EM and CCM

[JeetKuneDo]

---

Members do not see this ad.

I was wondering, for those with CCM fellowships, how their work schedule is spread out. Is it something like two weeks in the ICU and then two weeks at the ED?

Just wondering.

 

[RxnMan]

Take a look at Pitt's CC fellowship page (just Google it). Penn State I think has one. Check SAEM's fellowship page for other listings. Poster KGUNNER is a Pitt CCU alum. 👍

Most are pretty standard ICU rotations, i.e., they aren't any different whether you're Anest -> CCU, IM -> CCU, all are q4 in Neuro ICU, MICU, CCU, SICU, etc.

 

[howelljolly]

Yep, check out the fellowship websites....

But, CCM fellowships are just that... CCM. you do two years of rotations in the MICU, CCU, NeuroICU, SICU.... etc etc, and basic research. But, nothing in the ED.

You might be able to moonlight as an EM attending, but the Q3 call in the ICU might end you.

Once you finish your fellowship, you can practice whatever ER/ICU ratio you want.

 

[deleted65604]

I know, I know, I'm against ER fellowships.

Not practicing in the ER for 2 years seems like a huge negative. There goes your peds knowledge, the ophtho skills, the ortho reductions, the Ob-Gyn knowledge, etc.

If you want to practice ER, and want extra ICU experience, why not go to a four year program and make that your emphasis for all of your electives.

ICU knowledge is only applicable to a small part of what we do. Septic patient? Give lots of fluids. How much? Lots, and get them the heck out of here.

A lot of time on ICU patients is managing line infections, weaning vents, and deciding what antibiotics to give based on culture results. What antibiotics should we give them in the ER? Lots of them, strong ones that kill everything, and get them the heck out of here.

I'm not demeaning ICU docs. They have one difficult job. However, some people have the mistaken impression that they deal with only acute issues. I was surprised to run into a lot of really chronic problems with patients on ICU patients. It seemed that medical ICU was 50% chronic care issues (trach patients, vent dependent muscular dystrophy patients and chronically ill patients who land in the ICU every 2 months and spend half their lives in the hospital).

If you like the ER, train in the ER. If you like ICU, an internal medicine residency or anesthesiology residency with a fellowship is going to train you better for the ICU, and ultimately, get you more respect from your colleagues in the ICU.

 

[KGUNNER1]

I know, I know, I'm against ER fellowships.

Not practicing in the ER for 2 years seems like a huge negative. There goes your peds knowledge, the ophtho skills, the ortho reductions, the Ob-Gyn knowledge, etc.

If you want to practice ER, and want extra ICU experience, why not go to a four year program and make that your emphasis for all of your electives.

ICU knowledge is only applicable to a small part of what we do. Septic patient? Give lots of fluids. How much? Lots, and get them the heck out of here.

A lot of time on ICU patients is managing line infections, weaning vents, and deciding what antibiotics to give based on culture results. What antibiotics should we give them in the ER? Lots of them, strong ones that kill everything, and get them the heck out of here.

I'm not demeaning ICU docs. They have one difficult job. However, some people have the mistaken impression that they deal with only acute issues. I was surprised to run into a lot of really chronic problems with patients on ICU patients. It seemed that medical ICU was 50% chronic care issues (trach patients, vent dependent muscular dystrophy patients and chronically ill patients who land in the ICU every 2 months and spend half their lives in the hospital).

If you like the ER, train in the ER. If you like ICU, an internal medicine residency or anesthesiology residency with a fellowship is going to train you better for the ICU, and ultimately, get you more respect from your colleagues in the ICU.

From someone who does both, and works with 4 others who also do both, in an academic environment, I respectfully disagree 🙂

KG

kg

 

[howelljolly]

And so it is written

 

[deleted65604]

A friend of mine is doing a fellowship in critical care after an ER residency. He had the following to say last week. Interesting perspective I thought:

So, the perception toward ER in ICU is very similar to our perception of FP in ER. We think that FPs don't belong, and aren't adequately trained to run an ER. ICU docs think the same thing about ER trained folks.

 

[medic170]

I was curious about this too. Although I have chosen EM, I have totally loved my senior ICU rotation. I know you can get into critical care through gas or IM/Pulm, cardio, or neph etc. but are there any recognized fellowship paths through EM to do CC, particularly in Michigan? What are the options?

 

[KGUNNER1]

I friend of mine is doing a fellowship in critical care after an ER residency. He had the following to say last week. Interesting perspective I thought:

"I love critical care, but have been frustrated this year. The 'ivory tower' institutional bias is in full effect, and it has been difficult to succeed in an environment where most are skeptical of an ER doc doing ICU. There is a real lack of mentors here, and a poor set up for education. Education wise, it's mostly just a function of everything I manage to read and research myself, since every attending here has a different style, and they're not really interested in teaching you what is right or why they do things a certain way, it just is and always has been (shrug)."

So, the perception toward ER in ICU is very similar to our perception of FP in ER. We think that FPs don't belong, and aren't adequately trained to run an ER. ICU docs think the same thing about ER trained folks.

That can be a problem, but it is more of a function of the type of CCM training rather than the base specialty. I would be interested (off line) in where your friend is doing their fellowship, and if he/she is the first EM doc in the fellowship. There has been a HUGE proliferation of EM/CCM fellowships sprouting up in the past 5 yrs. Since there is no official recognition through ACGME and ABMS, the quality is unregulated. This is only part of the problem (much deeper than I can go into on this one post).

True multidisciplinary programs that have been around for a while provide learning experiences that are much different than this (Pitt, Shock Trauma, St. Johns in St. Louis, Hopkins, Cooper are a few that come to mind). If your friend is a "local trailblazer" then this type of experience is unfortunate but expected.

Another wrinkle, is that most of us who trained ONLY in a pure multidisciplinary CC program (not pulm assoc) view CC as a full time job. Many of my Pulm/CC colleagues (not all mind you) view CC as something they HAVE to do to support their pulm practice. The enthusiasm for the unit is quickly lost after fellowship.

So you see, there are quite different mentalities even within the subspeciality of CC. Not to mention the surgery programs (they have their own issues).

KG

 

[howelljolly]

Another wrinkle, is that most of us who trained ONLY in a pure multidisciplinary CC program (not pulm assoc) view CC as a full time job. Many of my Pulm/CC colleagues (not all mind you) view CC as something they HAVE to do to support their pulm practice. The enthusiasm for the unit is quickly lost after fellowship.

So you see, there are quite different mentalities even within the subspeciality of CC. Not to mention the surgery programs (they have their own issues).

KG

Interesting. I'd have thunk that the majority of PCCM docs feel exactly the opposite... that the pulm consults are a chore. Maybe its regional... programs in the east are CCM heavy, whereas in the west they tend to be Pulm heavy.

Anyway... thanks for the insight as always.

 

[KGUNNER1]

Interesting. I'd have thunk that the majority of PCCM docs feel exactly the opposite... that the pulm consults are a chore. Maybe its regional... programs in the east are CCM heavy, whereas in the west they tend to be Pulm heavy.

Anyway... thanks for the insight as always.

Usually (again this is a broad generalization and doesn't apply to individuals) the allure of the ICU loses it sparkle a few years after pulm/cc fellowship for many. Maybe my generation (graduated fellowship in last 10 yrs) is different, but I don't really think so. They (pulm) quickly find other aspects of their practice more interesting and lucrative. Once they get out into the "real world" they are sooo busy in their office practice this transition is easier than it looks from academia.

 

[EvoDevo]

Usually (again this is a broad generalization and doesn't apply to individuals) the allure of the ICU loses it sparkle a few years after pulm/cc fellowship for many. Maybe my generation (graduated fellowship in last 10 yrs) is different, but I don't really think so. They (pulm) quickly find other aspects of their practice more interesting and lucrative. Once they get out into the "real world" they are sooo busy in their office practice this transition is easier than it looks from academia.

Do you mind elaborating more on the actual practice of CCM and EM? Do you spend all of your time in the ICU? Or do you split time? Any degradation of skills?

I've spoken with several faculty on the topic (none of whom do CCM), and the overwhelmign consensus is something along Jarabacoa's thinking.

Anyway, thanks to you and everyone else for posting in this thread.

 

[KGUNNER1]

Do you mind elaborating more on the actual practice of CCM and EM? Do you spend all of your time in the ICU? Or do you split time? Any degradation of skills?

I've spoken with several faculty on the topic (none of whom do CCM), and the overwhelmign consensus is something along Jarabacoa's thinking.

Anyway, thanks to you and everyone else for posting in this thread.

I'm not exactly sure what you mean by this. I've posted many times on my practice environment, search some of my older posts (nothing has changed) and see if some of them answer your question.

I am a practicing EM physician (3-5 shifts/month) and a practicing intensivist (medical director of one of the units) and work as an intensivist, rounding in the ICU seeing patients as an intensivist, for 7-9 days/month. The rest is teaching and research.

I think my skills in the ED are fine. I don't work the fast-track, so those skills are diminished. All the EDs I've worked in were very large, academic, inefficient behemoths that just sucked the efficiency out of you. My colleagues on the other side of town can move patients through their systems much faster than I can.

We have a dedicated peds ED, so obviously my exposure to kiddies is much less, but it has nothing to do with me being an intensivist.

What faculty are talking to? EM? Pulm? Surg/Trauma? Anesth/CC? Where are you (big Ivory Tower with history - Harvard, Cincinnati, etc...) You don't need to name the institution, just describe the environment.

In my observations over the years, usually the more established (read moldy) academic centers build silos around clinical areas. These have very high walls and they are used to aggressively protect turf. Some places are in various stages of the walls coming down.

The same arguments I'm reading on this thread were used against EM as a specialty 25 yrs ago (and some still do).

KG

 

[deleted65604]

I stand corrected, in speaking more to my friend, he is actually is from a very new program in ER/CCM. He said that he basically created his own niche, and as was pointed out above, I guess a lot of the problems he is facing are due to that fact, not necessarily from a wide-spread bias against ER docs.

I'm guessing (correct me if I'm wrong) that these positions (part-time ER/CCU) are becoming more available, but right now pretty much limited to large academic settings.

 

[KGUNNER1]

I stand corrected, in speaking more to my friend, he is actually is from a very new program in ER/CCM. He said that he basically created his own niche, and as was pointed out above, I guess a lot of the problems he is facing are due to that fact, not necessarily from a wide-spread bias against ER docs.

I'm guessing (correct me if I'm wrong) that these positions (part-time ER/CCU) are becoming more available, but right now pretty much limited to large academic settings.

Jarabacoa,
It really depends. Some smaller places are so in need of qualified CC docs that one may be surprised as to how open they are to an EM/CCM doc rounding in the unit and picking up shifts in the ED. You really have to shop around. But you are correct in stating that most of the docs like me are in big academic centers (most, not all).

KG

 

[howelljolly]

On a related note.. about pre-hospital EM/CCM?

In the Pediatrics world, the pedi-intensivists provide the medical direction for interfacility transports, and sometimes go on the transport themselves.

In the Adult world, EM docs provide the medical direction, and leave things up to the CC/Flight medics.

Is anyone interested in critical care transport from a CCM perspective? Its been said on the SDN that intensivists are certainly welcome to get involved. However in reality, do intensivists work either administratively, or clinically in critical care transport, or is that turfed entirely to EM?

 

[KGUNNER1]

On a related note.. about pre-hospital EM/CCM?

In the Pediatrics world, the pedi-intensivists provide the medical direction for interfacility transports, and sometimes go on the transport themselves.

In the Adult world, EM docs provide the medical direction, and leave things up to the CC/Flight medics.

Is anyone interested in critical care transport from a CCM perspective? Its been said on the SDN that intensivists are certainly welcome to get involved. However in reality, do intensivists work either administratively, or clinically in critical care transport, or is that turfed entirely to EM?

I would say it would be rare to find a CC doc involved heavily in transport. You might find one that helps out the local/regional flight medical director, but usually the medical directors are EM trained.

That being said, I would be pleasantly surprised if I stumbled upon one.

 

[FDGB]

On a related note.. about pre-hospital EM/CCM?

In the Pediatrics world, the pedi-intensivists provide the medical direction for interfacility transports, and sometimes go on the transport themselves.

In the Adult world, EM docs provide the medical direction, and leave things up to the CC/Flight medics.

Is anyone interested in critical care transport from a CCM perspective? Its been said on the SDN that intensivists are certainly welcome to get involved. However in reality, do intensivists work either administratively, or clinically in critical care transport, or is that turfed entirely to EM?

There are intensivists who run CCT services. The CEO/Medical Director for Boston MedFlight is an intensivist.

 

[Dr. Dukes]

I would say it would be rare to find a CC doc involved heavily in transport. You might find one that helps out the local/regional flight medical director, but usually the medical directors are EM trained.

That being said, I would be pleasantly surprised if I stumbled upon one.

I believe (may be wrong) that Vandy's helicopter is co-run by the ED, Trauma ("Trauma" surgeons = surgical intensivists), and Peds (for all the peds/neunatal stuff), and I think the same goes for MetroHealth.

I think if you looked naturally you'd find more trauma surgeons (like I said earlier, they mostly did Surgical Critical Care as their fellowship) than regular intensivists involved with Helicopter EMS.