Lets talk about resuscitation and critical care

Discussion in 'Emergency Medicine' started by namethatsmell, 01.14.14.

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  1. namethatsmell

    namethatsmell 5+ Year Member

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    My program (probably like most others) fosters the notion that we, as EM docs, are the "resuscitation experts."

    However, now that there are multiple pathways for EM docs to get boarded in Critical Care I've heard from a few EM/CC attendings that completing a CC fellowship will be the new gold standard for being a resuscitation expert. Specifically, it's been suggested that if you wanted to do substantial research in this area or be the "go to guy/girl" for resus stuff in your shop you'd be best served by doing a fellowship. What do folks think about this?

    While resuscitation and CC are big interests of mine and I like the idea of doing advanced training in these areas, I'm a little apprehensive about committing to be away from emergency medicine for 2 years (the financial loss isn't super attractive either). Anybody know if programs allow fellows to moonlight in the ED once in awhile to keep these skills intact and make a few extra bucks?

    Also, I noticed that there are some 1 year "resuscitation fellowships" out there at places like VCU, Penn, UIC, etc. They look to be strictly research from what I can tell and don't seem to offer a clinical component (other than working shifts to pay your way)--anybody have any experience or thoughts on these?

    Lastly, as far as career options for EM/CC docs I've heard plenty about splitting time between the ED and the unit. How feasible is this outside of academics? Are there actually ED based jobs out there where an EM/CC doc could manage the "critical area" of an ED (a la Scott Weingart)?

    Discuss.
     
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  3. deuist

    deuist Stealthfully Sarcastic Lifetime Donor 10+ Year Member

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    Yes, moonlighting is permitted. However, keep in mind that you may already be working 80 hours a week as a CC fellow. When are you going to moonlight?
     
  4. namethatsmell

    namethatsmell 5+ Year Member

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    Most programs have dedicated research months and electives where I'd imagine there'd be some time. Was more wondering if there happened to be a culture against moonlighting in CC fellowships.
     
  5. dotcb

    dotcb --------- 10+ Year Member

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    There is one prevailing, compelling reason to do a critical care fellowship - if you want to spend a significant portion of your time as an attending in the ICU.

    Based on my experience, ED-based critical care is nowhere near being outsourced to intensivists. Ours are in-house 8 hours a day, and are happy to meet the patient when they arrive in the ICU.

    If you wanna provide good ED-based critical care, study hard, practice, and be an emergency physician. If you wanna be an intensivist, do a critical care fellowship.

    Resuscitation research can be done via either field, and has more to do with mentorship and research training than which board certification you hold.
     
  6. inspirationmd

    inspirationmd 5+ Year Member

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    Slightly different opinion than the above.

    Some deep questions you are asking here and a lot of the answers are in flux. First, you have to realize that the world of EM/CC is just starting to explode and so there is a lot of opportunity to carve out your own niche if you are proactive. I am pretty involved with advancing the EM agenda in the CC fellowship at my home institution and have done quite a bit of research on this topic so I think I can help a bit. Warning this is a long reply...

    1) http://emergencymed.arizona.edu/fellowships/critical-care

    Above is the link to a respected Critical care fellowship co-sponsored by the Departments of Internal Medicine and Emergency Medicine at the University of Arizona that will lead to ABIM/ABEM board eligibility and still has built in time for EM moonlighting both to keep up your skills in EM and to reduce the loss of income that comes with going into fellowship. I have heard rumors that other programs will let you do it but I do not believe they are as forthcoming about it and I do not remember which ones definitely did anymore (U of Florida-Anesthesia CC maybe?). You would do well to shoot the PD of any programs you are interested in an email and ask about the possibility. It will likely vary by institution.

    2) https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/gdelinesteachgresfctsht.pdf

    To go along with #1 check out page 3 of the above link. These are the rules governing Medicare billing and intern/resident/fellow moonlighting. Summation: you can bill as an attending with moonlighting in your own institution as an attending in the ED as long as:

    1) You are doing MD/DO duties
    2) You are fully licensed
    3) The services are separately identified from those you are doing as a trainee (ie. ICU duties)

    You can use this as a credible way to show whatever institution that you can make the hospital money while also keeping up your skills and avoid pissing off Medicare (ie. Accusations of fraud). I am pretty sure these rules are a holdover from the days when no one was staffing the ED except residents and burned out Surgeons/Internists and the need was too great. Regardless, they are still on the books. I have spoken to two EM/IM attendings who used these guidelines to justify EM work while doing their fellowships (Cardiology and Pulm-CCM). I plan to bring these up when I am doing my CCM fellowship and see no reason the institution will say no.

    3)http://www.ncbi.nlm.nih.gov/pubmed/20370766
    This a very informative study done a few years ago by EM/Surg-CC and EM/IM/CC folks at VCU. Very good read and I recommend it. Basically, 50% of EM/CC folks practice both and 62% practice in academic institutions. I have met a few who have community practices and while the jobs are a bit more scarce (possibly secondary to bias from Pulm/CC) they say it’s improving nd it is going to get even better over the next 5 years.

    4) Scott Weingart has a GREAT job. Opportunities for practices like this will open up in the next 5-10 years I think but for now I think he has a pretty unique setup. Nevertheless, the body of literature supporting his set-up is growing: http://www.ncbi.nlm.nih.gov/pubmed/23380127

    5) I think the resuscitation fellowships are good if you want to do academic research in an ED but if you want to be an intensivist and want the additional skills that come with it you need a full CC fellowship. These skills include but are not limited to Bronchoscopy, advanced vent modes, nutrition for critically ill, and advanced management of critically ill patients beyond the first 2-8 hours, etc. If you want to be an intensivist this is going to leave you unsatisfied.

    6) My personal opinion is that generally EM as a specialty is the best at the initial resuscitation compared to Surgery, Internal Medicine and Anesthesia. EM tends to be more aggressive with stabilization and have a more expansive knowledge base to address the immediate concerns without feeling a need to call a consultant immediately. However, again generally, outside of about a 2-4 hour window the comfort level seems to go away and a desire to get them out of the ED seems to be paramount regardless of how busy the ED is. I think this has to do with not being as well versed in what to do after the immediate danger has passed and since that’s not fully part of the residency that is ok. Resuscitation is not the same as CC IMO; it’s a subtle difference but there is one. This is not to say that a EM attneding can not become proficient at CC - I have many that are. The CC fellowship is necessary to go to the next level and I believe over the next 10-15 years Emergency Medicine-Critical Care will become its own section within a EM department. A multi-disciplinary fellowship should be your goal to make sure that you have exposure to all types of patients (ie. Pitt, Maryland, etc). It will be very important to ensure the curriculum will make you the most well rounded intensivist you can be.

    I know it was long but I hope this helps. Good luck with your decision.
     
  7. Bostonredsox

    Bostonredsox 2+ Year Member

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    You need to realize you are talking about two different animals to an extent. Emergency medicine critical care, meaning a pt coming in off an ambulance, is a much different daily job then being an intensivist and practicing medical critical care. Even in a EM crit unit, how long do you keep a pt? 12 hours, 18 hours? Basically you keep them till the MICU has a bed. Upstairs I manage those pts and there persistent shock states and vent dependency for days. weeks. Months sometimes. And while we also get fresh shock pts who need full resuscitation (floor fukups whose diagnosis was missed, post op pts who crash, etc) we do a lot more long term CC management then EM crit guy would do downstairs, whilst they do a lot more initial resuscitation management then me. Now if you want to do daily ICU work as an intensivist, then do the fellowship. But if you want to practice shock resuscitation in the Ed, while the fellowship will teach you more, as will any extra time learning as a fellow in any field, I doubt it's necessary to function in the Ed. I've met a handful, maybe 6 EM crit guys. 4 of them are full time intensivists. The other two split time between the two departments, but have started to spend more and more time upstairs.
     
  8. Khaos

    Khaos I beat the game, now what 7+ Year Member

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    I agree with boston. They are two different animals. Before you do a fellowship, you need to ask what you want to do. Do you want to work both or one? If you want to do EM with a CC background, I don't see any benefit. First, you WILL NOT get paid differently. We do the initial resusc and the CC does the long term. You will not be doing anything different from your partners other than maybe setting up the long term things a little sooner and better. If you want to work time in each field than you are going to most likely be a hospital employee where the hospital will allow you time in each. I can't imagine a private group wanting you to do take time from their group to work for the hospital ICU.
     
  9. namethatsmell

    namethatsmell 5+ Year Member

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    Thanks for all the helpful responses, I've actually been in the unit for the last few (long, busy) weeks. I agree with the premise that it really makes the most sense to do a fellowship if one wants to work at least part time in a unit. I guess I'm trying to parse out my interests since I tend to be most interested in ICU-bound patients in the ED. I learned a lot in the unit, but man I'm really looking forward to being back in the ED.

    inspirationmd--your post was great, thanks so much for taking the time to craft it.
     
  10. edgesofsanity

    edgesofsanity just some guy 10+ Year Member

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    I would hope that all residents going through an EM program nowadays would agree with this point. As such, I think there may be problems getting buy-in from groups to have docs who just do the "critical care" area of the emergency department. While I think the fellowships sound interesting, I doubt the rest of the EM trained docs will be booted from taking care of the sick patients anytime soon. If all you want is to take care of these patients in the ER, you'll have plenty of opportunity to do so without spending an additional 2 years in fellowship.
     

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