Importance of # of ICU months in a program

[willow18]

How many would be 'enough' for the development of an EP who probably won't be going into critical care? It's interesting how widely they vary, from places that do only 2 blocks (St. Lukes in NYC, 3 year) to the average four or five blocks in most 3 and 4-year programs that I interviewed at, to seven at UMDNJ-Cooper (a 3 year program).

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[EctopicFetus]

I am out of residency but... as Peter Rosen and my own PD said.. "You learn emergency medicine in the emergency department"

I think your question also should include what type of ICU months you are talking about? Some programs I believe do NICU months? This seems like an utter waste of time.

IMO you need 1 month minimum of each PICU, Surg ICU, Med ICU. I think if your ICU months are strong thats enough.

 

[nycqqe]

At Maimonides(3yr program) we do 3 months, MICU, CICU, and PICU.

I would say PICU month is crucial for peds critical care exposure since kids in general just aren't that sick and critical care just doesn't happen as often in the peds ED. You really need a good solid month of PICU for that.

CICU is good to learn about cath and what happens to the cardiac patients after you admit them since so much of EM is cardiac related.

As for MICU, its relative usefullness depends on how much critical care exposure the ED gets. I would be worried if a program relies heavily on its MICU months for critical care and procedures, because that means their ED probably doesn't see as many sick patients. MICU critical care exposure is good but it's not exactly the same as ED critical care. At Maimo, I feel like I learn more about critical care and do more procedures during a shift than a whole week in the MICU.

 

[deleted109597]

We do SICU and CICU first year, MICU and PICU second year.
SICU has sicker patients on average than MICU (here). CICU is more intermediate care than intubated cardiac patients.
I've found that CICU is better for learning how to decrease someone's risk, when to start certain drips (intergrilin, etc). I wish there was more EP involved, as at least it is more interesting.
PICU is a rotation where the nurses ask you for things then go ahead and ask the attending anyway. Sometimes you can touch the kids, but only when the nurses aren't watching. Otherwise they would shoo you out of the room, because they really think you're there to kill the babies.

 

[lucky_deadman]

PICU is a rotation where the nurses ask you for things then go ahead and ask the attending anyway. Sometimes you can touch the kids, but only when the nurses aren't watching. Otherwise they would shoo you out of the room, because they really think you're there to kill the babies.

Hence the reason we did away with the PICU rotation and added another month of EM. (Plus we get some sick as stink kids in the ED and have everything done and have them stabilized before sending them to the PICU to "babysit")

We also don't technically count Cards or Tox as Critical Care months, although Cards tends to have a significant amount and Tox is 90% critical care (inpatient Tox unit). We have MICU in 1st year and SICU in 2nd year.

I feel very comfortable with critical patients and don't feel that I've missed anything by not having more Critical Care months.

 

[Pinner Doc]

PICU is a rotation where the nurses ask you for things then go ahead and ask the attending anyway. Sometimes you can touch the kids, but only when the nurses aren't watching. Otherwise they would shoo you out of the room, because they really think you're there to kill the babies.

Totally disagree. At my program, pretty much the fellow and the attending go to sleep... and it's all you. The fellow will wake up for admits and oversee those, but for the most part it was just me, the kiddos, and a VERY active Vocera.

 

[nycqqe]

Same thing here. At my program there's no PICU fellow, and the peds 3rd yr is busy doing admissions and covering the floor, so the EM2s handle the PICU solo. The ICU nurses in general really like the EM residents because we know how to run the unit.

 

[deleted65604]

PICU months are terrible. I did 2 months. The year behind me got out of the second month. Anybody who claims that they are "running" the PICU as a 2nd year ER resident is smoking crack. Those are some sick kids, and the attending is on the floor a lot. Major decisions are not made by ER residents. The typical PICU kid on my rotation was a single ventrical with transposition of the arteries, with situs inversus, status-post crazy palliative surgery, on three different vasopressors, and lasix, and whatever you thought should be done with the patient, the answer was the opposite.

In retrospect, I thought that PICU was painful, but essential to get a taste of peds. THere are things that you see in a PICU that are in a much higher concentration than you will ever see in the ER. PICUs generally have a ginormous catchment area involving dozens, if not hundreds of hospitals. The reality is that as an ER doctor, you don't admit to the PICU all that often. If you do, it is because pediatricians have told them specifically to go to your hospital to get admitted because they are a transplant patient, or have some crazy cardiac anomaly as above described.

I don't think you should be comfortable going to a residency that doesn't require at least one month of PICU.

 

[xaelia]

I agree that PICU is basically useless. Tweaking oscillator settings? Uhm, ok. Salvage vent modes in the ER are probably going to be so uncommonly used that I'd have to look them up anyway. Calculating daily caloric requirements so I can set the tube feeds? Very useful PICU learning experience. Waiting for the trached 13 year old from the chronic care home to tell us when he feels like his breathing is good enough to go home? Oh, ok, how about today? No? Alright. Yes, we'll get you a hamburger.

If you're someplace where you have autonomy in the PICU, great, I guess. Still a low-yield experience, considering the relevance for critical care for the EM physician is almost exclusively confined to that first 24 hours of boarding, at worst, and not adjusting electrolytes on hospital day #9.

 

[EctopicFetus]

I thought PICU was pretty helpful and I learned a bunch but we rotate there as a PGY3 and basically run the show with an attending as there is no fellow. We make many of the decisions on our own and can ask for help when needed.

 

[Drawing Dead]

PICU is a rotation where the nurses ask you for things then go ahead and ask the attending anyway. Sometimes you can touch the kids, but only when the nurses aren't watching. Otherwise they would shoo you out of the room, because they really think you're there to kill the babies.

You are spot on. I just finished my PICU month, and on my last day, one of the nurses asked me how I liked it. I told her, it was ok, but I didn't appreciate how a nurse would ask me for an order, I would politely decline (with an explaination), and 2 minutes later have the charge nurse come up to me and say "And exactly why can't we do _________ for pt. ___________?" Then later on, my attending would be like "Oh, hey, I did __________ for ____________". The only reason I think the attending would cave would be so they would have some peace and quiet.

 

[willow18]

So PICU sounds like it's extremely location-dependent. What about TICU/SICU, is more than one month overkill? (pardon the pun)

 

[EM_Rebuilder]

We have 5 total I believe at our 1-4 program here at Univ of MS.

I would MUCH rather be in ANY unit than being a medicine floor monkey. At least my experience was when in call in the unit, I had rounded as a team on every patient and was truly only needed in an 'emergency' so I think it was a very positive experience.

On the ONE floor medicine month we do, my night was full of diets needing renewed, constipated people, etc.

I agree you learn EM in the ED, but, I think its hard pressed to argue that the ICU setting is not nearly the next best thing. There HAS to be some level of off service rotations per all the RRC requirements and I think the ICUs make for a good balance.

 

[ephedra]

In my oppinion ICU months are the most high yield compared to any off service rotation. My program does 5 months. Currently I am at a private hospital training under a famous Pulmonologist where I am the only person on covering a 40 bed Adult ICU at night and handle all critical care codes, support teams, airways, and critical consults and admitions in the entire hospital. Too good to be true I know but that is the way it is here. No attending in house at night. Just me the second year resident no other residents rotate. Emergent intubations with no back up, chest tubes, defib, transvenous pacing, 5 pressors going at once, swans, balloon pumps, dialysis cathetors, triple lumens, there is Nothing like it. This is training ast its finest and this is what EM physicians love to do.
How many months is enough? Well I think you need an ICU as an intern to gain some confidence, and at least a SICU and MICU functioning as the senior. As long as they are intense months I am sure you will be fine. But for me more is a good thing.
You need to gain confidence in emergent situation and the ICU is where you will gain that. HAndeling multiple codes and triaging patient that are dying is what we do in the ED. Granted you can get this in the ED but it depends how lucky you get each night. In the ICU everyone is usually sick and is a paradise for learning.

 

[enfuegoEP]

Same thing here. At my program there's no PICU fellow, and the peds 3rd yr is busy doing admissions and covering the floor, so the EM2s handle the PICU solo. The ICU nurses in general really like the EM residents because we know how to run the unit.

Pretty much exactly how it is at my program.