ER docs and Crit Care Fellowships

[stebb]

IOM made public their report on the FUTURE OF EMERGENCY MEDICINE today...and one of their findings was that ER docs should be allowed to partake in Crit Care Fellowships to eventually become boarded...

EMS --> ER ---> ICU

Makes sense to me...anyone have any thoughts? For or Against?

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[JackBauERfan]

IOM made public their report on the FUTURE OF EMERGENCY MEDICINE today...and one of their findings was that ER docs should be allowed to partake in Crit Care Fellowships to eventually become boarded...

EMS --> ER ---> ICU

Makes sense to me...anyone have any thoughts? For or Against?

I think residency training in EM is more than adequate to do a fellowship in critical care. Compared to the other specialites that can sit (IM, surg, anes), I think EM residencies offer an adequate skill/knowlege base. Of course there are things that IM/Anes/Surg offer in their residencies that also help out for critical care, i'm just saying EM also offers skills that they do not give. But i'm Biased haha.

 

[BMW19]

I thought the EM folks signed their life away to the IM boards that they would never try and apply for certification in CC? Was this just a myth?

IOM made public their report on the FUTURE OF EMERGENCY MEDICINE today...and one of their findings was that ER docs should be allowed to partake in Crit Care Fellowships to eventually become boarded...

EMS --> ER ---> ICU

Makes sense to me...anyone have any thoughts? For or Against?

 

[Eidolon6]

The jack of all trades mentality of ER makes this an easy argument for ER slanted folks to make for their involvement in the intensive care unit and in the ideal shift-work world, this may apply. Most critical care interactions I have with the ER involve rapid triage and a rapid call to myself to take the patient to the ICU to direct their critical care. And most of us critical care folk appreciate as little unnecessary tampering or experimentation in the ER before the patient gets to the ICU. In fact, the sooner to the ICU, the better (E. Rivers may dispute this based on his paper, but that study was a reflection of a treatment modality to physiologic endpoints, not a treatment location (despite his feather-fluffing editorial(s)). Intubating or lining a patient in the ER a critical care physician does not make. Additionally, most ICU settings, outside of academics, oft involve following and directing care of the patient beyond the ICU and which is beyond the scope of the average ER physician's training/purpose/practice goals. The final folly is to assume that since the ER doc does a little of this and a little of that, then he/she is more suited to a critical care career. That is a fairly moot and fragile point. All the current specialties with certification in critical care require some degree of cross training in viable areas important to critical care and guidelines exist for fellowship programs to follow to ensure as rich exposure as possible.

Now those are a few arguments against it but with the right fellowship training, I can see ER physicians being perfectly adaptable to it, should they accept that level of responsibility. I applaud efforts to adapt critical care training for ER physicians, although the governance of which could and should be disputed.

Critical care shortages are predicted in the midst of the aging baby boomers, a paradigm shift towards ICU heavy healthcare institutions and multimodality care. Most critical care fellowships have not grown significantly in the past decade. A recent HRSA report to congress (listed below, see CHEST website) has conveyed this fearful reality.

HRSA Report May 2006:
US Department of Health and Human Services; Health Resources and Services Administration. Report to Congress. The Critical Care Workforce: A Study of the Supply and Demand for Critical Care Physicians. Requested by: Senate Report 108-81.

Now the real question is, how many ER physicians would want to become critical care physicians and take on the inpatient responsibilities/liabilities in the face of a suboptimal reimbursement system and burdens of inpatient care responsibilities. My guess it that the concept sounds a lot better to most emergency physicians than the actual practice. Some 41% of 178 internal medicine residents surveyed in a study by S. Carson reported an interest in pulmonary/critical care at the onset of their residency but only a paltry 3.4% actually chose critical care careers. Another good example would be anesthesiologist-intensivists who make up the smallest proportion of critical care physicians, are mostly IMGs and typically work harder for less than their OR gassing colleagues.

It certainly looks like ER may be a viable critical care source, but its probably excessively optimistic that they will make a dynamic impact on critical care as a specialty/entity or on the current and forecast critical care shortages.

 

[dbiddy808]

I was talking to someone at work the other day and they were saying that ER docs would have to do a one-year fellowship only. This doesn't really make sense since IM have to do two-years and have a much better background to be able to deal with complicated medical patients. No offense to ER docs. I would think that ER docs should do AT LEAST as much training as IM docs? What do you guys think?

 

[Apollyon]

Most critical care interactions I have with the ER involve rapid triage and a rapid call to myself to take the patient to the ICU to direct their critical care. And most of us critical care folk appreciate as little unnecessary tampering or experimentation in the ER before the patient gets to the ICU.

Some 41% of 178 internal medicine residents surveyed in a study by S. Carson reported an interest in pulmonary/critical care at the onset of their residency but only a paltry 3.4% actually chose critical care careers.

It certainly looks like ER may be a viable critical care source, but its probably excessively optimistic that they will make a dynamic impact on critical care as a specialty/entity or on the current and forecast critical care shortages.

So, either you are at a place that does not have EM-trained docs or an EM residency, or your department is overbearing, or you are exaggerating.

Where I am at (for 2 more weeks), pulmonary is rock-solid, but critical care is less than pitiful. The MICU is loaded with pulmonary rocks and pre- and post-transplant failures, and the MICU is perpetually full - and staffed mostly by IM residents whose procedural skills, in a word, suck (there's an IM2 here who, after 2 years, has NEVER done an LP). As it is full, and the deal with the MICU is, even if they're accepted by the MICU, as long as the patients are in the ED, we manage them, because they won't, the acutely ill patients that are trying to box are actually NOT in the MICU.

Moreover, it is evident that you have not read this report or others as far as critical care patients in the ED - with nowhere to go (as many ICU/CCUs being full, critical care patients may be in the ED for 24 or 48 hours - except. apparently, at your place), someone has to manage them. You really think an ob/gyn is more qualified for CCM than an EM doc (in that there are ob/gyn critical care programs)?

One thing that you miss, also, is that, in my straw polling, EM docs that want to do critical care want that critical care - whereas you lump them in with pulmonary/critical care - and I don't know anyone in EM who wants to bronch people all day, or do pulmonary clinic with the lung CA and COPDers.

As to the person with the idle chatter that EM-residency grads would only have to do 1 year - that is no different from general surgery or anesthesia critical care programs, which are mostly in the SICU and virtually all are one year in length. Before IM screwed everyone (now that IM fellowship positions have to be 100% IM grads, except for FM in geriatrics, instead of the former 75%), everyone that did IM critical care did 2 years (and it is still that way at Pitt, where they hold 5 spots out of 25 every year for EM grads in their critical care fellowship, which is not subject to ABIM underhandedness) at minimum. Do even 5 minutes of research, instead of rabble-rousing.

And, to Eidolon6 - put up or shut up. Say where you're at, if you stand by what you say, and I'll tell you where I'm at. Otherwise, it's the SDN special of generically MFing EM, without having the guts to say where EM docs suck.

 

[stebb]

AMEN TO THAT BROTHER!!! (or sister)

 

[Apollyon]

Now those are a few arguments against it but with the right fellowship training, I can see ER physicians being perfectly adaptable to it, should they accept that level of responsibility. I applaud efforts to adapt critical care training for ER physicians, although the governance of which could and should be disputed.

Critical care shortages are predicted in the midst of the aging baby boomers, a paradigm shift towards ICU heavy healthcare institutions and multimodality care. Most critical care fellowships have not grown significantly in the past decade. A recent HRSA report to congress (listed below, see CHEST website) has conveyed this fearful reality.

Even though I read your entire post, I certainly did not appreciate this part until re-reading. If my response above sounds vituperative or acrimonious, I apologize.

As there is only enough coverage for ICUs in the US right now for 8 hours out of 24, any way to fill the gaps (as long as quality is maintained) is welcomed.

 

[JackBauERfan]

The jack of all trades mentality of ER makes this an easy argument for ER slanted folks to make for their involvement in the intensive care unit and in the ideal shift-work world, this may apply. Most critical care interactions I have with the ER involve rapid triage and a rapid call to myself to take the patient to the ICU to direct their critical care. And most of us critical care folk appreciate as little unnecessary tampering or experimentation in the ER before the patient gets to the ICU. In fact, the sooner to the ICU, the better (E. Rivers may dispute this based on his paper, but that study was a reflection of a treatment modality to physiologic endpoints, not a treatment location (despite his feather-fluffing editorial(s)). Intubating or lining a patient in the ER a critical care physician does not make. Additionally, most ICU settings, outside of academics, oft involve following and directing care of the patient beyond the ICU and which is beyond the scope of the average ER physician's training/purpose/practice goals. The final folly is to assume that since the ER doc does a little of this and a little of that, then he/she is more suited to a critical care career. That is a fairly moot and fragile point. All the current specialties with certification in critical care require some degree of cross training in viable areas important to critical care and guidelines exist for fellowship programs to follow to ensure as rich exposure as possible.

Now those are a few arguments against it but with the right fellowship training, I can see ER physicians being perfectly adaptable to it, should they accept that level of responsibility. I applaud efforts to adapt critical care training for ER physicians, although the governance of which could and should be disputed.

Critical care shortages are predicted in the midst of the aging baby boomers, a paradigm shift towards ICU heavy healthcare institutions and multimodality care. Most critical care fellowships have not grown significantly in the past decade. A recent HRSA report to congress (listed below, see CHEST website) has conveyed this fearful reality.

HRSA Report May 2006:
US Department of Health and Human Services; Health Resources and Services Administration. Report to Congress. The Critical Care Workforce: A Study of the Supply and Demand for Critical Care Physicians. Requested by: Senate Report 108-81.

Now the real question is, how many ER physicians would want to become critical care physicians and take on the inpatient responsibilities/liabilities in the face of a suboptimal reimbursement system and burdens of inpatient care responsibilities. My guess it that the concept sounds a lot better to most emergency physicians than the actual practice. Some 41% of 178 internal medicine residents surveyed in a study by S. Carson reported an interest in pulmonary/critical care at the onset of their residency but only a paltry 3.4% actually chose critical care careers. Another good example would be anesthesiologist-intensivists who make up the smallest proportion of critical care physicians, are mostly IMGs and typically work harder for less than their OR gassing colleagues.

It certainly looks like ER may be a viable critical care source, but its probably excessively optimistic that they will make a dynamic impact on critical care as a specialty/entity or on the current and forecast critical care shortages.

I don't think 'jack of all trades' is the main argument folks in EM use, I think its that it is a field that sees/manages critical care patients on a daily basis (even though it is short term), and with that also able to perform a lot of critical care procedures (that many in IM do not get). I don't think EM is MORE suited than IM/anesth/surg/ob-gyn, I just think that they have a skillset that can be advanced as a critical care doc.

Of course someone trained in EM residency isn't READY to go and do critical care, what I'm saying is (and you mention in the last paragraphs) is the skillset and knowledge base learned in residency should be adequate to START a critical care fellowship. Yeah yeah, 30 years ago when EM started they promised IM stuff, but like everything change happens and in this case is needed. Although the point made that we should let EM folks do critical care because there is a need for them is one that I do not agree with. I think they should be allowed regardless of need.

Also, I've too read about that even if EM was able to enter the market, that they would not make as much of an impact that is needed, but I think that many upcoming medical students and residents don't even see this as an option (because it really isn't right now) and so it would be hard to judge what exact impact it would have.

 

[Eidolon6]

Even though I read your entire post, I certainly did not appreciate this part until re-reading. If my response above sounds vituperative or acrimonious, I apologize.

As there is only enough coverage for ICUs in the US right now for 8 hours out of 24, any way to fill the gaps (as long as quality is maintained) is welcomed.

I accept the apology and enjoyed the angry (albeit misguided) undercurrent of the reply (as well as the use of vituperative in the above apology...nice diction). I preemptively apologize for the length of this reply (without retort).

The original question was argument for/against and I admit I evolved the question/conversation a bit...out of interest sake anyways. I presented a little of both and perhaps was a bit generic in the process. There is very little against in my statement. The teleology of the argument is superbly outlined in HT Huang et al treatise "Critical care medicine training and certification for emergency physicians" in Crit Care Med. The continuum of care part of the argument is okay but I feel that no matter the foundation of training, transition of care ultimately occurs and really should probably occur as early as possible following recognition of critical illness (experience based opinion here, open for interpretation and disagreement)

Regional differences aside (and just like all specialties, weak training exists in various places and results in other taking up the slack...I (as a lowly Pulm/CCM fellow) respect this, taking up a fair bit of slack myself. I don't think I made a clear statement in that my point is that the ICU is the place for critical care and that current evidence shows that patients treated by physicians without dedicated training in critical care have demonstrated increases in number of ICU days, morbidity and mortality, etc... I come from a place with very strong ER docs and very strong Pulm/CCM guys with good dialogue between us and we both have an appreciation for expediting care. I like the early call so I can have initial input to help facilitate the transition from ER to ICU...since I/we will ultimately be responsible for the patient and his/her care there. Its not a matter of being overbearing it's just that therapeutic backtracking doesn't help the critically ill patient. There is no "ER Sucks" within any of that...the place is just not designed to be the ICU nor should it be and its unfortunate when it (like the PACU) has to serve the dual role. Most of the ER residents I've interacted with (they rotate under me at the R3 level in the ICU) are fine, competent, well versed in acute care issues...no complaints here...

As for the loathing for the ABIM, I really can't speak to it other than it was the first organization to consolidate "critical care" into a specialty in 1987 and established criteria for certification (although critical care was obviously occurring long before that). The tie-in to pulmonary medicine was the result of the fact that the majority of physicians directing ICU care at the time were pulmonologists by training...a trend which continues today as 90% of the practitioners in critical care are indeed IM/CCM or Pulm/CCM trained. The choice of Pulm/CCM physicians to use that training is theirs. This is similar in fact to the roots of emergency medicine where most of the early emergency docs doing ER work were IM docs by training. Its just the evolution of medical specialization. As with most of these things, the issues of "certifications/priviliges" come down to red tape and politics.

That being said editorializing, slighting the current critical care workforce (rather than the shortage) is not likely going to help emergency medicine's cause. I recall a poorly conceived editorial to HT Huangs article by a frustrated and apparently poorly informed Jay Falk in Annals of Emergency Medicine, demonstrating poor understanding of the in/outs of critical care practice by people who happen to also know a little about the lungs, who stated:

"I believe the intensivist shortage is far worse than the “fellowship-trained” numbers indicate. The overwhelming majority of physicians certified in critical care medicine by the American Board of Internal Medicine are pulmonary physicians. While many of these people would be capable of being intensivists, in the real world of medical practice they are not. The practice model of office-based practice dominated by scheduled outpatient procedures, sleep lab and pulmonary function lab activities predominates. Practitioners willing to be full time intensivists are very much in the minority in this group. Emergency physicians, on the other hand, would take a “straight” critical care track with the goal and expectation of being hospital based, either in the emergency department, the ICU or both"

Not his shining moment.

The two year training track encorporates research time which is a component of many ABIM subspecialties...to answer the call to generate more academic physicians. The actual clinical time for critical care in most of these programs is 12 months....just like surgery or anesthesiology and the total training time for all three is 5-6 years. That being said, it has been successful as most seminal articles that have had the most impact within critical care in say the past five years (ARDS, sepsis, PAC use) have been generated by IM trained intensivists.

IM is in an identity and training crisis in some places and attempts to secure a foothold within certain specialties have probably lead to the perceived underhandedness. Your interaction with IM residents who, though cerebrally competent, lack adaptation and procedure skills is not uncommon as much of those skills are getting lost to the radiologists, surgeons and subspecialists. I was lucky to train in a place where IM had some balls and ownership of their procedures. Enhancing this training(airway mgmt, lines, thoracostomies, indwelling catheters, etc) among junior IM residents has become a crusade for myself and fellow colleagues currently.

As for your last statement, very accurate and disheartening....currently only ~23% of patients in "ICUs" are taken care of by physicians with specific training in critical care...in my mind, thats much like only 23% of patients who get brain surgery actually having it done by a real neurosurgeon...scary. And unfortunately, current forecasts don't look so good, despite the growth of the critical care industry.

 

[Apollyon]

I don't think I made a clear statement in that my point is that the ICU is the place for critical care and that current evidence shows that patients treated by physicians without dedicated training in critical care have demonstrated increases in number of ICU days, morbidity and mortality, etc...

See, now, one of our EM attendings did the 1-year CCM program at ShockTrauma, and he constantly reiterates that "critical care is an idea, not a location", and he is a devotee of Manny Rivers and the whole deal - the first guy in memory in our department to float a Swan. A few times, though, he's been caught by going overboard when the patient just wasn't that sick.

I had an interest in CCM with consideration for more training until I did my MICU month - even as my practice style changed (unlike after the SICU or PICU), I still say that the MICU was a failure month for me - and this one rotation turned me off to it. That's a bummer, but it happened. Even so, my desire is to provide critical care in the acute phase, and I realized that extended care (as in the unit) was not for me. However, at the same time, in a TRUE ICU (not a medicine floor plus, as we have here), I think that a sufficiently guided EM trained doc is as good as an IM trained doc as a precursor to fellowship.

 

[Eidolon6]

See, now, one of our EM attendings did the 1-year CCM program at ShockTrauma, and he constantly reiterates that "critical care is an idea, not a location", and he is a devotee of Manny Rivers and the whole deal - the first guy in memory in our department to float a Swan. A few times, though, he's been caught by going overboard when the patient just wasn't that sick.

Use of the "idea" of critical care is fine, but implementation is another issue. Manny Rivers uses his paper to justify the ER as a location to perform more involved care generally saved for the ICU there whereas my interpretation (as well as other intensivists) feel that the paper more or less proves that early recognition and implementation of a regimented strategy (in this case for sepsis, in a place designed to employ it) results in the better outcomes. Had he designed the protocol to send the patient to the ICU at first recognition of sepsis and implementation of the same early-goal directed protocol vs the sluggish control protocol, I suspect the outcomes would have been the same or better. It was the idea in that paper, not the location that resulted in improvement which is ironic given his subsequent arguments endorsing the ER as a place for critical care. But hey, he has a political agenda which may be noble...although given current ER crises...my feeling is adapting the ER (who has to do too many jobs already) to do the ICU's job is the wrong direction and maturing our current ICU workforce is the way to go. Its hard to hammer a nail with the palm of your hand which is why you should go where the tools are. Experience based opinions here, again free for interpretation.

 

[southerndoc]

Use of the "idea" of critical care is fine, but implementation is another issue. Manny Rivers uses his paper to justify the ER as a location to perform more involved care generally saved for the ICU there whereas my interpretation (as well as other intensivists) feel that the paper more or less proves that early recognition and implementation of a regimented strategy (in this case for sepsis, in a place designed to employ it) results in the better outcomes. Had he designed the protocol to send the patient to the ICU at first recognition of sepsis and implementation of the same early-goal directed protocol vs the sluggish control protocol, I suspect the outcomes would have been the same or better. It was the idea in that paper, not the location that resulted in improvement which is ironic given his subsequent arguments endorsing the ER as a place for critical care. But hey, he has a political agenda which may be noble...although given current ER crises...my feeling is adapting the ER (who has to do too many jobs already) to do the ICU's job is the wrong direction and maturing our current ICU workforce is the way to go. Its hard to hammer a nail with the palm of your hand which is why you should go where the tools are. Experience based opinions here, again free for interpretation.

Rivers did his study because at the time, the majority of patients were being boarded in the ED for prolonged periods of time before being moved into the ICU.

I agree with the statement that critical care should be started in the ED, but should primarily be provided in the ICU. I don't see an argument that ED physicians board patients in the ED longer instead of sending them to the general wards.

Critical care training for ED physicians can provide a couple benefits. Among them are earlier recognition and better management of critically ill patients in the ED, and the other benefit is to staff ICU's as attendings.

At my institution, critical care is stellar in the ICU's. Patients are shuttled from the ED to an ICU relatively quickly once an "ICU diagnosis" is established. We have automatic ICU admission criteria, such as ventilator-dependent respiratory failure, initiation of bilevel-PAP or CPAP, lactate >4 with evidence of sepsis, naloxone drip, GI bleed with hemodynamic instability, and a few others. Others require a consult. Once "sick" patients are identified in the ED, they are quickly central lined (if needed) and a-lined using sterile precautions (including gowns) and then sent to the ICU as soon as possible to continue care.

We choose to do the central lines because the resident/intern team for the medical ICU service is extremely busy (10-15 admissions per 24 hours with cross-coverage of 20-40 patients). It makes it difficult for them to perform procedures.

We start early goal directed therapy, but patients are NOT kept in the ED for six hours to fully implement it. There is absolutely no reason to do that. Quite frankly, when I'm seeing two patients per hour in a critical care area, I don't have the time to constantly check CVP's, central venous O2's, etc. on septic patients who could be better served by an ICU team and nurses who aren't assessing two new patients every hour.

I have not read the study, but one of our attendings trained with Rivers. He often mentions research that demonstrated nurse-driven early goal directed therapy protocols failed to improve mortality as much as the Rivers study.

 

[AJM]

I have not read the study, but one of our attendings trained with Rivers. He often mentions research that demonstrated nurse-driven early goal directed therapy protocols failed to improve mortality as much as the Rivers study.

Yes, that is a big criticism of the Rivers study. Other institutions have tried to duplicate his work, and while they found a reduced mortality, they haven't had nearly the reduction in mortality that he had. Another criticism that I recently heard was that apparently all the patients in the treatment arm of the study were treated by Manny Rivers himself, while the control group was treated by whoever was in the ED at the time..... that's just hearsay - I don't know if it's actually true.

As far as the nurse-driven EGDT protocols, I personally think they're a great idea. One of the hospitals I'm at has a pretty good protocol where the ED can call a "code sepsis", which then activates the full EGDT order set, which is then primarily administered by the nursing staff. This also frees up time for the ED physicians to deal with other patients, since they don't have to be the ones following the CVP or central venous sats -- the nurses are dealing with those and have pre-written orders that guides them in how to react with the data they get. This protocol has also helped to greatly reduce the mortality from sepsis at this hospital -- it's currently well below the national average. It also doesn't really matter where the septic patient is -- the protocol is the same whether they're in the ICU or the ED.

But I digress. I think ER physicians would fit quite naturally in the critical care environment. I just worked with an ED/CCM attending in the MICU, and I felt like he did an excellent job (he also trained under Manny Rivers -- has everyone worked with this guy??). I also really learned a lot from him, particularly since he was coming from a different perspective than myself and the other folks from my specialty. Personally I think it's an ideal situation when you can bring people who are all trained in critical care but who come from different backgrounds together to improve collaboration and to increase everyone's opportunity to learn.

*steps off the soapbox*

 

[Apollyon]

Use of the "idea" of critical care is fine, but implementation is another issue. Manny Rivers uses his paper to justify the ER as a location to perform more involved care generally saved for the ICU there whereas my interpretation (as well as other intensivists) feel that the paper more or less proves that early recognition and implementation of a regimented strategy (in this case for sepsis, in a place designed to employ it) results in the better outcomes. Had he designed the protocol to send the patient to the ICU at first recognition of sepsis and implementation of the same early-goal directed protocol vs the sluggish control protocol, I suspect the outcomes would have been the same or better. It was the idea in that paper, not the location that resulted in improvement which is ironic given his subsequent arguments endorsing the ER as a place for critical care. But hey, he has a political agenda which may be noble...although given current ER crises...my feeling is adapting the ER (who has to do too many jobs already) to do the ICU's job is the wrong direction and maturing our current ICU workforce is the way to go. Its hard to hammer a nail with the palm of your hand which is why you should go where the tools are. Experience based opinions here, again free for interpretation.

Good stuff. I, personally, follow the lesson I learned as EMS - play "hot potato" with patients. The longer you have a patient, the more likely you are to screw up, or have them screw you. If you "stay and play", chaos theory predicts that you will have untoward outcomes (aspiration, pt fall out of bed, day-night reversal, one pt assault another, mechanical failure of the vent, pneumothorax/barotrauma from the oscillator, et alii, ad nauseam).

Now, mind you, lest some less-erstwhile colleagues may carp, what I am speaking of is NOT EM docs dumping and dispositioning patients before they are ready - but, instead, sending them to the unit at the right time, instead of sitting on them in the ED playing CCM doc (as has been supported above).

 

[KGUNNER1]

This is all great! Wonderful discussion, these have really improved over the past 3 years and all of you are very well versed. I am greatly impressed. It seems like several people really know and understand the issues.

As always, I'll just throw my 2 cents in for minor clarification only.

1) Rivers and political agenda - Manny really has gotten away from any political agenda in the past 5 years. He is beyond that. He is boarded and trained in IM/EM/CCM so there is no personal agenda here. The political agenda about training issues were picked up by a few of us back in the late 90's and we've been slowly applying pressure up until our "white paper" last year. Manny will always have an influence, but he has very little time for politics.

2) The EGDT trial (I was a part of it for the 5 years I was in residency) was done at a time where the resuscitation of these patients was not too sophisticated. Remember, every sepsis trial before this was a huge bust. All the intensivists and ED docs had the impression that nobody could do anything for these patients, they'd get better or they wouldn't. The reason EGDT was completed in the ED for 6 hrs is because that was the avg. wait for an ICU bed & the environment at Ford at that time would not have been conducive for the protocol to continue up in the unit. I guarantee it! I was there on BOTH sides. It really was a paradigm shift.

3) Manny didn't do every resuscitation himself; he trained everyone how to follow the protocol though. Also, consider the Hawthorne effect, the control patients were being taken care of by the same residents and attendings that were following the EGDT protocol. Even though they weren't in the treatment arm, they did get a very aggressive resuscitation.

4) Eidolon, I'm glad you enjoyed our paper, but David T Huang spells his first name with a D not a H (just being a smart a**)

5) Remember the Father of Critical Care, the late Peter Safar, was an advocate of delivering critical care wherever the patient was. It was a specialty without walls. This concept was developed in the 1960's. Emergency care was just as important as care in the OR or ICU. Somewhere in between then and now, we all started protecting our own turf and ultimately the patients suffered, so now we're going back and re-discovering our origins and acting like we're saying something new. We're NOT. We ALL deliver critical care and it ALL is just as important.

Bottom line, we (as a CCM focused group of physicians) and the medical profession in general, need to quit sticking out our chests and put the petty ego-driven grudges aside and figure out what we're going to do with these patients that are sitting in the ED for 8-24 hours waiting for an ICU bed. We should be trying to find solutions to this problem rather than pointing fingers at who is "better". The problem is bigger than us individually and it will get bigger in the next 20 years.

I hope the combination of the IOM report, our paper, some open minded leadership in ABMS, ABIM, and ABEM will come together and open doors rather than shutting them.

Time to step down off my soap box now. Keep up the GREAT discussions all. I really am enjoying reading your posts. If you have any questions, drop me and email.

Kyle

 

[aliraja]

While I've enjoyed the discussion about whether or not EM docs can or should do CCM fellowships, I'm at the stage where I need to look at this from a more pragmatic point of view and I'd very much appreciate any input you folks might have on the subject.

I'd like to pursue an academic position at a research center and would obviously work primarily in their ED. However, I'd also like to work a week or so a month in an ICU. I'm more than willing to do a 1 or 2 year ICU fellowship in order to do so but I just don't know the answer to a couple of simple questions:

Are EM/CCM trained docs getting jobs at academic medical centers? Or are they limited only to smaller/community hospitals?

Thanks guys - again, any examples or anecdotes would be great!

 

[southerndoc]

Are EM/CCM trained docs getting jobs at academic medical centers? Or are they limited only to smaller/community hospitals?

One of our CC-fellowship trained ED attendings attends in the SICU one week per month. He loves it.

 

[waterski232002]

Here are a list of some academic hospitals where EM/CCM physicians are ICU attendings.

- University of Pittsburgh
- University of Pennsylvania
- NYU/North Shore University
- UMDNJ
- Brigham and Women's Hospital
- University of Florida
- University of Maryland/Shock Trauma

Other Programs which have a history of accepting EM physicians into CCM fellowships are listed below... I am sure there are others in addition to this.

- John's Hopkins
- University of Washington
- University of Alabama
- Dartmouth
- Yale

 

[KGUNNER1]

Here are a list of some academic hospitals where EM/CCM physicians are ICU attendings.

- University of Pittsburgh
- University of Pennsylvania
- NYU/North Shore University
- UMDNJ
- Brigham and Women's Hospital
- University of Florida
- University of Maryland/Shock Trauma

Other Programs which have a history of accepting EM physicians into CCM fellowships are listed below... I am sure there are others in addition to this.

- John's Hopkins
- University of Washington
- University of Alabama
- Dartmouth
- Yale

Other academic centers with EM/CCM attendings include:
- VCU Medical Center - Richmond
- Univ. of Virginia
- Univ. of Utah
- Univ of New Mexico

Just to add a few to the list. There are 4 at VCU medical center.

 

[roja]

Great discussion

A recent attending in our institution just started the ICU fellowship She wants to do part time in an ICU and part time in the ED. I don't think jobs are that difficult to find, as illustrated by the shortages in ICU staffing across the country.

Regarding Rivers and CCM in the ED: This is vital. In a perfect world, the instant a ICU player was identified they would get up to the ICU. However, most places I have been (and from others I know), patients sit in the ED for hours. So, the CCM needs to be delivered there. (I am currently holding a horribly septic patient on pressors, etc after recieving EGDT in the ED because there are no beds in the ICU... not an uncommon occurance for oru busy hospital.)

The relationship between the CCM and the ED needs to be one that is worked in combination. It should never be a "EM caring in teh first six hours" and then CCM taking over the rest.

I have worked for over 2 years to establish that relationship (and dispell the misconceptions on both sides) by establishing monthly joint hour long conferences and biannual full day critical care conferences. I have also worked closely with our Critical Care committee to develop our sepsis pathway, both for medicine house staff and ED staff. Its vital that it not become a 'he said/she said'. The Rivers trial showed that EGDT (recognition and agressive EARLY treatment of sepsis) has a phenomenal NNT (6). Even if you want to up those numbers, say to 20 or even 30, its still damn good and something that should be done. (sepsis being one of the top killers in the country with a national mortality greater than MI, breast CA, etc... If I remember, its about 215,000/year)

Many CCM minded EM docs (myself included) don't want to do fellowships or become ICU docs (I shudder at the rounding) but recognize that really sick patients land in our ED's and stay in our ED's for long periods of time. Its our job to recognize and treat, so we should draw on the experience and knowledge of those around us.... all for the betterment of our patient's care

 

[Dr. J?]

Great discussion


The Rivers trial showed that EGDT (recognition and agressive EARLY treatment of sepsis) has a phenomenal NNT (6). Even if you want to up those numbers, say to 20 or even 30, its still damn good and something that should be done. (sepsis being one of the top killers in the country with a national mortality greater than MI, breast CA, etc... If I remember, its about 215,000/year)

The following is not meant to bust chops or belittle sepsis (by any means), just to simply correct misinformation:

According to the AHA, in 2002 deaths in USA from ACS number 330,000.

http://www.americanheart.org/downloadable/heart/1136822850501OutofHosCA06.pdf

Add about 35,000 for breast CA and that's more than sepsis.

Actually, looks like sepsis is about #10.

http://www.cdc.gov/nchs/data/nvsr/nvsr49/nvsr49_11.pdf#search='sepsis%20AND%20death%20ranking'

 

[roja]

The following is not meant to bust chops or belittle sepsis (by any means), just to simply correct misinformation:

According to the AHA, in 2002 deaths in USA from ACS number 330,000.

http://www.americanheart.org/downloadable/heart/1136822850501OutofHosCA06.pdf

Add about 35,000 for breast CA and that's more than sepsis.

Actually, looks like sepsis is about #10.

http://www.cdc.gov/nchs/data/nvsr/nvsr49/nvsr49_11.pdf#search='sepsis%20AND%20death%20ranking'

National Vital Statistic Report, 2004

Deaths from-
MI: 179, 969
CVA: 163,010
Lung CA: 158,258
Breast CA: 49,189

Death from Septic Shock (if you go to NVSR it unfortunately doesn't have a mortality for just sepsis, you have to plow through the numbers for urinary/pulmonary/intrabdominal, etc)

Estimated 215,000 (from Angus, et al. Epiemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Critical Care Med. 2000: 29:1303-1310)

 

[Dr. J?]

National Vital Statistic Report, 2004

Deaths from-
MI: 179, 969
CVA: 163,010
Lung CA: 158,258
Breast CA: 49,189

Death from Septic Shock (if you go to NVSR it unfortunately doesn't have a mortality for just sepsis, you have to plow through the numbers for urinary/pulmonary/intrabdominal, etc)

Estimated 215,000 (from Angus, et al. Epiemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Critical Care Med. 2000: 29:1303-1310)

OK, fair enough. According to the http://www.survivingsepsis.org/ web-site the number may actually be up to 750,000! I stand corrected.

 

[roja]

I think the number is high, however, I wasn't aware until recently how significant. Its a huge mortality, and most importantly early intervention such as the Rivers paper has a phenomenal NNT. You need to treat 6 patients to have a positive outcome for one. Aspirin is only about 40, which is still huge.

 

[Dr. J?]

I think the number is high, however, I wasn't aware until recently how significant. Its a huge mortality, and most importantly early intervention such as the Rivers paper has a phenomenal NNT. You need to treat 6 patients to have a positive outcome for one. Aspirin is only about 40, which is still huge.

Your correct, giving aspirin for 1 mos (post MI?) yields a NNT (to prevent 1 vascular death for 5wks) of 40.

Here's a few more NNT's for comparison. An NNT=6 would be very much in the ballpark of many other "routine" medical therapies.

http://www.jr2.ox.ac.uk/bandolier/painres/download/whatis/NNT.pdf

 

[KGUNNER1]

OK, fair enough. According to the http://www.survivingsepsis.org/ web-site the number may actually be up to 750,000! I stand corrected.

Actually the INCIDENCE of SEVERE SEPSIS is around 750,000 per year and rising. The MORTALITY of this is roughly 35%. Septic shock mortality is close to 50%.

Keep in mind, severe sepsis is a disease of incidence rather than prevalance. There aren't too many people walking around with chronic sepsis for 3 years waiting to die.

Cancer and other chronic disease states can be described by both; new cases each year, and those who are living with it year after year.

Just FYI,
Kyle

 

[roja]

Your correct, giving aspirin for 1 mos (post MI?) yields a NNT (to prevent 1 vascular death for 5wks) of 40.

Here's a few more NNT's for comparison. An NNT=6 would be very much in the ballpark of many other "routine" medical therapies.

http://www.jr2.ox.ac.uk/bandolier/painres/download/whatis/NNT.pdf

I don't know that I would put decreasing mortality (NNT of EGDT of 6 to prevent death) along side some of the 'routine' medical therapies.

The impressiveness of both aspirin and EGDT is that they have such profound effects on MORTALITY.

 

[ambiguous]

sorry to revive this old thread but I was curious as to how much progress there has been in regards to EM/CCM. Are more hospitals accommodating physicians now to be able to practice part-time EM and part-time CCM? I am currently an MS3 and struggling between whether to go the IM to pulm/ccm route or just straight into EM.

 

[KGUNNER1]

sorry to revive this old thread but I was curious as to how much progress there has been in regards to EM/CCM. Are more hospitals accommodating physicians now to be able to practice part-time EM and part-time CCM? I am currently an MS3 and struggling between whether to go the IM to pulm/ccm route or just straight into EM.

Yes. We are currently finishing up a survey and are getting ready to publish the results, but we now have over 100 EM/CCM docs practicing. Many are in academic centers and most practice both EM and CCM. There are new fellowships starting each year. We've recently hired our 5th EM/CCM attending.

There is a very active section of Critical Care in ACEP http://www.acep.org/acepmembership.aspx?id=24886, it's brother section of Emergency Medicine in SCCM http://www.sccm.org/Membership/Specialty_Sections/Emergency_Medicine/Pages/default.aspx, and the newly formed EMRA critical care committee http://www.emra.org/emra_about.aspx?id=28810. These are all great places to get more information about EM/CCM and to start the networking process.

If you are still interested, I would highly consider joining one (or all) of these groups. Most of us are members of multiple sections, since the total "n" is still small.

KG

KG

 

[ambiguous]

Yes. We are currently finishing up a survey and are getting ready to publish the results, but we now have over 100 EM/CCM docs practicing. Many are in academic centers and most practice both EM and CCM. There are new fellowships starting each year. We've recently hired our 5th EM/CCM attending.

There is a very active section of Critical Care in ACEP http://www.acep.org/acepmembership.aspx?id=24886, it's brother section of Emergency Medicine in SCCM http://www.sccm.org/Membership/Specialty_Sections/Emergency_Medicine/Pages/default.aspx, and the newly formed EMRA critical care committee http://www.emra.org/emra_about.aspx?id=28810. These are all great places to get more information about EM/CCM and to start the networking process.

If you are still interested, I would highly consider joining one (or all) of these groups. Most of us are members of multiple sections, since the total "n" is still small.

KG

KG

Thanks for those links kgunner. From what I could tell from some of those sites, it seems the options are still very limited. Just to tease out all the options available, could you let me know what some of the advantages are of going into CCM through EM? Are they any better/worse than pulm/CCM docs?

 

[howelljolly]

I've got a similar request. Could you mention some of the advantages of going at it via IM-PCCM? Are there more opportunities in academia and research? Will you be more suitied as a consultant for other services? Is pulmonary disease something that you can form a niche in, and not feel like you have to drag yourself to the clinic?

 

[KGUNNER1]

There really isn't a right answer as to how you get your CC training. My suggestion is do the residency you want to do first. If you hate IM and love EM, then do EM. There are more CC programs accepting EM grads each year. You may have to look a little harder for a job, but today we have over 100 EM/CCM docs in the country and each year we graduate about 10 fellows (maybe more). So you'll have the opportunity.

IM/Pulm is definitely the most common route. You'll find a job pretty much anywhere in the country. If you go the IM route, and like pulm, then this is the route I'd take. Most groups will want you to share in clinic/consult time, but you may be able to negotiate this for more ICU time. Pulm has many "niches" pulm HTN, COPD, Asthma, transplant, sarcoid, interventional, sleep, etc... you can sub-specialize if you feel the need.

Hope this helps,
KG