Going from micu-based pccm fellowship to mixed ICU

[Student3322]

I'm finishing a pccm fellowship which has been MICU heavy but took a job in a multidisciplinary critical care setting where attendings rotate through surgical (including post-cardiac) and neuro ICU in addition to MICU, all closed units. We spent limited time in neuro/sicu/cardiothoracic icu in fellowship but I feel nowhere near as comfortable being the primary attending on these patients as I do for micu patients.

Are there some resources out there to review managing these patients? Any common mistakes you guys see from people with pulm backgrounds in these units? Would appreciate any advice, especially from others who have made this transition.

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[ShockIndex]

Be honest with your future employer and let them know your comfort and limitations. Get to know a couple of your partners with anesthesia, neuro, or EM-CCM backgrounds who are comfortable with mechanical support, neuro, CVICU etc. They are generally more than happy to mentor you. Get to know your consultants. Although you mentioned “closed units” the overwhelming majority of non-MICU patient care is driven by cards, NSG, and surgeons - we are just there for the ride and handle the fundamentals of critical care.

 

[gro2001]

Be honest with your future employer and let them know your comfort and limitations. Get to know a couple of your partners with anesthesia, neuro, or EM-CCM backgrounds who are comfortable with mechanical support, neuro, CVICU etc. They are generally more than happy to mentor you. Get to know your consultants. Although you mentioned “closed units” the overwhelming majority of non-MICU patient care is driven by cards, NSG, and surgeons - we are just there for the ride and handle the fundamentals of critical care.

That's only half true for neurocritical care. There are just too many things that the surgeons aren't involved in (status epilepticus, meningitis/encephalitis, ICH without intervention, neuromuscular, etc). And even in a lot of the surgical diseases (eg aneurysmal SAH) they generally prefer to defer to intensivists on a lot of questions (medical management of ICP, seizure meds beyond prophylactic keppra, what mix of modalities to use to monitor for vasospasm, etc). Sure, they will drive the EVD wean and god forbid you start subQ heparin without talking to them. But a lot of these other questions (arguably the big ones, most importantly prognosis) they would generally prefer to defer to the intensivists (unless the intensivists don't really know enough to be helpful).

 

[gro2001]

I'm finishing a pccm fellowship which has been MICU heavy but took a job in a multidisciplinary critical care setting where attendings rotate through surgical (including post-cardiac) and neuro ICU in addition to MICU, all closed units. We spent limited time in neuro/sicu/cardiothoracic icu in fellowship but I feel nowhere near as comfortable being the primary attending on these patients as I do for micu patients.

Are there some resources out there to review managing these patients? Any common mistakes you guys see from people with pulm backgrounds in these units? Would appreciate any advice, especially from others who have made this transition.

That's what a lot of jobs in the community are like these days.

Some of your discomfort might be just not being used to being in charge of something that is much more siloed in academia (like who gets to play with ECMO, who can write CRRT orders) that are much more fluid in the community. But it may be that you were more insulated from some stuff you should have been more exposed to.

I think the key steps here are two fold:

1) Understand your limitations. Be honest about your unknowns, most importantly with yourself. Be aware there may be unknown unknowns. Maybe this is my neurointensivist bias, but I think that applies first of all to neurocrit. Disasters can be subtle. A lot of people who die (or do poorly) are condemned by your misunderstanding of their prognosis (over reliance on ICH score for example, not realizing that the patient in front of you is stuporous because of hydrocephalus and will do really well actually if they get an EVD). For context, in cardiac arrest, the leading cause of death (like 80% of those who survive to ICU) is withdrawal of life sustaining therapy. About 20% of the time it's withdrawn it's done on people who would have had a CPC1 (ie back to work) outcome at 1 year.

2) Make a study plan. I can speak most specifically about neurocrit here. I would recommend several resources:

-ENLS course (or at least just the papers) for a basic overview
-SCCM neurocrit board review course
-The NeuroICU book

Textbooks in general are your friend in that they provide a pre-made curriculum so you know what the general corpus of knowledge looks like. You are fresh out of Pulm Crit training, so you don't need refreshers in Pulm (or maybe even the bulk of CCM), so for your first couple of conferences go to ones in areas for which you feel underprepared (Neurocritical care society for neurocrit, maybe another for mechanical circulatory support, etc).

 

[lunaire]

If you lack the experience, you NEED to lean on the consultant services and colleagues. By all means study, but understand that each of the ICUs you are describing would usually require months of fellowship rotation to really get the basics, and then there's the more advanced stuff that they are paying attending the big bucks for. There's quite a lot of nuances between the subspecialty critical care that you will need to pick up on, and until you do, you will miss things in independent practice.

If possible, I would request shift to focus on one subspecialty at a time, while you get your bearing and knowledge base up to par. Honestly, if you do not get adequate support from consultants, I would look for a new job. It would be very frustating.

 

[grt398]

Agree with all of the above, and just throwing out there that in my experience at least, CTICU patients can crash harder and faster than almost any other subset of patients, and definitely lean on your colleagues until you're comfortable with them. And learn when you need to insist on that TEE being done immediately and not the following morning. And know who is going to do the resternotomy if they code...and if it's you, just make sure you're ok with that.

 

[The kitchen sink]

Agree with all of the above, and just throwing out there that in my experience at least, CTICU patients can crash harder and faster than almost any other subset of patients, and definitely lean on your colleagues until you're comfortable with them. And learn when you need to insist on that TEE being done immediately and not the following morning. And know who is going to do the resternotomy if they code...and if it's you, just make sure you're ok with that.

CTICU intensivist do resternotomy’s ?

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[The kitchen sink]

If you lack the experience, you NEED to lean on the consultant services and colleagues. By all means study, but understand that each of the ICUs you are describing would usually require months of fellowship rotation to really get the basics, and then there's the more advanced stuff that they are paying attending the big bucks for. There's quite a lot of nuances between the subspecialty critical care that you will need to pick up on, and until you do, you will miss things in independent practice.

If possible, I would request shift to focus on one subspecialty at a time, while you get your bearing and knowledge base up to par. Honestly, if you do not get adequate support from consultants, I would look for a new job. It would be very frustating.

Not having adequate support from consultants is a largely unspoken contributor to burnout for ICU physicians. Sick patients, not much help. I think thats why there is trend for intensivist to become more and more ‘complete physicians’ i.e. the move towards bedside POCUS, echo/TEE certifications etc

 

[Student3322]

Thanks this is helpful. I guess one thing that I'm unsure about is just how much is expected to be run by the surgeon for these patients vs. what the intensivist is supposed to do. Are things like fluid boluses, starting/changing antibiotics, or sending someone to the floor all things that are expected to be discussed with a surgeon before ordering?

 

[CCM-MD]

Thanks this is helpful. I guess one thing that I'm unsure about is just how much is expected to be run by the surgeon for these patients vs. what the intensivist is supposed to do. Are things like fluid boluses, starting/changing antibiotics, or sending someone to the floor all things that are expected to be discussed with a surgeon before ordering?

This will vary. Depends on the surgeon and the institutional culture. This is why CTICU/SICU work is often less desirable/undesirable.

 

[chessknt]

Thanks this is helpful. I guess one thing that I'm unsure about is just how much is expected to be run by the surgeon for these patients vs. what the intensivist is supposed to do. Are things like fluid boluses, starting/changing antibiotics, or sending someone to the floor all things that are expected to be discussed with a surgeon before ordering?

Institution and even more than that surgeon dependent. The more academic the less likely you'll be in charge of. I've never seen a CT surgeon let an intensivist manage much of anything beyond a vent and never on when to send a patient to the floor. This is because so much of their pay tends to be tied to esoteric metrics with minimal clinical relevance and they want to be in charge of making sure those metrics are achieved since they frequently require unnecessary high resource utilization that would be stopped by a neutral third party.

Other fields will depend on how busy/chill the surgeons are.

 

[Siggy]

CTICU intensivist do resternotomy’s ?

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American Thoracic Society guidelines for post cardiac surgery cardiac arrest is for any qualified person available to do the resternotomy, including training senior ICU nurses to do so if a thoracic surgeon isn't available around the clock. Emergency resternotomy should be done within 5 minutes of identifying the arrest since it will take care of both tension pneumos and tamponade, tamponade being the most common cause of arrest.

https://www.sts.org/sites/default/files/documents/ExpertConsensus_ResuscitationAfterCardiacSurgery.pdf

 

[grt398]

CTICU intensivist do resternotomy’s ?

Tell me more

As Siggy mentioned above, the goal is to be done within 5 min if at all possible, and while it's uncommon, in training fellows did it, attendings did it, and even the overnight PA's/NP's did it occasionally if no one else was in house and it would be 15-20 minutes for the surgeon to get bedside. The surgeon would be on the phone the entire time but yes, non CT surgeons will cut the sternal wires and reopen the chest to eliminate the pressure component of tension pneumos/tamponade as mentioned.

 

[lunaire]

Just to add to the resternotomy - anybody can get training in it, and if you are primarily in the cardiac ICU, you probably should be able to open up the chest. High volume cardiac centers would usually have the surgical/ICU NP open the chest in the event of refractory cardiac arrest, well before the surgeon gets to bedside. It is not difficult. No reason why the intensivist should not be able to do the same thing.

Here's one resource for training and certification:

https://www.csu-als.org/default.aspx

 

[The kitchen sink]

Thanks for the explanation guys