly qualified to train in PCCM.

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[psychbender]

There is no ED-->PCCM pathway that doesn't involve doing an IM residency. There is an EM-->CCM pathway that just involves doing a two year CCM fellowship (sponsored by either ABIM or ABA).

Anesthesiologists also do critical care fellowships, and can work in more MICU-type environments. My little community shop is much more a MICU than a SICU, by far. The problem is, as has been said before, the job market. There are private Anes/CC jobs, but they are not common and spread out. Most academic Anes/CC jobs involve mainly SICU, Neuro ICU, or CVICU coverage, with Pulm having a lock on academic MICUs (there are always exceptions, though).

 

[fakin' the funk]

I work in a closed mixed med/surg ICU. My fellowship was MICU heavy so it is a tad closer to my comfort zone than if I'd done one of the CTICU/SICU heavy fellowships. We all have a lot to teach each other, it usually comes down to the group or hospital's culture and history more than anything else.

 

[deleted171991]

Hey all,

MS4 here applying to anesthesia. I loved both SICU and MICU as an MS4, but to be completely honest, MICU beat SICU by miles, the main difference being the sense of ownership being greater in MICU.

I know the ED - > PCCM pathway was recently created. Is there any possibility of there being an anesthesia -> PCCM fellowship pathway being approved in the next 5 or so years? What would the barriers be? I was initially surprised when I learned about the ED->PCCM route (it seems like ED gets to do all sorts of fellowships?!), while I would argue that anesthesiologists would also be similarly qualified to train in PCCM.

It's about the ABA, not qualifications. The ABA doesn't have a deal with the ABIM, like the ABEM does.

Of course one is more than qualified to run a community MICU after doing a good anesthesiology-CCM fellowship (mine included 3 months of MICU, not including the nights when I was covering it, too). The problem is not with the fellowship, is with getting a good MICU job. Internists are pretty territorial when about the MICU (are they afraid of us being better?), even in community hospitals. If they take anesthesiologists, you can bet it's a job most internists wouldn't want.

So, if you want MICU, you are on the bad track, buddy. IM-CCM is the same total number of years as Anesthesiology-CCM, except it opens many more doors. I hope you have a very good reason for choosing a residency in anesthesiology. This is the right choice if you want to do cardiac anesthesia + CCM, otherwise it's dumb.

I would do an extra year of MICU-only fellowship in a heartbeat, if that allowed me to be ABIM-boarded in CCM (I love critical care enough to not care about an extra year of training even after years as an attending). There is more than one reason that pathway doesn't exist.

 

[flabbergabber]

It's about the ABA, not qualifications. The ABA doesn't have a deal with the ABIM, like the ABEM does.

Of course one is more than qualified to run a community MICU after doing a good anesthesiology-CCM fellowship (mine included 3 months of MICU, not including the nights when I was covering it, too). The problem is not with the fellowship, is with getting a good MICU job. Internists are pretty territorial when about the MICU (are they afraid of us being better?), even in community hospitals. If they take anesthesiologists, you can bet it's a job most internists wouldn't want.

So, if you want MICU, you are on the bad track, buddy. IM-CCM is the same total number of years as Anesthesiology-CCM, except it opens many more doors. I hope you have a very good reason for choosing a residency in anesthesiology. This is the right choice if you want to do cardiac anesthesia + CCM, otherwise it's dumb.

I would do an extra year of MICU-only fellowship in a heartbeat, if that allowed me to be ABIM-boarded in CCM (I love critical care enough to not care about an extra year of training even after years as an attending). There is more than one reason that pathway doesn't exist.

This was awesome - thank you. I still would rather take being in the OR vs having to do clinic or medicine wards anyway. I have no qualms (for now) about going into anesthesiology. I'm just being selfish in preferring an academic OR/MICU mix rather than OR/CVICU mix.

Is there any possibility of lobbying the ABA to create a pathway with ABIM? With all the concern about CRNA among medical students, having another setting to practice in and differentiating MDs from CRNAs seems like it would be good for the field. Like you said, even practicing attending anesthesiologists out there might be interested in this path.

 

[psychbender]

ABIM has no reason to certify anesthesiology-trained intensivists. They created the EM pathway to attract EM grads, as there was sizeable new interest in that group, with no other board providing certification for them at the time. It was a strategic decision to attract more warm bodies into their programs. ABA then did much the same thing, programs are opening or expanding, but the same number of anesthesiology residents are applying. They need to fill those spots somehow. The only anesthesiologists I know who are certified in critical care through ABIM were internists before doing anesthesiology. I do wonder, however, about some of the programs like Wake Forest's that is certified through ABIM, but accepts anesthesiologists.

Fakin' do you work in the OR, too, or straight CCM? What part of the country?

 

[bigdan]

OP -

Why don't you look into this type of training? The American Board of Anesthesiology - Internal Medicine & Anesthesiology

You would have board eligibility in two fields of medicine at the end of your training, and could pick from fellowship training in one or the other as the time comes.

One caveat (and maybe times have changed, but...): LOTS AND LOTS of medical students say they "really want to do critical care" after anesthesia. And then they apply to pain fellowships.

Either way, good luck in whatever you choose. I did CCM fellowship, and love it!

 

[Mman]

MS4 here applying to anesthesia. I loved both SICU and MICU as an MS4, but to be completely honest, MICU beat SICU by miles, the main difference being the sense of ownership being greater in MICU.

Your love of the MICU will quickly fade away as you go through an anesthesia residency

 

[deleted171991]

OP -

Why don't you look into this type of training? The American Board of Anesthesiology - Internal Medicine & Anesthesiology

You would have board eligibility in two fields of medicine at the end of your training, and could pick from fellowship training in one or the other as the time comes.

One caveat (and maybe times have changed, but...): LOTS AND LOTS of medical students say they "really want to do critical care" after anesthesia. And then they apply to pain fellowships.

Either way, good luck in whatever you choose. I did CCM fellowship, and love it!

But you didn't do JUST a or any CCM fellowship, "big" brother! You are not the rule: you have a strong "pedigree" in a lot of things.

 

[deleted171991]

Your love of the MICU will quickly fade away as you go through an anesthesia residency

It will probably increase. Anybody who really loves CCM prefers a closed ICU, instead of dealing with quasi-amateurs every day.

 

[GravelRider]

Just do IM->PCCM. It’s the best of all options presented if you want a career in critical care. There are way more jobs in critical care for PCCM. The only way to get the pulmonary component is via IM. You will be triple board certified in IM, Pulm, and CCM. You can even throw sleep medicine on for an extra year if you want variety. Pulm is a nice field for when you want some clinic time outside the ICU and for when you want to slow down in the later stages of your career.

It’s hard for me to recommend anesthesia for a student primarily interested in critical care at the present moment.

 

[CCM-MD]

I am IM-CCM and I used to work with an anes-CCM in a community hospital that saw a mix of Med/Surg/Card/Neur patients. Primarily MICU style patients. He was doing 100% CCM at the time but went to doing 100% anesthesia after some time. Turns out he was doing it to satisfy a visa requirement to obtain his green card.

There were definitely practice differences between him and the rest of the physicians in our group who were IM trained. His reasons for not doing CCM anymore: #1 OR paid the same for less work; #2 he felt like he was dealing with disease pathologies he was not interested in dealing with (I think it was because he was not comfortable with it, but he would never admit it); #3 our hospital did not have the best consulting physicians for “back-up”.

The reality is most community ICUs are MICU heavy. IM trained/IM-CCM probably have an edge but I believe that this is something an interested anesthesiologist could overcome with some effort.

Agree that Pulm-CCM probably leads to the most opportunities but who knows what the future holds - looks like things may be changing.

No matter what path you choose, it’s extremely important to train in a fellowship that gives you exposure to all types of ICU patients. I tell aspiring IM-CCM and Pulm-CCM guys the same thing. And you want to make sure that when you are rotating through the different units, you get to be the primary guy and aren’t hanging out on the sidelines - this is also very important.

 

[MoMoGesiologist]

This may be a silly question, but what is so different about the IM-CCM training? Heme/onc is on board for all the cancer patients, GI is on board for the liver patients, etc. Don't they just consult specialty services same as anes-CCM once it moves beyond just keeping the patient alive with vent and pressors?

 

[Mman]

It will probably increase. Anybody who really loves CCM prefers a closed ICU, instead of dealing with quasi-amateurs every day.

anybody that loves anesthesia wants nothing to do with MICU style management of patients. (I just love some septic patients with norepi going through a 22 g IV and no CVP or art line in a patient). So if somebody wants to be in a MICU, they will be suffering during anesthesia residency.

 

[deleted171991]

anybody that loves anesthesia wants nothing to do with MICU style management of patients. (I just love some septic patients with norepi going through a 22 g IV and no CVP or art line in a patient). So if somebody wants to be in a MICU, they will be suffering during anesthesia residency.

That's a very broad generalization. Where I trained, the MICU patients had the same standard of care as the SICU ones (same criteria for A-lines, central lines etc.). As an attending, nothing stops you from putting in a line, except for laziness or incompetence (which are the usual culprits in the medical world).

I agree, though, that people who like to be captain of the ship will have a VERY hard time in anesthesia, both as residents and attendings. One simply cannot have an ego in anesthesia, or one will get into trouble in every job. Beyond the OR culture that the surgeon is the captain of the ship, there are many anesthesiologists who went into the specialty because they were literally lazy/greedy/low-scoring (especially in the 90's), and also don't like to deal with the parts of patient care that don't bring them (the same amount of) money (e.g. PACU, ICU). Because of this, in some places, the surgeon has the last say, by local culture, even in the PACU. That can get very annoying very fast, because most surgeons simply lack the medical knowledge necessary to deal with medical conditions at the same level as an internist (while those of us who love internal medicine don't). Just a few days ago, the PACU nurses wrote a note about a patient that simply did not mention my significant input, just the surgeon, as if I hadn't even been there. And it's not that we are not friendly; it's how they see the world. You are the surgeon's consultant (in the best case scenario), and as relevant as the surgeons make you.

I have a favorite anecdote to tell students who are trying to choose between IM and anesthesia, and are wondering about the status difference. When I was a CA-3, a cleaning person bumped into me, in the OR, as he was turning around the corner while talking on the phone. Not only did he not apologize, but he had the nerve to chastise me for "not paying attention and not apologizing to him right there and then". He was also younger than me. At the same time, while I was a medical INTERN, patients regularly identified me as their DOCTOR, and their faces literally lit up when seeing me in the morning (still happens in the ICU as an attending, and much more rarely in anesthesia - the doctor part).

So if money is very important, anesthesia wins. If status is important, and the feeling of having done something meaningful at the end of the day, IM wins, hands down. As an internist, you may not get a lot of respect when consulting on a surgical floor, but, on the medical ones, the buck stops with you. Just expect more work for less money (at least currently).

 

[chocomorsel]

IM CCM is better received in America. However, I am interviewing for a MICU position in a couple of weeks, and just interviewed for a mixed bag CCM position covering both surgical, medical and CV ICU patients as a gas doc. Doors are opening my friend. People are realizing that intensivists come from varied back grounds.

 

[CCM-MD]

Just expect more work for less money (at least currently).

This is what the bitter truth is for CCM. It’s hard work, long hours, sick patients, many tough conversations - all leading to high burnout. As good as 7 on/off or some other form of “shift work” sounds it isn’t that lifestyle friendly. There’s many easier ways to make the same amount of money - especially for anesthesiologists. Jobs will probably always be plenty because of the above reasons - so I wouldn’t worry about that. Being able to sustain CCM for a career is definitely something to think about - needs a special kind of personality.

 

[IMGASMD]

A lot of good points all have been brought up. The most important factor may be OP’s personality. Do you actually enjoy prolong patient care? All day, every day you’re on? Do you enjoy the ownership of the patient? Sometimes, not just one week on, one week off, they’re essentially yours for a long long time? Do you enjoy having family conversations, end of life discussions?

I did IM, I enjoyed my CCM months during residency. Many, many people asked why don’t I just stay in IM and do Pulm-CCM.... I didn’t. Instead I entered an anesthesia residency.

I moonlight at a rural hospital with a small ICU, twice a month as a nocturnist. Do I miss medicine? Sometime. I do miss the interaction with patients, families, and yes, respect from patients and staff. But I don’t miss the rounding and asking nurses/supporting staff to do things for me. In OR, I do and I give whatever is necessary. In medicine, I wait. Sure I can do it myself, but i don’t have access to Pyxis. I don’t want to step on my ICU nurses toes. I am also much less aggressive with my airway management, because that’s just not how medicine does things. The personality of two fields are very different, and people working in them are different as well, is the best way that I can explain it.

In conclusion, good luck OP, I wish you find a way to satisfy your life needs. Also realize, I don’t think anyone love their job 100% of the time. There are always parts that I wish I don’t have to do. Pasture is always greener on the other side, because we always focus on the good parts that we enjoy, no one ever talks about the mundane, uninteresting or straight up fu@k up part of their jobs.

 

[MoMoGesiologist]

A lot of good points all have been brought up. The most important factor may be OP’s personality. Do you actually enjoy prolong patient care? All day, every day you’re on? Do you enjoy the ownership of the patient? Sometimes, not just one week on, one week off, they’re essentially yours for a long long time? Do you enjoy having family conversations, end of life discussions?

I did IM, I enjoyed my CCM months during residency. Many, many people asked why don’t I just stay in IM and do Pulm-CCM.... I didn’t. Instead I entered an anesthesia residency.

I moonlight at a rural hospital with a small ICU, twice a month as a nocturnist. Do I miss medicine? Sometime. I do miss the interaction with patients, families, and yes, respect from patients and staff. But I don’t miss the rounding and asking nurses/supporting staff to do things for me. In OR, I do and I give whatever is necessary. In medicine, I wait. Sure I can do it myself, but i don’t have access to Pyxis. I don’t want to step on my ICU nurses toes. I am also much less aggressive with my airway management, because that’s just not how medicine does things. The personality of two fields are very different, and people working in them are different as well, is the best way that I can explain it.

In conclusion, good luck OP, I wish you find a way to satisfy your life needs. Also realize, I don’t think anyone love their job 100% of the time. There are always parts that I wish I don’t have to do. Pasture is always greener on the other side, because we always focus on the good parts that we enjoy, no one ever talks about the mundane, uninteresting or straight up fu@k up part of their jobs.

Trying not to step on nurses toes is something I think that takes up waaay too much time and energy in medicine

 

[IMGASMD]

Trying not to step on nurses toes is something I think that takes up waaay too much time and energy in medicine

Medicine in general or in Internal Medicine? I think we do spent too much time not to hurt anyones feelings, this includes LPN all the way to DNP. But isn’t that the culture we live in?

We have a few very seasoned CRNA, practiced almost as long as I have been alive. The other day, I, the newly minted attending, was complemented by one of them for telling another one to just intubate a whale for a quick gyn procedure. Obviously, it took longer than they thought. And it was for a whale.

“O, if it was me, I’d just do it under MAC.”
“I’d prefer we just tube her...”
“Whatever you want, she’s your patient.....”

Yes I do know what I am doing, crNa. <the little voice in my head>

 

[IMGASMD]

Not for nothing. Here is a bad call for CCM can look like.
You may not have to stay in house, but get called in for an admission. That takes an hour or two. Patient finally stabilized. There is a code blue, in your unit. You ran the code for an hour. Patient dead. Now you need to call family, do discharge summary, debrief your icu staff. At the same time, other nurses see you there, started to ask for orders. The family arrives, you spent time to talk to them. All while making sure your nurses are okay with the unexpected death. Oh, it’s 6am. Your night is gone, and you’re still up dealing with all the administrative and emotional issues of everyone else.

Anesthesia bad call. Stays in house 24 hours. Late room didn’t get done until 11pm. You finally walks to your call room. At 1am, L&D called for an epidural. You go, struggle for 45 mins. Finally got it. OR called, there is ischemic bowel on a 90 yo. You never get bp under control, unfortunately, patient expired on the table. You ran the code, of course, surgeon is standing there without breaking scrub, because he can. You go talk to the family with or without surgeon. You get all the blame and/or your blame yourself. Oh it’s 6am. You go home and tomorrow is another day.

I don’t know if I conveyed what I am trying to say in these two scenarios. CCM your ARE the captain, everyone looks at you for direction. You have to make sure all your soldiers are okay at end of the day. Also the family looks at you for direction and comfort. You can not leave that for anyone else, because you’re it. Your nurses, your support staff look up to you and you don’t want to let them down. You get the glory and all other junk.

Anesthesia is different. You’re playing second fiddle. Sure you can make sure your OR nurses are okay. But usually they don’t give much thought about how you look at them, they certainly don’t need any comfort from you. You get ALL the blames when things go wrong, but you shoulder that all by yourself. You certainly won’t get any glory for getting any patient through any difficult surgeries. Biggest take away for here is, you don’t have to give a crap about how THEY (nurse, staff, surgeon, even family) feel unless you want to. You don’t have to carry anyone else’s baggage other than your own.

Maybe I just “feel” too much, so CCM is not really my gig.

 

[deleted547339]

anybody that loves anesthesia wants nothing to do with MICU style management of patients. (I just love some septic patients with norepi going through a 22 g IV and no CVP or art line in a patient). So if somebody wants to be in a MICU, they will be suffering during anesthesia residency.

It’s funny how different peoples practice styles are and how if you do it differently than someone else, they do it wrong.

The number of medical patients who need art lines is extremely small and peripheral pressors have more and more data showing safety while CVLs have a measurable infection/mortality rate. Do whatever you want in the OR, but understand that someone may do something different that isn’t necessarily wrong.

 

[deleted547339]

Not for nothing. Here is a bad call for CCM can look like.
You may not have to stay in house, but get called in for an admission. That takes an hour or two. Patient finally stabilized. There is a code blue, in your unit. You ran the code for an hour. Patient dead. Now you need to call family, do discharge summary, debrief your icu staff. At the same time, other nurses see you there, started to ask for orders. The family arrives, you spent time to talk to them. All while making sure your nurses are okay with the unexpected death. Oh, it’s 6am. Your night is gone, and you’re still up dealing with all the administrative and emotional issues of everyone else.

Anesthesia bad call. Stays in house 24 hours. Late room didn’t get done until 11pm. You finally walks to your call room. At 1am, L&D called for an epidural. You go, struggle for 45 mins. Finally got it. OR called, there is ischemic bowel on a 90 yo. You never get bp under control, unfortunately, patient expired on the table. You ran the code, of course, surgeon is standing there without breaking scrub, because he can. You go talk to the family with or without surgeon. You get all the blame and/or your blame yourself. Oh it’s 6am. You go home and tomorrow is another day.

I don’t know if I conveyed what I am trying to say in these two scenarios. CCM your ARE the captain, everyone looks at you for direction. You have to make sure all your soldiers are okay at end of the day. Also the family looks at you for direction and comfort. You can not leave that for anyone else, because you’re it. Your nurses, your support staff look up to you and you don’t want to let them down. You get the glory and all other junk.

Anesthesia is different. You’re playing second fiddle. Sure you can make sure your OR nurses are okay. But usually they don’t give much thought about how you look at them, they certainly don’t need any comfort from you. You get ALL the blames when things go wrong, but you shoulder that all by yourself. You certainly won’t get any glory for getting any patient through any difficult surgeries. Biggest take away for here is, you don’t have to give a crap about how THEY (nurse, staff, surgeon, even family) feel unless you want to. You don’t have to carry anyone else’s baggage other than your own.

Maybe I just “feel” too much, so CCM is not really my gig.

Dude, when a 90yo with dead gut dies, it means your surgeon doesn’t have the balls to tell a family he won’t operate on a dead person - it doesn’t mean you did anything wrong.

 

[Mman]

The number of medical patients who need art lines is extremely small and peripheral pressors have more and more data showing safety while CVLs have a measurable infection/mortality rate. Do whatever you want in the OR, but understand that someone may do something different that isn’t necessarily wrong.

The morbidity from infiltrated vasopressors is not exactly trivial. And please note I never said someone else was wrong, merely pointing out why someone enjoying anesthesia would not take kindly to MICU management.

 

[CCM-MD]

I’m IM trained and I don’t use peripheral vasopressors - especially not through an itty bitty 22g peripheral IV line.

 

[deleted171991]

It’s funny how different peoples practice styles are and how if you do it differently than someone else, they do it wrong.

The number of medical patients who need art lines is extremely small and peripheral pressors have more and more data showing safety while CVLs have a measurable infection/mortality rate. Do whatever you want in the OR, but understand that someone may do something different that isn’t necessarily wrong.

Respectfully, no ICU patient who needs pressor titration should have his arm squeezed every 5 minutes or so for many hours. Also, if the patient will need regular ABGs, please respect the darn artery, and put in a line.

Also, NO studies on peripheral pressors (which I am a HUGE fan of) support the idea of short IV catheters (i.e. less than 2 inch-long) and have entire protocols set up in case the line gets infiltrated, many times with vasodilators at bedside. Most MICUs, (read ALL) I have seen crappy setups in, have no idea how to fix a norepi extravasation when it happens, putting patients in harm's way big time.

Btw, since septic shock is way more frequent and severe in the MICU, I would argue that A-lines and central lines are actually needed more than in the SICU. I can't stand surgeons who think everybody needs a procedure, but you simply cannot defend not having those lines in the MICU, no offense. Especially an A-line, which takes 5 minutes, and will save a lot of poking the patient's arteries and veins. And I am also half MICU-trained.

 

[deleted171991]

The morbidity from infiltrated vasopressors is not exactly trivial. And please note I never said someone else was wrong, merely pointing out why someone enjoying anesthesia would not take kindly to MICU management.

Except for phenylephrine.

 

[CCM-MD]

Respectfully, no ICU patient who needs pressor titration should have his arm squeezed every 5 minutes or so for many hours. Also, if the patient will need regular ABGs, please respect the darn artery, and put in a line.

Also, NO studies on peripheral pressors (which I am a HUGE fan of) support the idea of short IV catheters (i.e. less than 2 inch-long) and have entire protocols set up in case the line gets infiltrated, many times with vasodilators at bedside. Most MICUs, (read ALL) I have seen crappy setups in, have no idea how to fix a norepi extravasation when it happens, putting patients in harm's way big time.

Btw, since septic shock is way more frequent and severe in the MICU, I would argue that A-lines and central lines are actually needed more than in the SICU. I can't stand surgeons who think everybody needs a procedure, but you simply cannot defend not having those lines in the MICU, no offense. Especially an A-line, which takes 5 minutes, and will save a lot of poking in the patient's arteries and veins.

Rare to see a case of norepinephrine extravasation but you only need to see one to remember it for life.

Every intensivist I have encountered since I started training runs pressors through central lines, IM trained or not makes no difference. Not everyone has the same threshold for putting in an Art line, however.

 

[deleted171991]

Not for nothing. Here is a bad call for CCM can look like.
You may not have to stay in house, but get called in for an admission. That takes an hour or two. Patient finally stabilized. There is a code blue, in your unit. You ran the code for an hour. Patient dead. Now you need to call family, do discharge summary, debrief your icu staff. At the same time, other nurses see you there, started to ask for orders. The family arrives, you spent time to talk to them. All while making sure your nurses are okay with the unexpected death. Oh, it’s 6am. Your night is gone, and you’re still up dealing with all the administrative and emotional issues of everyone else.

Anesthesia bad call. Stays in house 24 hours. Late room didn’t get done until 11pm. You finally walks to your call room. At 1am, L&D called for an epidural. You go, struggle for 45 mins. Finally got it. OR called, there is ischemic bowel on a 90 yo. You never get bp under control, unfortunately, patient expired on the table. You ran the code, of course, surgeon is standing there without breaking scrub, because he can. You go talk to the family with or without surgeon. You get all the blame and/or your blame yourself. Oh it’s 6am. You go home and tomorrow is another day.

I don’t know if I conveyed what I am trying to say in these two scenarios. CCM your ARE the captain, everyone looks at you for direction. You have to make sure all your soldiers are okay at end of the day. Also the family looks at you for direction and comfort. You can not leave that for anyone else, because you’re it. Your nurses, your support staff look up to you and you don’t want to let them down. You get the glory and all other junk.

Anesthesia is different. You’re playing second fiddle. Sure you can make sure your OR nurses are okay. But usually they don’t give much thought about how you look at them, they certainly don’t need any comfort from you. You get ALL the blames when things go wrong, but you shoulder that all by yourself. You certainly won’t get any glory for getting any patient through any difficult surgeries. Biggest take away for here is, you don’t have to give a crap about how THEY (nurse, staff, surgeon, even family) feel unless you want to. You don’t have to carry anyone else’s baggage other than your own.

Maybe I just “feel” too much, so CCM is not really my gig.

Let me give you a different perspective.

In anesthesia, almost anything bad that happens to the patient is blamed on you first. Nobody gives you much respect, until the **** hits the fan, then they all expect you to suddenly become the God-Emperor of the OR. If you can do that, they will treat you with SOME respect afterwards, for a while, until their memories fade. It's all smoke and mirrors to them, anyway.

In critical care, almost anything bad is already expected by the family. You also have a different rapport with them. Anything good is considered a result of your medical genius, especially in the MICU. The proof for this is also the lower malpractice risk in CCM versus anesthesia. People can see/read more of your medical thinking (because you have to write notes), so it's much more obvious who's good and whose mouth is just moving air. Half of somebody's image in anesthesia is pure posturing.

The main problem is the f-ed up way critical care is set up in the US, because of all the incompetent internists who can't push a drug. One shouldn't need a code to be able to rapidly push and titrate drugs and stabilize a deteriorating patient, like in the ED or OR, instead of waiting for the pharmacy, nurses etc. There should be a drug cart at the side of every patient. That's the part that I distinctly hate. It has nothing to do with safety (I have never misdosed a patient in 10+ years, and neither have my colleagues), it has to do with the incompetence of many people allowed to work in the ICU (I have had nurses give 10 times the prescribed dose, because, hey, basic math is hard and not required for a job in healthcare). Let's not mention nurses and RTs playing ownership over infusion pumps or ventilators (you are not allowed to touch this or that, even as an attending). Are they friggin' kidding me?

The problem with American medicine is that it has DEGENERATED into this "team" BS, to make the less important (oh, wait, that's not PC, doctor!) healthcare workers feel appreciated. And, as usual, the humanly smaller and less intelligent the person, the bigger the head gets when you give them power, so they will think themselves your equal and behave accordingly. Hence there is a lot of this touchy-feely stuff (they are called "orders", but you actually have to ask them really nicely to actually do their job NOW), where it's OK for nurses to give the MD an attitude, but it's not OK for the doc to call them out on that. Solo anesthesia avoids most of this problem, but I would take the ICU over supervising CRNAs (which is becoming the new norm, more and more) any day.

 

[sandwiches9]

but I would take the ICU over supervising CRNAs (which is becoming the new norm, more and more) any day.

I'm a CA-2 resident. Just out of curiosity, what is so bad about supervising CRNA's? Is it just bad attitude?

 

[IMGASMD]

Dude, when a 90yo with dead gut dies, it means your surgeon doesn’t have the balls to tell a family he won’t operate on a dead person - it doesn’t mean you did anything wrong.

Tell that to the family and see how well that goes. “He’s the only one who will try to save grandpa.....”

 

[MoMoGesiologist]

Let me give you a different perspective.

In anesthesia, almost anything bad that happens to the patient is blamed on you first. Nobody gives you much respect, until the **** hits the fan, then they all expect you to suddenly become the God-Emperor of the OR. If you can do that, they will treat you with SOME respect afterwards, for a while, until their memories fade. It's all smoke and mirrors to them, anyway.

In critical care, almost anything bad is already expected by the family. You also have a different rapport with them. Anything good is considered a result of your medical genius, especially in the MICU. The proof for this is also the lower malpractice risk in CCM versus anesthesia. People can see/read more of your medical thinking (because you have to write notes), so it's much obvious who's good and whose mouth is just moving air. Half of somebody's image in anesthesia is pure posturing.

The main problem is the f-ed up way critical care is set up in the US, because of all the incompetent internists who can't push a drug. One shouldn't need a code to be able to rapidly push and titrate drugs and stabilize a deteriorating patient, like in the ED or OR, instead of waiting for the pharmacy, nurses etc. There should be a drug cart at the side of every patient. That's the part that I distinctly hate. It has nothing to do with safety (I have never misdosed a patient in 10+ years, and neither have my colleagues), it has to do with the incompetence of many people allowed to work in the ICU (I have had nurses give 10 times the prescribed dose, because, hey, basic math is hard and not required for a job in healthcare). Let's not mention nurses and RTs playing ownership over infusion pumps or ventilators (you are not allowed to touch this or that, even as an attending). Are they friggin' kidding me?

The problem with American medicine is that it has DEGENERATED into this "team" BS, to make the less important (oh, wait, that's not PC, doctor!) healthcare workers feel appreciated. And, as usual, the humanly smaller and less intelligent the person, the bigger the head gets when you give them power, so they will think themselves your equal and behave accordingly. Hence there is a lot of this touchy-feely stuff (they are called "orders", but you actually have to ask them really nicely to actually do their job NOW), where it's OK for nurses to give the MD an attitude, but it's not OK for the doc to call them out on that. Solo anesthesia avoids most of this problem, but I would take the ICU over supervising CRNAs (which is becoming the new norm, more and more) any day.

My favorite is when you ask for a pressor dose change or vent change, waste ten minutes to find the nurse or RT and explain why in person, then come back an hour later and it’s not done...

And preemptively, yes I come back to pts bedside more than once an hour, but try asking a nurse or RT to do something twice and feel the tension rising in the air, or sometimes you get focused on a sick patient and assume RN/RT is doing what you ask

 

[MoMoGesiologist]

Also love not being allowed to have phenylephrine at bedside. Sure you can have the crash cart outside the room (with no phenyl sticks in it), but when you just need a bump of phenyl, be ready to wait ten minutes while someone grabs it from the pyxis

 

[Iso4ane]

Also love not being allowed to have phenylephrine at bedside. Sure you can have the crash cart outside the room (with no phenyl sticks in it), but when you just need a bump of phenyl, be ready to wait ten minutes while someone grabs it from the pyxis

Sticks are great when you need that tiny bump to get an arterial line. Bcause they won’t let you start predators without one.

 

[deleted171991]

I'm a CA-2 resident. Just out of curiosity, what is so bad about supervising CRNA's? Is it just bad attitude?

Even those who affirm that they "want to work as part of a team" will get pissed if you micromanage them. And, unfortunately, many times micromanagement is the only thing that prevents mismanagement (for example, untreated intraop relative hypotension, i.e. running a 70 year-old with atherosclerosis at a 50 mmHg lower SBP than his usual). Even the less militant think about themselves as anesthesiologist-lite, and see your role as their go-to resource, helping them only when they want you to, and being their firefighter and lightning rod.

Just the other day I was thinking how abnormal it was that I was doing a BURP maneuver for a CRNA, instead of the other way round. But that's the way it is in most American practices. I have to ask to do the intubation. And if you do take over, you'd better hope that their airway setup is good and you know where it is, and you won't have to wait even for an oral airway, or the suction to work.

 

[nimbus]

Also love not being allowed to have phenylephrine at bedside. Sure you can have the crash cart outside the room (with no phenyl sticks in it), but when you just need a bump of phenyl, be ready to wait ten minutes while someone grabs it from the pyxis

That’s when you walk back to the OR, grab a stick of neo from the anesthesia cart, return to the unit and give it 2min after you make the decision.

 

[deleted547339]

Respectfully, no ICU patient who needs pressor titration should have his arm squeezed every 5 minutes or so for many hours. Also, if the patient will need regular ABGs, please respect the darn artery, and put in a line.

Also, NO studies on peripheral pressors (which I am a HUGE fan of) support the idea of short IV catheters (i.e. less than 2 inch-long) and have entire protocols set up in case the line gets infiltrated, many times with vasodilators at bedside. Most MICUs, (read ALL) I have seen crappy setups in, have no idea how to fix a norepi extravasation when it happens, putting patients in harm's way big time.

Btw, since septic shock is way more frequent and severe in the MICU, I would argue that A-lines and central lines are actually needed more than in the SICU. I can't stand surgeons who think everybody needs a procedure, but you simply cannot defend not having those lines in the MICU, no offense. Especially an A-line, which takes 5 minutes, and will save a lot of poking the patient's arteries and veins. And I am also half MICU-trained.

The difference is that MICU patients have almost no minute-to-minute variation in hemodynamics outside of the peri-intubation period like you experience in the OR. And the number of times I need an ABG is minimal.

Unless I’m missing it, this study is standard angiocaths.
Safety of peripheral intravenous administration of vasoactive medication. - PubMed - NCBI

 

[deleted171991]

The difference is that MICU patients have almost no minute-to-minute variation in hemodynamics outside of the peri-intubation period like you experience in the OR. And the number of times I need an ABG is minimal.

Unless I’m missing it, this study is standard angiocaths.
Safety of peripheral intravenous administration of vasoactive medication. - PubMed - NCBI

You're NOT missing it. They used various lengths. As far as I remember, the shorter ones (in their or other studies, not sure) had a much higher incidence of extravasation, probably due to the infusion site being too close to the insertion site (hence possible lesions in the opposite wall of the vein during insertion). Also, they used very good quality large veins, ultrasound guidance, and trained operators, not your garden variety ICU nurses. That's a great study, by the way. Link to full study: Peripheral Administration of VM .

Table 1.Summary of the Requirements for PIV Access Used for Infusion of VM

• NOTE: Abbreviations: PIV, peripheral intravenous; VM, vasoactive medication.

Vein diameter >4 mm measured with ultrasonography
Position of PIV access documented to be in the vein with ultrasonography before starting infusion of VM
Upper extremity only, contralateral to the blood pressure cuff
Intravenous line size 20 gauge or 18 gauge
No hand, wrist, or antecubital fossa PIV access position
Blood return from the PIV access prior to VM administration
Assessment of PIV access function every 2 hours as per nursing protocol
Immediate alert by nursing staff to the medical team if line extravasation, with prompt initiation of local treatment
72 hours maximum duration of PIV access use

Regarding arterial lines: that's not why I put one in. That's probably the least important indication for an A-line in the ICU. High probability of a prolonged ICU stay with daily or more frequent labs, occasional ABGs to reassure dumb surgeons, multiple or high-dose pressors, unstable patient with frequent BP measurements etc. Most of the time, the A-line is there either because the patient is really sick or for the patient's comfort. I am a minimalist, by the way, both because I am lazy and well-read.

 

[vector2]

PIV pressors can definitely be done safely, but just keep in mind that the protocol they used in the study is about 4000 times more time and labor intensive than just throwing in a central line, and maybe only about 1/20 IV's I put in meets all these criteria. Better solution is to put in an ultrasound guided 12cm argon or arrow catheter as a "midline." Avoid the risks of PIV pressors and central line placement in one fell swoop.

 

[deleted547339]

You're missing it. It's 2 inch-long angiocaths (and I haven't looked at that study in 2 years). The shorter ones had a much higher incidence of extravasation, probably due to the infusion site being too close to the insertion site (hence possible lesions in the opposite wall of the vein during insertion). Also, they used very good quality veins, ultrasound guidance, and trained operators, not your garden variety ICU nurses.

Regarding arterial lines: that's not why I put one in. That's probably the least important indication for an A-line in the ICU. High probability of a prolonged ICU stay with daily or more frequent labs, occasional ABGs, multiple or high-dose pressors, unstable patient with frequent BP measurements etc. Most of the time, the A-line is there either because the patient is really sick or for the patient's comfort. I am a minimalist, by the way, both because I am lazy and well-read.

That’s fine. We’ll agree to disagree. I understand extrav events can be horrific, but we as a medical society would rather kill people by droves because of clabsi’s than let one person have to get some topical ntg. I get that you’ve practiced longer than I have, but I can’t imagine you’ve had more people die from extrav events than clabsi’s.

 

[kidthor]

I have a favorite anecdote to tell students who are trying to choose between IM and anesthesia, and are wondering about the status difference. When I was a CA-3, a cleaning person bumped into me, in the OR, as he was turning around the corner while talking on the phone. Not only did he not apologize, but he had the nerve to chastise me for "not paying attention and not apologizing to him right there and then". He was also younger than me. At the same time, while I was a medical INTERN, patients regularly identified me as their DOCTOR, and their faces literally lit up when seeing me in the morning (still happens in the ICU as an attending, and much more rarely in anesthesia - the doctor part).

I currently do almost 100% peds anesthesia and everyone in the room functions well as a team. The surgeons thank my team (which is some combo of myself or myself with a resident/fellow/crna) almost every time I work with them. It's a great environment. We all respect each other's skills and contributions.

But where I did residency was pure pestilence. Everything flew downhill and EVERYONE blamed anesthesia. I remember being in a room where the surgeon blamed my attending for the surgical H&P not being done. He actually expected the anesthesiologist should either do his H&P or check if it was done then track down some random surgical resident to do it. It was toxic comedy. I also remember so many times where the surgeons thanked literally everyone in the room except for anesthesia - and not out of directed malice... it was simply because they didn't even notice that someone was there keeping the patient alive while they hacked away. Again... toxic comedy. I'd never work there again.

Maybe the answer is to do peds anesthesia in a nice environment? Or to do whatever sort of anesthesia in a nice environment... such places are out there

 

[deleted171991]

That’s fine. We’ll agree to disagree. I understand extrav events can be horrific, but we as a medical society would rather kill people by droves because of clabsi’s than let one person have to get some topical ntg. I get that you’ve practiced longer than I have, but I can’t imagine you’ve had more people die from extrav events than clabsi’s.

I corrected my post. You were NOT wrong.

Catheter length was 30 mm, 45 mm, or 48 mm depending on availability

Still, they used really good veins, in sites which could not get the flow obstructed by extremity flexion.

I probably haven't practiced longer than you, and I love peripheral IV pressors (my boss doesn't). Still, I would not run norepi on just any peripheral line. I have had enough of them fail on me during MICU intubations.

Btw, extravasations won't kill people, but can mutilate them (especially if first aid is not promptly administered). Look up some of the case reports; they are scary.

 

[Mman]

That’s fine. We’ll agree to disagree. I understand extrav events can be horrific, but we as a medical society would rather kill people by droves because of clabsi’s than let one person have to get some topical ntg. I get that you’ve practiced longer than I have, but I can’t imagine you’ve had more people die from extrav events than clabsi’s.

What is the average time duration from line insertion to CLABSI?

People get CLABSI because lines get left in too long, not because they had one put in originally.

 

[deleted547339]

What is the average time duration from line insertion to CLABSI?

People get CLABSI because lines get left in too long, not because they had one put in originally.

Not necessarily true - that’s one component but certainly not the only one. There’s sterility in how it’s put in, there’s nursing care of the line itself, their care during med administration. Then there’s the possiblility if transient bacteremia from another site seeding a line. Of course, there is duration of cvl, but some people are tough to get other access on.

Again, different types of medicine are practiced based on what and where you practice. If I was in the OR, I’d probably line everyone because it’s reliable and I can get it done super fast - and who cares if it comes out immediately after surgery. It’s just that the MICU is a different beast.

 

[deleted171991]

What is the average time duration from line insertion to CLABSI?

People get CLABSI because lines get left in too long, not because they had one put in originally.

Actually they don't (with proper line care, including perfect sterility for the insertion). There is no proof for what you said, hence there are no expiration dates for uninfected lines (except in the history of medicine). A properly inserted and cared for IJ catheter can last for weeks. That's one of the reasons I put in A-lines, so that the nurses don't use the CVC for blood draws. The less that CVC gets accessed the lower the chances for CLABSI.

@TimesNewRoman, putting in lines in the OR is not much different than the ICU. We don't place them because we are good at them, we are good at them because we have to place them (for patient safety). If anything, one may have more space in a newer (i.e. bigger) ICU room, and more help. Especially in an already intubated and sedated patient, there are very few acceptable excuses for running a pressor on a peripheral line, or not having an arterial line when running more than one low-dose pressor. The MICU is NOT a different beast: it's the same science and the same resuscitation. If anything, MICU patients tend to be sicker, with longer stays. It's just that many medical intensivists suck at (ICU) procedures (even putting in a large bore peripheral IV), and find all kinds of excuses not to do them.

Getting back to my theory about laziness: I find that MICU docs who don't know how/or are too lazy to intubate or place lines, become very generous with them when somebody else has to do them. Hence the lack of respect for many medical intensivists among non-intensivist anesthesiologists and surgeons.

 

[Katheudontas parateroumen]

It will probably increase. Anybody who really loves CCM prefers a closed ICU, instead of dealing with quasi-amateurs every day.

This has been my feeling