ICU procedures at the beginning of fellowship

[BritAnaesthesia]

Hi guys, just wondering what procedures are expected of a fellow right at the beginning of their fellowship during on calls vs becoming proficient by the end of fellowship. I'm an anaesthesia resident so I'm happy with tubing, videolaryngoscopy, fibreoptics, a lines, CVCs, Vascaths. I've done a bit of bronc and bedside perc trachy but not yet happy doing these unsupervised. I'm also not TTE certified yet as it's not very relevant to anaesthetic practice. Are these skills I would need to have before applying for a fellowship?

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[lunaire]

I would say intubation, central line placement, a line, basic POCUS, leading CPR/ACLS at the beginning of fellowship

At the end, add chest tube placement, therapeutic bronch, PA cath placement, basic TTE/CCeXAM, spinal taps, paracentesis. Depending on your ICU/future career goals, can also add use of fluoroscopy, ECLS cannulation, IABP/impella/LVAD related mgt/procedures, temp venous pacer insertion, pericardial drain, basic periop TEE cert, EVD placement, trach/PEG.

If you end up practicing in the middle of nowhere, you'll notice they'll let you do whatever procedure you are comfortable doing. One job was asking me to place endobronchial valves and actual endobronchial biopsies.

As you can see, list is pretty extensive. I would recommend being strategic with your time, plan what you actually want to do, what kind of ICU doc you want to be, and look up what you need to be certified in them. Some are much easier to acquire in residency, some are easier to learn when you get good at other skills first. You still learn new skills as attending; I'm still getting new certification and privileges 10+ years post residency.

 

[SpacemanSpifff]

Hi guys, just wondering what procedures are expected of a fellow right at the beginning of their fellowship during on calls vs becoming proficient by the end of fellowship. I'm an anaesthesia resident so I'm happy with tubing, videolaryngoscopy, fibreoptics, a lines, CVCs, Vascaths. I've done a bit of bronc and bedside perc trachy but not yet happy doing these unsupervised. I'm also not TTE certified yet as it's not very relevant to anaesthetic practice. Are these skills I would need to have before applying for a fellowship?

No. Many internal medicine trainees come to critical care fellowship with very little procedural training. There is no universal expectation that new fellows be proficient in any procedures, that’s part of the curriculum of fellowship. As an anesthesiologist you will have had much more exposure to many of the common procedures.

 

[Tipsy McStagger]

Any reputable program should be able to take you with the assumption that you know 0 procedures. It’s of course better if you have experience, but it’s not required. You’ll be fine.

 

[lunaire]

No. Many internal medicine trainees come to critical care fellowship with very little procedural training. There is no universal expectation that new fellows be proficient in any procedures, that’s part of the curriculum of fellowship. As an anesthesiologist you will have had much more exposure to many of the common procedures.

That's why IM critical care fellowship is two years. Anesthesia CCM fellowship is 1 year. Generally, we graduate residency with good procedural skills, but relatively behind on inpatient & ICU medical knowledge base. I personally studied my ass off in that one year, and still graduated with a ton of incomplete learning objectives in those topics.

Also, not gonna lie, if my anesthesiology board-eligible CCM fellow is noticeably lacking in proficiency with basic procedures, I would have an unfavorable impression of them. WTF have they been doing all residency?

 

[SpacemanSpifff]

That's why IM critical care fellowship is two years. Anesthesia CCM fellowship is 1 year. Generally, we graduate residency with good procedural skills, but relatively behind on inpatient & ICU medical knowledge base. I personally studied my ass off in that one year, and still graduated with a ton of incomplete learning objectives in those topics.

Also, not gonna lie, if my anesthesiology board-eligible CCM fellow is noticeably lacking in proficiency with basic procedures, I would have an unfavorable impression of them. WTF have they been doing all residency?

That’s fair. I think there are a few reasons why the fellowships are different lengths, but procedural proficiency is probably less important than institutions needing cheap labor. EM trainees have a two year pathway regardless of the route we choose (anesthesia, IM, neuro, surgical) - is that because we need more procedural training than a neurologist or internist? I don’t think so.

I agree that one year is a tough to learn the breadth and depth of critical care, and that anesthesia trainees should be fairly competent in many of the procedures OP lists.

 

[BritAnaesthesia]

That's why IM critical care fellowship is two years. Anesthesia CCM fellowship is 1 year. Generally, we graduate residency with good procedural skills, but relatively behind on inpatient & ICU medical knowledge base. I personally studied my ass off in that one year, and still graduated with a ton of incomplete learning objectives in those topics.

Also, not gonna lie, if my anesthesiology board-eligible CCM fellow is noticeably lacking in proficiency with basic procedures, I would have an unfavorable impression of them. WTF have they been doing all residency?

My question was more with regards to procedures that are more inherent to ICM rather than anaesthesia. For example tubes, art lines, CVC, Vascath are very bread and butter for anaesthesia as is sedation/pain control/an array of blocks including neuraxial/putting sick people to sleep, involvement in cardiac arrests and trauma. But bronchs aren’t something we do day to day in theatres, we do a few during ICU time but won’t be as independent with it. Similarly for bedside echo, while this is a relatively commonly practiced skill in the ICU, you don’t really use it in anaesthesia so easy to lose that skill.

 

[BritAnaesthesia]

That’s fair. I think there are a few reasons why the fellowships are different lengths, but procedural proficiency is probably less important than institutions needing cheap labor. EM trainees have a two year pathway regardless of the route we choose (anesthesia, IM, neuro, surgical) - is that because we need more procedural training than a neurologist or internist? I don’t think so.

I agree that one year is a tough to learn the breadth and depth of critical care, and that anesthesia trainees should be fairly competent in many of the procedures OP lists.

Also in Canada it’s all 2 years anyway and they take people from a variety of backgrounds. I would imagine each person would have some strengths and some weaknesses. I’m very comfortable tubing and venting someone whereas my minutiae knowledge of medical management of xyz disease might be rusty and I’d imagine an internal medicine colleague might be more rusty on rapid GAs on sick patients and tubing a hypoxic 120kg patient. I just think there are some procedures that you can only get proficient at by spending lots of time in the ICU doing them day in day out. Like spend enough time in Neuro ICU and you’d get good at perc trachy but you’d never develop that skill as fast elsewhere

 

[chessknt]

Agree that you really shouldnt be coming in with the expectation of doing procedures unsupervised in any decent program. You may be proficient at a variety of procedures but there is always more to learn so might as well get some feedback/training on stuff you think you know really well before never having that opportunity again. If the program is expecting you to be able to do everything from day 1 what is the point of it?

Procedures more inherent to CCM that the average anesthesiologist may not be quite proficient in are chest tubes, vent management on the non-anesthetized patient, paracentesis, and running a code if you want a specific list but as above this should be part of the training program.

 

[SpacemanSpifff]

Also in Canada it’s all 2 years anyway and they take people from a variety of backgrounds. I would imagine each person would have some strengths and some weaknesses. I’m very comfortable tubing and venting someone whereas my minutiae knowledge of medical management of xyz disease might be rusty and I’d imagine an internal medicine colleague might be more rusty on rapid GAs on sick patients and tubing a hypoxic 120kg patient. I just think there are some procedures that you can only get proficient at by spending lots of time in the ICU doing them day in day out. Like spend enough time in Neuro ICU and you’d get good at perc trachy but you’d never develop that skill as fast elsewhere

I love that your mind goes to 120kg as the weight for an obese patient - definitely not an American 😂

 

[BritAnaesthesia]

I love that your mind goes to 120kg as the weight for an obese patient - definitely not an American 😂

Haha we are catching up! Currently our point of horror is around 150-160kg lol It is scary reading about some of the weights mentioned by our US counterparts though, that'll be an experience just in itself! I feel like what we consider obese in the UK ICUs would be considered an average weight here.