Peds critical care...how about combined with anesthesia training?

[mytirf]

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I'm a pediatrics intern and have also enjoyed the ICU. Every rotation I took I always found myself in the ICU so I think my eventual path will lead in that direction. My question is whether or not people think I would greatly benefit, i.e. worth the extra 2-3 years of additional fellowship time doing a combined pediatric critical care/anesthesia fellowship? I realize that anesthesia training provides unbeatable skills when it comes to managing airway and post-op care but is that truly necessary over a good pediatrics training where all the emergencies are secondary to airway anyways.

Also what are the general preceptions concerning how the ORs work in terms of who runs it in regards to patient care. One hears horror stories of surgeons barking orders and the anesthesiologist just saying "yes sir". Or is it more collabrative? I also realize this is an over generalization but just curious what people's experiences have been.


Peace.

"People are stupid; given proper motivation, almost anyone will believe almost anything. Because people are stupid, they will believe a lie because they want to believe it’s true, or because they are afraid it might be true."
- Sword of Truth,

 

[TIVA]

Abso-frigging-lutely.

I completely recommend doing a peds anesthesia/critical care fellowship if you are so inclined.

The attendings I've met who've trained in both peds and anesthesia are phenomenonal doctors and phenomenal people.

Do you end up losing 2, 3, or 4 extra years to further training? Yes, plus all those years when you would've been making $100K+ per year.

But at the end of it, you're definitely a better doctor for it overall. You'll have more skills, more knowledge, and more confidence under your belt. And the starting salaries for peds anesthesia (250+) and peds critical care (225+) will help you quickly make up for the lost money.

Not only that, but you'll also be able to diversify your practice if you wish. You can do pediatrics, pediatric critical care, pediatric anesthesia, adult and pediatric anesthesia, emergency peds, etc. This will keep your interests peaked -- part OR theatre work, part ICU work, part whatever.

As far as who calls the shots in the OR. Ideally the surgeons and anesthesiologists should collaborate for the benefit of the patient. In real life, it comes down to who has seniority, who commands more respect, who has a louder voice, etc. In our OR's, that means it's the nurses who often call the shots.


There's an old adage: a good surgeon deserves a good anesthesiologist; and a mediocre surgeon needs a good anesthesiologist. The key to commanding respect in the OR is to be the one calm, cool voice when ****e hits the fan.

So for example, this one time the surgeon blew a hole in the aneurysm he was trying to clip and freaked out. My attending burst-suppressed the patient with an induction dose of thiopental, increased the phenylephrine gtt to keep MAPS > 80 and said, "the patient is doing just fine, you have 20 minutes to fix it." (Normally surgeons shouldn't need more than 5 minutes to fix it). This relaxed the surgeon and he promptly steadied his hands and fixed it.

Another time, the cardiac surgeon accidentally tore off one of the bypass grafts during an off-pump bypass. The surgeon started working on it frantically. We put the patient on 100% O2, bolused 10 mg of metoprolol, and said, "the patient is doing just fine," in spite of some TWI and STD. Once the graft was re-attached, EKG changes normalized and there was no apparent damage to the heart muscle (i.e. good cardiac output, no post-op inotropes or pressors, etc.).

So, moral of the story: we're all humans, we're not emotionless robots, when something scary happens, be the cool and calm voice in the OR, or ICU, or during a code no matter how scared you yourself are feeling or don't know what to do. Sometimes you have to fake confidence in order to have confidence.

I hope this helps.

 

[jetproppilot]

Abso-frigging-lutely.

As far as who calls the shots in the OR. Ideally the surgeons and anesthesiologists should collaborate for the benefit of the patient. In real life, it comes down to who has seniority, who commands more respect, who has a louder voice, etc. In our OR's, that means it's the nurses who often call the shots.


There's an old adage: a good surgeon deserves a good anesthesiologist; and a mediocre surgeon needs a good anesthesiologist. The key to commanding respect in the OR is to be the one calm, cool voice when ****e hits the fan.

So for example, this one time the surgeon blew a hole in the aneurysm he was trying to clip and freaked out. My attending burst-suppressed the patient with an induction dose of thiopental, increased the phenylephrine gtt to keep MAPS > 80 and said, "the patient is doing just fine, you have 20 minutes to fix it." (Normally surgeons shouldn't need more than 5 minutes to fix it). This relaxed the surgeon and he promptly steadied his hands and fixed it.

Another time, the cardiac surgeon accidentally tore off one of the bypass grafts during an off-pump bypass. The surgeon started working on it frantically. We put the patient on 100% O2, bolused 10 mg of metoprolol, and said, "the patient is doing just fine," in spite of some TWI and STD. Once the graft was re-attached, EKG changes normalized and there was no apparent damage to the heart muscle (i.e. good cardiac output, no post-op inotropes or pressors, etc.).

So, moral of the story: we're all humans, we're not emotionless robots, when something scary happens, be the cool and calm voice in the OR, or ICU, or during a code no matter how scared you yourself are feeling or don't know what to do. Sometimes you have to fake confidence in order to have confidence.

I hope this helps.

Very well said.

This dude's been around the block a few times. 👍

 

[canavarim]

But be sure to be realistic as well

 

[fakin' the funk]

gtt = ?
TWI = ?
STD = ?

thx

 

[bubalus]

gtt = guttae, Latin for drip
TWI = T wave inversion
STD = S-T depression, or something else depending on the context.

 

[mytirf]

Thanks for the advice...any suggestions on where I should apply for good combined programs?

 

[jetproppilot]

STD = S-T depression, or something else depending on the context.

Reminds me of a story from my residency days at Tulane....the on-call beeper was one of those voice pagers....we'd wait 'til whoever was carrying it was on the elevator going to the cafeteria or wherever....then we'd page the poor dude:

"DOCTOR ROMAN, PLEASE CALL THE STD CLINIC IMMEDIATELY AS THERE SEEMS TO BE A PROBLEM WITH ONE OF YOUR TESTS. PLEASE CALL. THANK YOU."

 

[IceDoc]

Thanks for the advice...any suggestions on where I should apply for good combined programs?

Hopkins has a well established combined program.

 

[KidDoc29]

guttae actually translates as "drops", NOT "drip" as is often incorrectly thought

 

[KidDoc29]

I'm a pediatrics intern and have also enjoyed the ICU. Every rotation I took I always found myself in the ICU so I think my eventual path will lead in that direction. My question is whether or not people think I would greatly benefit, i.e. worth the extra 2-3 years of additional fellowship time doing a combined pediatric critical care/anesthesia fellowship? I realize that anesthesia training provides unbeatable skills when it comes to managing airway and post-op care but is that truly necessary over a good pediatrics training where all the emergencies are secondary to airway anyways.

Also what are the general preceptions concerning how the ORs work in terms of who runs it in regards to patient care. One hears horror stories of surgeons barking orders and the anesthesiologist just saying "yes sir". Or is it more collabrative? I also realize this is an over generalization but just curious what people's experiences have been.


I am doing the very combined PICU/Anesthesia training you speak of, starting in July, and am psyched about it. It will be 5 years total, but well worth it. There is no question that folks with dual training such as this have a richer understanding of cardiopulmonary physiology, pharmacology, and technical procedures than any straight intensivist. They also have an obvious mechanism for establishing rapport with surgeons, as they know you can take good care of their patients both in the OR, and post-operatively in the ICU. The money is clearly better, and being able to do Anesthesia on the months when you are not on service in the PICU frees you from the burden of getting grants, doing sedations, doing bench science, or administrative bull**** that staright intensivists have to do to earn their salary. I will be able to work in the PICU for fun, and earn my salary in the OR, and if research doesn't suit me, oh well. I cannot wait. By the way, the programs that really advertise this heavily are Hopkins and CHOP (both phenomenol) but if you inquire at other PICU programs, most are more than willing to set up such a training package for you. Some advice - do as much peds anesthesia as you can during you first two years, as a formal elective or even just shadowing when you are on a light month. This will serve to make you known to the Anesthesia faculty, give you some great skills, and most importantly allow you to confirm if it is something you really want to do. Also, apply to the PICU programs early. Most combined programs will want you to do your anesthesia training first, so you need to secure a spot in the anesthesia residency class. Usually not too hard to do, but remember that those spots are given out a year in advance b/c all categorical anesthesia residents do a prelim year first (which your peds residency will count as) So, you need to make sure that they have an unfilled spot, or are willing to arrange additional funding to support you. Hope this helps, and good luck