Critical care procedures

[857937]

I'm in love with critical care.
I want to do ICU for life.

I did two pulmonary rotations so far during residency and it's really not for me except for procedures. I can't stand the clinic. I don't want to spend most of my time on floors teaching hospitalists and cardiologists alike how to diurese their patients.

If I do pure critical care fellowship (2 years),

Can I do my own diagnostic bronchoscopies in ICU (BAL and mucus suction)? (I understand biopsies and other interventions need a pulmonologist).

Can I do my own thoracentesis?

Do I need to consult pulmonary for ventilator management? (Absurd question but I've seen in it!).

What other instances I'll need to consult pulmonary?

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[Hernandez]

It depends on the hospital.

 

[chocomorsel]

I would think as an intensivists, if you have the skills and get the privileges you should do it all.
I plan on doing it all and getting privileges to do it all. What I don't know, I will pass on to the specialists.
I guess some hospitals may prevent you from doing it all though. Stay away from those hospitals.

 

[CCM-MD]

Vent management, bronchs and other ICU bedside procedures are bread and butter critical care medicine. We do our own trachs and even cannulate for ECMO. You don’t need to consult anyone unless you want to.

 

[CCM-MD]

Like you, I debated between doing a 2 year CCM vs a 3 year program that included pulmonary. I ended up choosing not to do pulmonary and do not regret my choice. Here is a Critical Care Medicine privilege list from my previous institution, perhaps this might help:

Performance of history and physical exam
Airway maintenance intubation, including fiberoptic bronchoscopy and laryngoscopy
Arterial puncture and cannulation
Calculation of oxygen content, intrapulmonary shunt, and alveolar arterial gradients
Cardiac output determinations by thermodilution and other techniques
Cardiopulmonary resuscitation
Temporary cardiac pacemaker insertion and application
Cardioversion and defibrillation
Echocardiography and electrocardiography interpretation
Evaluation of oliguria
Insertion of central venous, arterial, and pulmonary artery balloon flotation catheters
Insertion of hemodialysis and peritoneal dialysis catheters
Interpretation of intracranial pressure monitoring
Lumbar puncture
Management of anaphylaxis and acute allergic reactions
Management of critical illness in pregnancy
Management of life-threatening disorders in intensive care units, including but not limited to shock, coma, heart failure, trauma, respiratory arrest, drug overdoses, massive bleeding, diabetic acidosis, and kidney failure
Management of massive transfusions
Management of the immunosuppressed patient
Monitoring and assessment of metabolism and nutrition
Needle and tube thoracostomy
Paracentesis
Percutaneous needle aspiration of palpable masses
Percutaneous tracheostomy/cricothyrotomy tube placement
Pericardiocentesis
Peritoneal dialysis
Peritoneal lavage
Preliminary interpretation of imaging studies
Thoracentesis
Tracheostomy
Transtracheal catheterization
Image-guided procedures
Use of reservoir masks, nasal prongs/canulas, and nebulizers for delivery of supplemental oxygen and inhalants
Ventilator management, including experience with various modes and continuous positive airway pressure therapies
Wound care
Maintenance of ACLS and ATLS (required)
Moderate Sedation

 

[Hernandez]

I would think as an intensivists, if you have the skills and get the privileges you should do it all.
I plan on doing it all and getting privileges to do it all. What I don't know, I will pass on to the specialists.
I guess some hospitals may prevent you from doing it all though. Stay away from those hospitals.

I think your last sentence is very important. I had looked at a place for CC only and I'm pulm-cc. They were telling me that I'd be required to consult their pulm for vents and I'd have no bronch privileges. No thank you. That is likely an indication of significant hospital politics

 

[deleted547339]

I think your last sentence is very important. I had looked at a place for CC only and I'm pulm-cc. They were telling me that I'd be required to consult their pulm for vents and I'd have no bronch privileges. No thank you. That is likely an indication of significant hospital politics

Hahahahahagavahahahahavahahaha.

 

[857937]

Like you, I debated between doing a 2 year CCM vs a 3 year program that included pulmonary. I ended up choosing not to do pulmonary and do not regret my choice. Here is a Critical Care Medicine privilege list from my previous institution, perhaps this might help:

Performance of history and physical exam
Airway maintenance intubation, including fiberoptic bronchoscopy and laryngoscopy
Arterial puncture and cannulation
Calculation of oxygen content, intrapulmonary shunt, and alveolar arterial gradients
Cardiac output determinations by thermodilution and other techniques
Cardiopulmonary resuscitation
Temporary cardiac pacemaker insertion and application
Cardioversion and defibrillation
Echocardiography and electrocardiography interpretation
Evaluation of oliguria
Insertion of central venous, arterial, and pulmonary artery balloon flotation catheters
Insertion of hemodialysis and peritoneal dialysis catheters
Interpretation of intracranial pressure monitoring
Lumbar puncture
Management of anaphylaxis and acute allergic reactions
Management of critical illness in pregnancy
Management of life-threatening disorders in intensive care units, including but not limited to shock, coma, heart failure, trauma, respiratory arrest, drug overdoses, massive bleeding, diabetic acidosis, and kidney failure
Management of massive transfusions
Management of the immunosuppressed patient
Monitoring and assessment of metabolism and nutrition
Needle and tube thoracostomy
Paracentesis
Percutaneous needle aspiration of palpable masses
Percutaneous tracheostomy/cricothyrotomy tube placement
Pericardiocentesis
Peritoneal dialysis
Peritoneal lavage
Preliminary interpretation of imaging studies
Thoracentesis
Tracheostomy
Transtracheal catheterization
Image-guided procedures

This is amazing!

May I ask where did you do your training if you don't mind?

I have a friend who's doing her CC training in NY in a procedures heavy program and I think her procedures list is similar to yours.

 

[857937]

I think your last sentence is very important. I had looked at a place for CC only and I'm pulm-cc. They were telling me that I'd be required to consult their pulm for vents and I'd have no bronch privileges. No thank you. That is likely an indication of significant hospital politics

I train at such hospital and it's as absurd as you can imagine.

 

[CCM-MD]

This is amazing!

May I ask where did you do your training if you don't mind?

I have a friend who's doing her CC training in NY in a procedures heavy program and I think her procedures list is similar to yours.

I did not do my fellowship in NY.

That isn't necessarily a procedure list - it is a list of basic privileges all CCM attendings were given at my previous institution. All were trained at different places so you don't necessarily have to be trained at a procedure heavy fellowship program. I shared it to give you a general idea but as mentioned, every hospital is slightly different when it comes to credentialing.

I have yet to encounter a gig that mandates a consult to pulmonary for vented patients - sounds like a good way to increase consult revenue for the local pulmonary group though. Could do it for every organ system: mandatory consult to neurology for encephalopathy, cards for A Fib, anesthesia for intubation and sedation, nephrology for AKI, GI for ileus, ID for antibiotics, endocrine for diabetes. What a joke.

 

[857937]

I did not do my fellowship in NY.

That isn't necessarily a procedure list - it is a list of basic privileges all CCM attendings were given at my previous institution. All were trained at different places so you don't necessarily have to be trained at a procedure heavy fellowship program. I shared it to give you a general idea but as mentioned, every hospital is slightly different when it comes to credentialing.

I have yet to encounter a gig that mandates a consult to pulmonary for vented patients - sounds like a good way to increase consult revenue for the local pulmonary group though. Could do it for every organ system: mandatory consult to neurology for encephalopathy, cards for A Fib, anesthesia for intubation and sedation, nephrology for AKI, GI for ileus, ID for antibiotics, endocrine for diabetes. What a joke.

Thanks again for for the clarification.
This makes me feel much better and more confident about going to CC only.

 

[lura]

Seems sort of redundant to me if you are critical care trained which necessitates the knowledge base of vent management, to then be forced to consult non-critical care physicians/pulmonologist for vent management. Then what is the point of having an intensivist? I too would stay away from those jobs. BTW the listing of critical care privileges by CCM2017 above is completely accurate and should be the norm for any position you find you interested in taking. Any decent fellowship will train you in all.

 

[chocomorsel]

Seems sort of redundant to me if you are critical care trained which necessitates the knowledge base of vent management, to then be forced to consult non-critical care physicians/pulmonologist for vent management. Then what is the point of having an intensivist? I too would stay away from those jobs. BTW the listing of critical care privileges by CCM2017 above is completely accurate and should be the norm for any position you find you interested in taking. Any decent fellowship will train you in all.

Most pulmonologists are critical care trained. I know there are some that aren’t but most go thru a combined fellowship.

 

[cbrons]

I don't want to spend most of my time on floors teaching hospitalists and cardiologists alike how to diurese their patients.

arrogance isn't a good quality in an intensevist or any physician for that matter

 

[deleted547339]

arrogance isn't a good quality in an intensevist or any physician for that matter

And yet....CT surgeons.

 

[jdh71]

And yet....CT surgeons.

I don’t know. I kind of want the guy who throws sutures into my beating heart to be confident AF.

The rest can be kind of annoying but that beast better be “arrogant”.

The bigger problem isn’t arrogance it is not knowing what you CAN’T do.

 

[deleted547339]

I don’t know. I kind of want the guy who throws sutures into my beating heart to be confident AF.

The rest can be kind of annoying but that beast better be “arrogant”.

The bigger problem isn’t arrogance it is not knowing what you CAN’T do.

I disagree. I think arrogance is a bigger problem. I’ve seen a patient die and multiple almost die because “I couldn’t have possibly caused that complication”

 

[Robotic Wis-Hipple]

I don’t know. I kind of want the guy who throws sutures into my beating heart to be confident AF.

The rest can be kind of annoying but that beast better be “arrogant”.

The bigger problem isn’t arrogance it is not knowing what you CAN’T do.

As a guy who works with CT surgeons daily, I’ll say give me the cool, confident surgeon who thinks he’s fallible over the arrogant god complex one. Believe me, more iatrogenesis and time spent dealing with complications or imperfect conditions occurs with arrogance, by a large amount.

 

[Colorado outliers]

I did not do my fellowship in NY.

That isn't necessarily a procedure list - it is a list of basic privileges all CCM attendings were given at my previous institution. All were trained at different places so you don't necessarily have to be trained at a procedure heavy fellowship program. I shared it to give you a general idea but as mentioned, every hospital is slightly different when it comes to credentialing.

I have yet to encounter a gig that mandates a consult to pulmonary for vented patients - sounds like a good way to increase consult revenue for the local pulmonary group though. Could do it for every organ system: mandatory consult to neurology for encephalopathy, cards for A Fib, anesthesia for intubation and sedation, nephrology for AKI, GI for ileus, ID for antibiotics, endocrine for diabetes. What a joke.

I know you're joking, but what you're describing is unfortunately fairly routine for many private hospitals...$$$. Some of our pulm-CCM fellows have taken jobs in either pulm groups or ICU groups working in hospitals where Pulm is generally consulted for every vent.

 

[Colorado outliers]

I'm in love with critical care.
I want to do ICU for life.

I did two pulmonary rotations so far during residency and it's really not for me except for procedures. I can't stand the clinic. I don't want to spend most of my time on floors teaching hospitalists and cardiologists alike how to diurese their patients.

If I do pure critical care fellowship (2 years),

Can I do my own diagnostic bronchoscopies in ICU (BAL and mucus suction)? (I understand biopsies and other interventions need a pulmonologist).

Can I do my own thoracentesis?

Do I need to consult pulmonary for ventilator management? (Absurd question but I've seen in it!).

What other instances I'll need to consult pulmonary?

While you seem to have great enthusiasm for ICU medicine, I would throw in a word of caution...I have seen many ICU physicians burn out when
they do only ICU medicine. The ICU is a pressure cooker, and it's good to have something else to fall back on (clinic, administration, research) especially as you get older and don't want to admit 8 sick patients overnight to the ICU at age 50. But, I'm sure some will disagree.
Also, your description of what a pulmonologist does is way off base.

 

[jdh71]

As a guy who works with CT surgeons daily, I’ll say give me the cool, confident surgeon who thinks he’s fallible over the arrogant god complex one. Believe me, more iatrogenesis and time spent dealing with complications or imperfect conditions occurs with arrogance, by a large amount.

We are perhaps defining arrogance here a bit different.

 

[CCM-MD]

I know you're joking, but what you're describing is unfortunately fairly routine for many private hospitals...$$$. Some of our pulm-CCM fellows have taken jobs in either pulm groups or ICU groups working in hospitals where Pulm is generally consulted for every vent.

I haven’t seen it.

 

[Hamhock]

I know you're joking, but what you're describing is unfortunately fairly routine for many private hospitals...$$$. Some of our pulm-CCM fellows have taken jobs in either pulm groups or ICU groups working in hospitals where Pulm is generally consulted for every vent.

Is anyone able to speak about UCSF?

IIRC they require pulmnology for all bronchs or something like that...not for vent management, but similar.

HH

 

[deleted547339]

Is anyone able to speak about UCSF?

IIRC they require pulmnology for all bronchs or something like that...not for vent management, but similar.

HH

Hahahahahhahahahaha

 

[NITRAS]

None of our MICU docs are just CC. It may limit your job opportunities.

I think everyone thinks the ICU is fun.....at first.

 

[deleted547339]

None of our MICU docs are just CC. It may limit your job opportunities.

I think everyone thinks the ICU is fun.....at first.

Definitely limits, but going away from that. As icu patients get sicker and hospitals focus more on throughout; its getting harder to have one person do both. I suspect by the end of our career, it will be the exception, not the norm, but not for a long time.

 

[jdh71]

Definitely limits, but going away from that. As icu patients get sicker and hospitals focus more on throughout; its getting harder to have one person do both. I suspect by the end of our career, it will be the exception, not the norm, but not for a long time.

That's not true at all, especially since we all work in shifts. In the MICU there is four decades of folks doing pulmonary and critical care, that isn't going to stop any time soon with the fellowship being linked together the way it is. Pure critical care physicians will continue to plug holes in gaps for these groups and work in locations without a strong pulmonary and critical care presence.

Right now my group is recruiting an intensivist, BUT we also want them pulmonary boarded so they can also see the inpatient pulmonary consult load and do more complicated bronchs than BALs and suctions when taking call.

 

[CCM-MD]

I am sure there is regional variation. But pretty much everything in my area (large Midwest city) is hospital employed intensivists or corporate groups like ICC, sound, team health etc. Typically they are looking for intensivists - doesn’t matter if you are pulmonary, nephrology, EM, anesthesia or whatever because you aren’t going to be doing any. In fact it’s become so bad in my area that there are pretty much ZERO gigs that allow one to do both pulmonary and critical care.

I talk to some fellows from time to time and hear this recurring theme of not being able to practice CCM and something else. In fact, many of my colleagues are dual trained and don’t do pulmonary (or nephrology or EM for that matter).

I’m moving to the south in a few months and it’s pretty much the same situation there. I’m IM & CCM and will be hospital employed with a few other intensivists, some are pulmonary trained but don’t do Pulm, one is a nephrologist who doesn’t do nephro. I personally have had no problems finding good gigs in most medium to large cities. I get calls for jobs all the time...

The whole “pulmonary group” covering the ICU is going away. Are you going to have more job opportunities if you are pulmonary trained? Of course you will - because you are trained in an extra specialty and will be able to access a whole different type of jobs. You might have some advantage but not a huge one at finding an Intensivist job.

 

[deleted547339]

That's not true at all, especially since we all work in shifts. In the MICU there is four decades of folks doing pulmonary and critical care, that isn't going to stop any time soon with the fellowship being linked together the way it is. Pure critical care physicians will continue to plug holes in gaps for these groups and work in locations without a strong pulmonary and critical care presence.

Right now my group is recruiting an intensivist, BUT we also want them pulmonary boarded so they can also see the inpatient pulmonary consult load and do more complicated bronchs than BALs and suctions when taking call.

You’re entitled to your opinion. Obviously, we’re both trying to predict the future, so we’re just making educated guesses. But patients are getting sicker and there are times when you just can’t leave the unit. Hospital higher ups (read clipboard nurses) don’t understand this and why it is taking a while to complete a consult that is holding up dispo.

Mind you, I didn’t look at any hospitals under 400 beds, but, when I looked for jobs, not one of them cared that I wasn’t pulm. And fwiw, my group has an exceedingly strong pulm department and quite well respected cc group.

 

[jdh71]

You’re entitled to your opinion. Obviously, we’re both trying to predict the future, so we’re just making educated guesses. But patients are getting sicker and there are times when you just can’t leave the unit. Hospital higher ups (read clipboard nurses) don’t understand this and why it is taking a while to complete a consult that is holding up dispo.

Mind you, I didn’t look at any hospitals under 400 beds, but, when I looked for jobs, not one of them cared that I wasn’t pulm. And fwiw, my group has an exceedingly strong pulm department and quite well respected cc group.

Sure. But it’s almost all shift work. The pulmonary and critical person isn’t sitting in clinic when rounding in the unit. They are in the unit. Places that have an extra pulmonary consult service won’t care if you are boarded in pulmonary obviously. Different places will have different needs. But the natural workflow to n the community when in the ICU is also seeing in patient pulmonary consults for those groups that are already pulmonary/cc. None of this means I think the outlook for critical care only folks is “bad”. I think the opposite. With that said I do think the guy with pulmonary plus CC is playing his hand with the best cards and will be going forward for a long long time.

 

[gulmohr]

I am sure there is regional variation. But pretty much everything in my area (large Midwest city) is hospital employed intensivists or corporate groups like ICC, sound, team health etc. Typically they are looking for intensivists - doesn’t matter if you are pulmonary, nephrology, EM, anesthesia or whatever because you aren’t going to be doing any. In fact it’s become so bad in my area that there are pretty much ZERO gigs that allow one to do both pulmonary and critical care.

I talk to some fellows from time to time and hear this recurring theme of not being able to practice CCM and something else. In fact, many of my colleagues are dual trained and don’t do pulmonary (or nephrology or EM for that matter).

I’m moving to the south in a few months and it’s pretty much the same situation there. I’m IM & CCM and will be hospital employed with a few other intensivists, some are pulmonary trained but don’t do Pulm, one is a nephrologist who doesn’t do nephro. I personally have had no problems finding good gigs in most medium to large cities. I get calls for jobs all the time...

The whole “pulmonary group” covering the ICU is going away. Are you going to have more job opportunities if you are pulmonary trained? Of course you will - because you are trained in an extra specialty and will be able to access a whole different type of jobs. You might have some advantage but not a huge one at finding an Intensivist job.

Same situation in NYC.