Pulmonologist/ICU vs. Anesthesia/ICU

[MD Dreams]

Before I start, congrats to all who matched and good luck to all who are scarmbling.

In the past I always thought that the pulmonologists were the ICU docs. I'm curious how their role differs from anesthesiologists who are ICU docs. Which group is the main decision maker when it comes to the pts. day to day care? Also, do anesthesiologists mainly work in the SICU vs. MICU? Thank you in advance.

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[AJM]

The role does not differ too much between anesthesia/CC and pulm/CC. Both of them can work in both MICU and SICU, and I have seen both pulm and anesthesia attendings in all the arenas. In general, however, anesthesia/CC attendings will work in the SICU, while pulm/CC work in the MICU, but this is not a hard-and-fast rule.

As far as who the desicion-maker is, it's whoever the current attg is in the ICU. They do not share responsibility or co-attend, unless they are in a huge ICU where you need multiple attendings.

As far as deciding between anesthesia/cc and pulm/cc, it really depends what you want to do as your "day job". You won't be working in the ICU full time unless you want to get burned out within 5 years, so what would you be interested in doing when you're taking a break from the ICU? Do you want to be doing OR anesthesia, or do you want to do inpatient pulm consults/pulm clinic?

 

[nitecap]

this was a good one too

 

[MD Dreams]

Thank you both for your extensive reply. nitecap, I'm asking these question in order to determine which specialty I'd be interested in. It sound like you know your stuff. Perhaps you can comment on any differences you have seen between surgeon (general ?)trained in CCU vs. anesthesiologist trained in CCU.

Also, it sounds like anesthesiologist play a very important role in health care. In other words it sounds like it's more than just passing gas Would you agree? I'm curious to see what your impression is of this specialty and of surgery as well. Thank you for your time.

 

[AJM]

I have found drastic differences between critical care pulmonologist and MDA's. First and foremost I know that both do fellowships in the ICU and both have extensive training however being a RN in a major academic facility and working with both professions I without a doubt prefer to manage pt's of the mda's. Here are a few differencs I have noticed:

1- It seems that ICU MDA's may be more used to managing the comlexity of all hemodynamic systems together. Many of these MDA have been doing CV anesthesia, managing ballon pumps, initiating CVVHD in OR, transfusing and initiating pressors ect to sustain the pt in the OR. Most Pulmonary guys do not have this, while I know that pulm has CC fellow ships I find MDA's working in OR and also having CC fellows I find them in my institution to be way more proactive preventing many problems before they even happen.

2- Another thing and big thing is sedation and pain mgmt. MDA's in my facility have dev. great sedation/pain mgmt protocols. For instense pt sedation in ICU with ards Eg. Fent 100mcg/hr, versed or ativan infusion, nimbex drip titration to TOF goal, titrate sedation to BIS monitor values in ICU ect.I found pulm guys to be so fixated on pulm status that they way under treat pain or under sedated pt or use the wrong sedation. For ex managed a liver TP pt 2 days ago with ards and on CVVHD, 10 mcg norepi, .08 vaso, BP was in toilet and they were sedating with fentanyl 400mcg yes 400mcg per hour basal infusion. As soon as I weaned the fentanyl I weaned the pressures and was able to pull more fluid with CVVHD. Now i am a RN and about to be SRNA but it doesnt take a rocket scientist to know that if the pt isnt adequetly sedated on 400mcg of fent then its time to adjunct. Plus they dont use BIS or anything like that. I know if that pt would have been in SICU under anesthesia care he wold have been better off.

3. Another thing is vent weaning ect. I find the pulm guys to wean vent much more harshly than anesthesia guys. Anesthesia say will put pt on CPAP trial they maybe TC then get parameters NIF, VC , Min vent then if looks good extubate. Pulmonary guys go to CPAP, maybe TC, then allow the pt to struggle with PS 0 not even assisting the pt thru the vent circuit. Most end up intubated an extra day or so.

this is just a few of my observations from mangaing pt's under both services care. I have more just ask.

Well, I'd prefer not to see this thread degenerate into an diatribe as to who's better in the ICU. I personally have worked with both anesthesia and pulm crit care attendings in various SICUs and MICUs, in addition I have worked with anesthesia/cc fellows, medicine/cc fellows, and pulm/cc fellows. Sure, there is a difference in their backgrounds, and there are some things that one group is more comfortable with than the other, but it goes both ways. For example, an anesthesiologist is prob better at resuscitating a crashing patient, but I would trust pulm/cc more in sorting out a very complicated medical patient.

Most of the issues you bring up sound like individual physician style issues rather than global differences between the specialties. Vent weaning style is just one example where you can't generalize what you've seen done in one hospital to mean that that's how all people in the specialty do it. There's just too much variability even among individuals. I can tell you that I've had the opposite experience with the anesthesiologists I've worked with -- there were a couple of them that I worked with who did a terrible job in weaning, where the pulm/cc guys were excellent at it. I didn't think it had anything to do with their training -- it was just the way they had gotten used to doing things.

oh - and as for the sedation issue -- it doesn't take a crit care fellowship or even an anesthesia residency to know that fentanyl alone is not adequate sedation for an intubated patient. Heck, I'm an IM resident and (gasp!) I even know that! IMHO, the problem that you have with the pulm/cc attendings is not because of the pulmonary training, but the problem lies in the individual physicians that you've worked with.

Anway, the point is that pulm/cc and anesthesia/cc both can staff ICUs, and can do so competently.

 

[Furrball]

I have completed ICU rotations in two very large teaching hospitals on both coasts. I have not yet encountered MDA intensivists. Where I am there are both surgical and medical intensivists, and of course their ICU practices are very dependent on the type of patient they see day to day. The critical care fellows are both surgical, medicine, and probably anesthesia and they work with both medical and surgical teams.

My goal is either critcal care or pulm-critcal care, because I like medicine. One of the fellows I know calls it being an internist to the sickest of patients. I know some people who combined a straight critical care fellowship -- sans pulm -- with nephrology. For me the idea of a nephrology fellowship and dovetailing in a critical care fellowship is intriguing. I have no idea if this is possible though.

It seems to me that sedation and pain management protocols are more of a systems issue; e.g. it shouldn't matter if the attending is a surgeon, medicine, or anesthesia. Unit protocols should be standard within a hospital -- less chance of iatrogeniticizing some pour bastard to death or complication.

 

[KGUNNER1]

I know some people who combined a straight critical care fellowship -- sans pulm -- with nephrology. For me the idea of a nephrology fellowship and dovetailing in a critical care fellowship is intriguing. I have no idea if this is possible though.

Very possible, and several have done it. One of the most well respected intensivists in the world is a nephrologist from Austrailia who did his critical care fellowship at Pitt. Rinaldo Bellomo. I had a nephrologist in my class as well.

KG

 

[Idiopathic]

Let me ask a newbie question:

What is a typical salary for an MDA who runs a critical care unit/ICU in a large (+500,000) city?

 

[cchoukal]

on a related note, does anyone know about the board certification for ICU physicians training in either medicine or anesthesiology? I had been led to believe that one could be "board certified" in critical care medicine from anesthesiology, but most of the ICU fellowships I've looked into (casually; I'm still an MS4), make mention of something like a "special certificate of qualification" from the ABA, or something worded similarly. Anyone know anything more specific?

 

[KGUNNER1]

on a related note, does anyone know about the board certification for ICU physicians training in either medicine or anesthesiology? I had been led to believe that one could be "board certified" in critical care medicine from anesthesiology, but most of the ICU fellowships I've looked into (casually; I'm still an MS4), make mention of something like a "special certificate of qualification" from the ABA, or something worded similarly. Anyone know anything more specific?

Many subspeciality training certifications are actual "CAQ" or Certificate of Added Qualification. Very few are actual "boards". Boards are controlled throught the ABMS http://www.abms.org/newbrds.asp directly, while the CAQs are controlled through each invidual speciality (ABA, ABS, etc...) http://www.abms.org/member.asp

As far as critical care, every certification up until 2003 was a CAQ (IM, Surg, ABA) In 2003 IM considered going to the "boarding" format. I think my shingle is actually calle a "board", but the website is still referencing the CAQ. http://www.abim.org/cert/policies_aqccm.shtm

This is all semantics and a CAQ, for every practical purpose known, is equal to a "board". As long as it goes through an approved site. (Even though the ABMS doesn't directly regulate each CAQ, the only way a CAQ can be developed for a base speciality is with the initial approval of the ABMS).

KG

 

[jetproppilot]

Very interesting observations, Nitecap. I'm an MDA in private practice and, although your observations have stroked my ego vicariously, I kinda agree with AJM in that its more the individual MD than their background. One of my best ICU attendings when I was a resident was Ben DeBoisblanc (probably spelled wrong) at the infamous Charity Hospital in New Orleans- he was a pulmonary medicine dude that knew his stuff and practiced what he preached better than any intensivist I've seen to this day. I learned more from him in one month about managing the critically ill than all the other months combined. Very knowledgable, excellent post. You'll make a great CRNA!

I have found drastic differences between critical care pulmonologist and MDA's. First and foremost I know that both do fellowships in the ICU and both have extensive training however being a RN in a major academic facility and working with both professions I without a doubt prefer to manage pt's of the mda's. Here are a few differencs I have noticed:

1- It seems that ICU MDA's may be more used to managing the comlexity of all hemodynamic systems together. Many of these MDA have been doing CV anesthesia, managing ballon pumps, initiating CVVHD in OR, transfusing and initiating pressors ect to sustain the pt in the OR. Most Pulmonary guys do not have this, while I know that pulm has CC fellow ships I find MDA's working in OR and also having CC fellows I find them in my institution to be way more proactive preventing many problems before they even happen.

2- Another thing and big thing is sedation and pain mgmt. MDA's in my facility have dev. great sedation/pain mgmt protocols. For instense pt sedation in ICU with ards Eg. Fent 100mcg/hr, versed or ativan infusion, nimbex drip titration to TOF goal, titrate sedation to BIS monitor values in ICU ect.I found pulm guys to be so fixated on pulm status that they way under treat pain or under sedated pt or use the wrong sedation. For ex managed a liver TP pt 2 days ago with ards and on CVVHD, 10 mcg norepi, .08 vaso, BP was in toilet and they were sedating with fentanyl 400mcg yes 400mcg per hour basal infusion. As soon as I weaned the fentanyl I weaned the pressures and was able to pull more fluid with CVVHD. Now i am a RN and about to be SRNA but it doesnt take a rocket scientist to know that if the pt isnt adequetly sedated on 400mcg of fent then its time to adjunct. Plus they dont use BIS or anything like that. I know if that pt would have been in SICU under anesthesia care he wold have been better off.

3. Another thing is vent weaning ect. I find the pulm guys to wean vent much more harshly than anesthesia guys. Anesthesia say will put pt on CPAP trial they maybe TC then get parameters NIF, VC , Min vent then if looks good extubate. Pulmonary guys go to CPAP, maybe TC, then allow the pt to struggle with PS 0 not even assisting the pt thru the vent circuit. Most end up intubated an extra day or so.

this is just a few of my observations from mangaing pt's under both services care. I have more just ask.

 

[placeboy]

.

As far as deciding between anesthesia/cc and pulm/cc, it really depends what you want to do as your "day job". You won't be working in the ICU full time unless you want to get burned out within 5 years, so what would you be interested in doing when you're taking a break from the ICU? Do you want to be doing OR anesthesia, or do you want to do inpatient pulm consults/pulm clinic?

Perhaps I should have just inserted my question here instead of foolishly starting a new post. AJM (or any others with knowledge in this area), your response here partly answers my question. I am interested in anesthesia--but I like both the idea of critical care as well as care in a clinical, non-hospital setting. Since you mention a "day job," do you know of any crit. care (anesth) that do pain management as their "break from the ICU?" If so, what is a normal type of schedule (or is it pretty flexible)?

 

[nitecap]

and yes yes yall and ya dont stop.

 

[s204367]

Interesting post, as I had a friend bail out of anesthesia only to return to medicine and now entering a pulmonary fellowship.....Here at Columbia the SICU/Cardiothoracic ICU are run by MDA's. Interesting though, 3 are boarded in Internal medicine/Anesthesia/ and Critical Care. There is a huge difference in the way the SICU/CTICU vs the MICU/ cards ICU are run. Which is better??? I'll keep that to myself.
To the question about Med/pulm vs anes/crit care....I think the route of anesthesia crit care is by far a much better route to take, but again i am biased. For the most part, as a gas passer, every hour of your time out of the ICU is billable. Second, the market is, and will probably remain very good for gas. Also, for myself, the thought of not having to run a clinical wsa a huge deciding factor for me to choose anesthesia. There is nothing I hate more than dealing with running an office, overhead etc...

In terms of sedating etc......we use a lot of dexmetetomidine( NOT ETOMIDATE) in our ICU's as well as fentanyl. If you haven't heard of it or used it...look it up. It is great. I also play around with it and have used it for awake CEA's, and for waking up pt's from aneurysm clippings with extremely smooth and HD stable wake-ups.
Just some thoughts as I try to pass some time here on OB call..........

 

[jetproppilot]

I agree wholeheartedly with your opinion on Precedex. In my previous practice where we did over 400 hearts annually, we used it on EVERY one...amazing...dramatically reduced opioid and volatile anesthetic requirements- usually 250mcg or less of fentanyl for the entire case- railroad track hemodynamics- earlier extubations.
I remember doing an emergency heart in the middle of the night where we were so rushed that we didnt use it and it reminded me how great a drug Dex is- I was fighting labile hemodynamics the whole case, which is rare with Dex as an adjunct. Great drug also for CEAs, big back cases, etc.

Interesting post, as I had a friend bail out of anesthesia only to return to medicine and now entering a pulmonary fellowship.....Here at Columbia the SICU/Cardiothoracic ICU are run by MDA's. Interesting though, 3 are boarded in Internal medicine/Anesthesia/ and Critical Care. There is a huge difference in the way the SICU/CTICU vs the MICU/ cards ICU are run. Which is better??? I'll keep that to myself.
To the question about Med/pulm vs anes/crit care....I think the route of anesthesia crit care is by far a much better route to take, but again i am biased. For the most part, as a gas passer, every hour of your time out of the ICU is billable. Second, the market is, and will probably remain very good for gas. Also, for myself, the thought of not having to run a clinical wsa a huge deciding factor for me to choose anesthesia. There is nothing I hate more than dealing with running an office, overhead etc...

In terms of sedating etc......we use a lot of dexmetetomidine( NOT ETOMIDATE) in our ICU's as well as fentanyl. If you haven't heard of it or used it...look it up. It is great. I also play around with it and have used it for awake CEA's, and for waking up pt's from aneurysm clippings with extremely smooth and HD stable wake-ups.
Just some thoughts as I try to pass some time here on OB call..........

 

[UTSouthwestern]

I am a big proponent of dex as well and I hope to be on the speaker circuit in a year or two touting its virtues. We're working on a study for pediatric sedation with dex and will hopefully have some date shortly.

 

[Eidolon6]

I do get your point on that it may be just the way diff MD's practice but here is the catch. The MD's that I explained above are teaching physicians. Some Anesthesia Critical care and some pulmonary CC Docs. They all have fellows and residents. NOw the Pulmoanry CC fellows are adiment on using super high dose fentanyl 400 plus mcg/hr to sedate pt's in ICU just because their attending dose not like to use alot of ativan, versed or paralytics. So this teaching Doc has his own style and his fellows respect him and think he is the man and all. SO in turn you have these fellows using his style that I and most anesthesia MD's in the facility think is incorrect. SO I guess its the case of a pulm attending passing on subpar practice habbits/ preferences to his fellows and in turn them thinking and being insistant that it is the correct call despite many RN's and MD's questioning the habbits.

I think you are suffering from a degree of tunnel vision in that a lot of what is done in the ICU is not RCT verified or even evidence based. Often practice habits are dictated by a physician's experience and training in the past which may, sometimes unfortunately, get passed along to vacuous trainees. The example of which you speak is certainly not what I have been trained to do, nor, would use in any routine practice (in fact, avoiding maximal sedation and paralytics, with prompt attention to symptom managment in ventilated patients is the trend, and the other tenent, at least for me is that anaethesia and analgesia are two entirely different subjects). It sounds like anesthesiology has a fairly heavy hand in managing critically ill patients where you are located, which is probably a good thing not that they are superior in CCM mgmt, but that they have a different slant you may draw from.

Frankly, it also doesn't sound like the CCM part of the Pulm/CCM fellowship where you are located is very strong. This heterogeneity seems to curse all training disciplines (for example, the anesthesia CCM training where I am located is not very strong or well developed). If you see something that doesn't jive with what you know or believe, question it, look for the evidence and challenge it if need be. One of the follies of many physicians is not to challenge the "oral tradition" of senior physicians...after all we are all learning to practice evidence-based medicine. PAs, NPs and monkeys can read textbooks and spit out random facts, but the synthesis, understanding, and application of medical knowledge and research is what makes true clinicians stand out. Remember too that no CCM subspecialty has the "brain-trust" on CCM and stylistic differences between disciplines will remain (as do the differences in the populations they treat)...but beware to discount the wisdoms of non-anesthesia CCM folks to quickly or you may actually miss things that will enrich rather than detract from your practice.

Its easy to get caught up in these arguments about how "Anesthesia does it better or is superior....etc." usually from fourth year med students and junior housestaff who have only a modicum of experience which to base such judgements and some starving juvenile ego to feed. You'd be better off avoiding this kind of schlock and strive to correlate what is handed to you by all disciplines in the real world with the ever-increasing amount of evidence based information.

 

[jetproppilot]

DUUUUUDE! Well said.

I think you are suffering from a degree of tunnel vision in that a lot of what is done in the ICU is not RCT verified or even evidence based. Often practice habits are dictated by a physician's experience and training in the past which may, sometimes unfortunately, get passed along to vacuous trainees. The example of which you speak is certainly not what I have been trained to do, nor, would use in any routine practice (in fact, avoiding maximal sedation and paralytics, with prompt attention to symptom managment in ventilated patients is the trend, and the other tenent, at least for me is that anaethesia and analgesia are two entirely different subjects). It sounds like anesthesiology has a fairly heavy hand in managing critically ill patients where you are located, which is probably a good thing not that they are superior in CCM mgmt, but that they have a different slant you may draw from.

Frankly, it also doesn't sound like the CCM part of the Pulm/CCM fellowship where you are located is very strong. This heterogeneity seems to curse all training disciplines (for example, the anesthesia CCM training where I am located is not very strong or well developed). If you see something that doesn't jive with what you know or believe, question it, look for the evidence and challenge it if need be. One of the follies of many physicians is not to challenge the "oral tradition" of senior physicians...after all we are all learning to practice evidence-based medicine. PAs, NPs and monkeys can read textbooks and spit out random facts, but the synthesis, understanding, and application of medical knowledge and research is what makes true clinicians stand out. Remember too that no CCM subspecialty has the "brain-trust" on CCM and stylistic differences between disciplines will remain (as do the differences in the populations they treat)...but beware to discount the wisdoms of non-anesthesia CCM folks to quickly or you may actually miss things that will enrich rather than detract from your practice.

Its easy to get caught up in these arguments about how "Anesthesia does it better or is superior....etc." usually from fourth year med students and junior housestaff who have only a modicum of experience which to base such judgements and some starving juvenile ego to feed. You'd be better off avoiding this kind of schlock and strive to correlate what is handed to you by all disciplines in the real world with the ever-increasing amount of evidence based information.

 

[DocFocker]

Let me ask a newbie question:

What is a typical salary for an MDA who runs a critical care unit/ICU in a large (+500,000) city?

WTF is an MDA?

 

[deleted171991]

MDA is the name illiterate CRNAs/MBAs call physician (MD) anesthesiologists (A).

 

[DocFocker]

Ahhh its a propaganda thing, intended to blur the meaning of what an MD is in anesthesia. There are no MDM (MD medicine) or MDS (MD surgeons).

 

[deleted171991]

The militant fraction is trying to blur the line between CRNAs and anesthesiologists, for the general public, by making the titles sound the same. The same people tend to avoid using nurse anesthetist when introducing themselves: "I am Blondie from anesthesia."

That's also the reason they are introducing DNP as a requirement for new CRNAs, so they can introduce themselves as Dr. Blondie from anesthesia.

 

[BuzzPhreed]

No offense to my flea colleagues, but if I am ever really sick and actually have a chance, I want a surg/anes trained CC doc taking care of me. I've seen too much.