PICU procedures

[shishka32]

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MS3 here. I go to a school with a pretty small peds program and PICU so I wanted to ask these questions to others. I love kids but really enjoy procedures so I'm trying to decide between PICU or the hell that is pediatric surgery residency + fellowship.

What types of procedures can PICU docs do? I'm assuming intubation, central lines, chest tubes, etc. What about ECMO and more involved procedures?

Also, do PICU procedures happen all the time similar to MICU/SICU or is it difficult to get the numbers in fellowship?

 

[physicsnerd42]

There are fewer procedures in kids than in adults. At my institution, our PICU and MICU are the same size and I did far, far more procedures in the MICU than the PICU as a resident because adults require more procedures. There tends to be a higher threshold for doing procedures in children so a graduating PICU fellow will likely do fewer procedure in their 3 year fellowship than an adult intensivist fellow will do in their 1-2 years of fellowship.

The types of procedures we do it children in the non-OR part of the hospital are (from most to least common): LP, intubation, arterial line, central line, chest tube. At my institution surgeons obtain ECMO access, and I'm guessing that's pretty much everywhere. At the county hospital my residency covers there are very few of any of the above procedures done in the PICU. At our academic hospital there are a decent amount, but nowhere near SICU/MICU levels.

There is, however, a third answer to your dilemma: Peds anesthesia. Anesthesia residency is tough, but definitely not in the same league as gen surg. Peds anesthesia fellowship is one year long and not all that difficult to match into when compared to the dismal match rate of Peds surg fellowship (and do you want to go through gen surg and possibly never be able to get into Peds surg?). You do tons of intubations, IVs and a-lines in kids. Depending on the cases you'll also do central lines, caudals, epidurals, spinals, nerve blocks. Just something to think about.

I actually had a similar dilemma to yours, but I was choosing between Peds and ENT (I did consider Peds Surg through gen surg but decided the low Peds surg match rate -- and so much time with the gut in a tough residency -- wasn't worth it). I ended up choosing a combined Peds-Anesthesia residency. That's something else to think about if you're considering a combined career, like Peds anesthesia-PICU, Peds pain management, Peds anesthesia-hospitalist, etc.


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[SurfingDoctor]

Procedure competency should be for the following (according to the ACGME):

From the ACGME "Fellows must become proficient in critical care procedures with patients sufficiently ill and cases sufficiently complex. These procedures include, but are not limited to, peripheral arterial and venous catheterization, central venous catheterization (including dialysis catheter placement), endotracheal intubation, thoracostomy tube placement, and sedation of conscious patients." Procedural sedation (AKA moderate and deep sedation) is counted as a procedure by the ACGME and depending on the location of practice, probably the most commonly performed by pediatric intensivists.

Some people have comfort with paracentesis and/or drain placement, but it is typically not within the scope of practice. While I suppose it would be possible for pediatric intensivists to do VV ECMO cannula (since it is essentially a big central internal jugular line), I have not seen it personally. VA ECMO is generally left to surgeons.

Procedures do not happen everyday. Generally speaking, children don't have as many comorbidities as adults and can clip along with critical illness to a better degree than adults. Many PICUs attempt to use non-invasive tools to manage children and can do so to a reasonable degree. There has also been a realization that invasive procedures can cause risk without any benefit (PA catheters, which used to be done, nowadays are never done, except in the cath lab). Though I don't know the numbers as well as others, overtime, the number of procedures has been decreasing.

PICU is more of a physiology based specialty. It is more about managing critical illness (or preventing children from becoming critically ill). That's not to say procedures aren't done, probably more that most other general pediatric subspecialties (similar number to NICU and a little less that Interventional Cardiology), but the day to day is more management and less procedures. The good thing about that is you get to treat a variety of illnesses and management all sorts of random diseases (congenital or acquired) and when management requires, perform procedures. It really is a jack-of-all-trades type of specialty.

 

[Stitch]

There is, however, a third answer to your dilemma: Peds anesthesia. Anesthesia residency is tough, but definitely not in the same league as gen surg. Peds anesthesia fellowship is one year long and not all that difficult to match into when compared to the dismal match rate of Peds surg fellowship (and do you want to go through gen surg and possibly never be able to get into Peds surg?). You do tons of intubations, IVs and a-lines in kids. Depending on the cases you'll also do central lines, caudals, epidurals, spinals, nerve blocks. Just something to think about.
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This is good advice. You should especially look at pediatric cardiac anesthesia. The training is a bit longer, but you'll be very popular on your job search, and there are a ton of procedures. The physiology is fascinating. The cardiac surgeons tend to really trust their anesthesiologists as well.

But you also need to think about what you want to do in general. As an intensivist, I do central lines, chest tubes, arterial lines, intubations like others have mentioned above. Those seemed exciting to me when I was a trainee, but they aren't the bread and butter of what I do every day. Mostly I am at the bedside managing physiology. Maintaining cardiac output, blood pressure, making ventilation changes. A large part of what I do is coordinating care between multiple sub specialists, including surgeons. End of life discussions are also a big part of PICU life. You have to be comfortable doing all of these things.

Also, you have to be ready for a pediatric residency, which will have a lot of out patient clinic time and in patient general hospital admissions. These are essential to learning peds and a good PICU doc knows general pediatrics well. If you're going to hate these things, then don't do a peds residency.

If you want to do surgery, then you have to love the OR. You will be there all the time. You have love learning about common surgical things like appendectomies and gall bladders and trauma. A peds fellowship is quite competitive, but peds surgeons love being in the OR doing surgery. This is very different from what I do in the ICU.

 

[BigRedBeta]

The above answers are all excellent. I'd add that there are a few units across the country where the intensivists do their own bronchs as well. But they are scant and it's hard to say how long they'll keep that away from the pulmonologists. Chest tubes for complicated effusions I feel are becoming more and more the purview of IR in many places.

Would triple stamp the idea that intensivists manage physiology more than doing procedures. It's a more procedurally based specialty than say ID and the procedures are more involved than those in the Peds ED (eg. lines vs suturing/splinting), but the real expertise of intensivists goes beyond technical skill.

Percutaneous cannulation for ECMO hasn't reached pediatric populations yet as far as I'm aware, but the day-to-day management of ECMO is certainly part of the intensivist skill set. At many places, the surgeons (CT or Peds) are merely technicians for ECMO cases, putting the patient on and then walking away until it's time to take the cannulas out. There are a few places where the surgeons are more involved in the management...which can be a good thing or a bad thing depending on who you ask.

 

[shishka32]

Thank you everyone for the fantastic answers. I agree that my decision needs to incorporate more than just wanting procedures but I was curious as to what PICU involves. As far as the OR, I really did like surgery but I am not sure if I can’t live without which pushes me away from general surgery which we all know is a brutal residency and lifestyle.

I will do some more thinking about peds anesthesia. That could be a great way to combine my interests.

 

[mvenus929]

Also, you have to be ready for a pediatric residency, which will have a lot of out patient clinic time and in patient general hospital admissions. These are essential to learning peds and a good PICU doc knows general pediatrics well. If you're going to hate these things, then don't do a peds residency.

I've found that the attitude of the PICU docs varies significantly by institution. At my Med school, the PICU docs saw themselves (mostly) as pediatricians first, and ICU docs second, so they cared about a lot of health maintenance stuffs. The PICU docs at my residency are only engaged while that patient is actively sick...things tend to get lost when we have the chronic kids, especially with so many trading off of residents on service. Maybe it's the size of the PICU that makes the difference, but it's an interesting dichotomy.

OP, I would also recommend looking into EM--lots of procedures, though lots of routine gen peds stuffs too. As residents, we do more procedures in the ED than we do in the PICU, mostly because half the time the procedures are already done before the patient arrives to the PICU.

 

[Step Up]

Agree with Peds ED idea, which probably has overall more procedures than peds critical care. Lots of lacs to repair in the ED, as well as LPs and I&Ds, and the occasional intubation and chest tube.

Also consider peds interventional cardiology and electrophysiology. These docs spends tons of time in the cath lab, and do more interesting procedures than their adult cardiologists counterparts, IMO. You have to be very smart and driven to pursue these sub-sub-specialties however, as there are only so many jobs for them available.

Have you considered any of these?

 

[shishka32]

Agree with Peds ED idea, which probably has overall more procedures than peds critical care. Lots of lacs to repair in the ED, as well as LPs and I&Ds, and the occasional intubation and chest tube.

Also consider peds interventional cardiology and electrophysiology. These docs spends tons of time in the cath lab, and do more interesting procedures than their adult cardiologists counterparts, IMO. You have to be very smart and driven to pursue these sub-sub-specialties however, as there are only so many jobs for them available.

Have you considered any of these?

First, thanks again everyone.

I have considered these but a few things have turned me off (maybe prematurely I admit). After spending some time in the peds ED here, the fellow and attendings led me to believe procedures in the ED are actually somewhat rare and most visits are more urgent care than anything else. This may be because, again, I go to school with a small peds program. It is reassuring to hear this is not the case everywhere. Before I found out how much I loved kids

Peds interventional cardiology was actually something I thought about before so I spent some time with the department. Two of the peds cards fellows and one of the attendings said the job market is abysmal in interventional and getting a job anywhere can be difficult. I really enjoy the congenital heart defects and this would be such a great way to make all of my interests align, but I want a job when I finish PGY-7! Granted that is 8+ years from now so things could change. I have not considered electrophysiology but that is a great point.

 

[SurfingDoctor]

After spending some time in the peds ED here, the fellow and attendings led me to believe procedures in the ED are actually somewhat rare and most visits are more urgent care than anything else. This may be because, again, I go to school with a small peds program.

Actually, this is generally true. The ACGME lists the procedures that PEM people are suppose to be competent at (http://www.acgme.org/portals/0/pfassets/programrequirements/114_emergency_med_peds_2016.pdf, starting page 15). That being said, in my experience, they probably about 50% of the ones listed (especially not complicated ones like pericardiocentesis, arthocentesis, chest tubes or central lines). Generally a lack of frequent experience, practice and need and the availability of more skilled subspecialists at most training centers prevent them performing many of the procedures listed.

Peds interventional cardiology was actually something I thought about before so I spent some time with the department. Two of the peds cards fellows and one of the attendings said the job market is abysmal in interventional and getting a job anywhere can be difficult. I really enjoy the congenital heart defects and this would be such a great way to make all of my interests align, but I want a job when I finish PGY-7! Granted that is 8+ years from now so things could change. I have not considered electrophysiology but that is a great point.

This is likely true for both EP and Cath. Unfortunately, you need to be at a large academic center with an active CVICU and CT surgery program for either one of these subspecialities to have volume. Typically, either the EP or Cath physicians also do consults, inpatient wards and outpatient primary cardiology.