Residency ICU Rotations

[BringBackScrubs]

Hey everyone,

Wanted to ask what ICU rotations you felt helped contribute to your EM training the most?

Currently, my program has a Medical ICU in 1st year. Pediatric and Trauma ICU 2nd year. And we're adding another Trauma ICU 3rd year.

Thoughts on having 2 Trauma ICU months during training? I was thinking another Medical ICU as a senior?

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[SpacemanSpifff]

Hey everyone,

Wanted to ask what ICU rotations you felt helped contribute to your EM training the most?

Currently, my program has a Medical ICU in 1st year. Pediatric and Trauma ICU 2nd year. And we're adding another Trauma ICU 3rd year.

Thoughts on having 2 Trauma ICU months during training? I was thinking another Medical ICU as a senior?

Two trauma ICU rotations seems like overkill, especially if you manage any significant amount of trauma in the ED. Sick trauma patients need one of four things: control of external hemorrhage, blood, a temporizing procedure, and a surgeon. Certainly trauma can be more complicated, especially beyond the first 4 hours, but for our purposes there just isn't much else we do for these people.

Sick medical patients have more diverse pathophysiology, (usually) more chronic conditions, and can be much more challenging to manage. More time in the MICU would be more high yield than more trauma ICU time -- especially if it is a *true* trauma ICU and you don't see other sick surgical patients like transplants, esophagectomies, etc.

 

[turkeyjerky]

Yeah, I tend to agree that a 2nd MICU month (esp as a senior) would be more useful than another trauma icu month. I tend to recall the trauma ICU months being fairly high yield in terms of procedures, but not much else. Lots of watching people for 24 hrs post-op before downgrading and TBI rocks.

 

[TheComebacKid]

100% more MICU time.

Surgical/Trauma ICU at most academic centers is usually not ONLY trauma. They put complex post operative spine surgery cases in those units, and other various things that aren't relevant to the practice of emergency medicine. While the surgeons get really excited about their Frankenstein medicine of conduits, anastomoses, and the never-ending quest to place drains in the most weird locations, I find it to be very low yield. The vast majority of post operative care in the ICU is rote, based on check lists and protocols, and from what I have experienced is very much heavily weighted towards good nursing and respiratory care. What an intern/resident is going to do in a SICU is not really going to make that much of a difference. It's all about wound care, physical therapy, etc. I'm sure the EM/CCM people in this forum will likely disagree with me, and I know many of them are trained via the anesthesia pathway and spend a lot of time in the trauma ICU. But that is my n=1 experience. Perhaps other centers are different, but that is how it is my shop.

MICU is much more an extension of emergency medicine. While it's easy to waste time down the rabbit hole of all the intricacies of managing the different types of pulmonary hypertension with a pulm/crit trained attending, it is much more high yield. Sepsis, DKA, bad GI bleeds, bad asthma/COPD, etc is all your bread butter EM resuscitation.

Having rotated in both units, I found that I got way more procedures in the MICU. In the SICU/trauma ICU, most of the patients are coming out of the OR or ED all lined up, intubated, chest tubes in place etc.

 

[CliveStaples]

Agreed 2nd trauma ICU month is likely unnecessary assuming your time in the ER is at a level 1 trauma center. You should have trauma resuscitations down by the time you're a senior.

A rotation that was particularly interesting/potentially useful at my program was a month in Cardiothoracic Surgical ICU. Learned more about managing LVAD patients, cardiogenic shock, ECMO, etc. than I could ever have on normal ICU services or in the ER. It's niche information that I'll probably only ever use a few times but that's the job in the ER a lot of times.

 

[Groove]

We had Neuro ICU, CCU (during cards rot), SICU, PICU and MICU (4 yrs). I think the highest yield were Neuro, MICU and SICU but I don’t think you need 2 SICUs. I’d vote another MICU or Neuro ICU.

 

[deleted547339]

100% more MICU time.

Surgical/Trauma ICU at most academic centers is usually not ONLY trauma. They put complex post operative spine surgery cases in those units, and other various things that aren't relevant to the practice of emergency medicine. While the surgeons get really excited about their Frankenstein medicine of conduits, anastomoses, and the never-ending quest to place drains in the most weird locations, I find it to be very low yield. The vast majority of post operative care in the ICU is rote, based on check lists and protocols, and from what I have experienced is very much heavily weighted towards good nursing and respiratory care. What an intern/resident is going to do in a SICU is not really going to make that much of a difference. It's all about wound care, physical therapy, etc. I'm sure the EM/CCM people in this forum will likely disagree with me, and I know many of them are trained via the anesthesia pathway and spend a lot of time in the trauma ICU. But that is my n=1 experience. Perhaps other centers are different, but that is how it is my shop.

MICU is much more an extension of emergency medicine. While it's easy to waste time down the rabbit hole of all the intricacies of managing the different types of pulmonary hypertension with a pulm/crit trained attending, it is much more high yield. Sepsis, DKA, bad GI bleeds, bad asthma/COPD, etc is all your bread butter EM resuscitation.

Having rotated in both units, I found that I got way more procedures in the MICU. In the SICU/trauma ICU, most of the patients are coming out of the OR or ED all lined up, intubated, chest tubes in place etc.

EM/CCM attending here. I work in a Micu so I’m biased, but i think Micu is where you’ll learn more there. I think it is also somewhat institution dependent.

 

[ShockIndex]

EM/CCM fellow (anesthesia) here - another vote for MICU. The TICU would likely be the last place that I’d want doubled.

IMHO, the dedicated ICU rotations for EM should look something like this: PGY1 (MICU intern), PGY2 (TICU, CCU, PICU), PGY 3 (MICU SAR). CCU months can be very hit or miss depending on the institution, so I might drop it in favor of another MICU month in second year if it is low yield at your shop. Also, I’d have SICU, CVICU, and Neuro ICU electives for those who want to pursue a CCM fellowship.

Of note, there are places where the SICU is distinct from the TICU and can be a very busy and sick place. This is especially true if they are doing a high volume of liver transplants or if ECMO patients go to the SICU.

 

[TheComebacKid]

At our place all ECMO is done in the cardiothoracic ICU (even once they cannulate in other units, they transfer to cardiothoracic because I guess that's where the nurses know how to manage the pumps). We rotate there as an interns, and is overall a well liked rotation. The physiology is fascinating. Fairly procedure heavy, and you get to hone in some basic cardiology stuff. MICU is also an intern rotation for us, and then again as a PGY-3. It's pretty awesome to be a senior EM resident in the MICU, you get a decent amount of autonomy. We obviously have fellow coverage 24/7, so it's not like you really run the unit per se, but it's still great as a senior.

We also do neuro ICU. I liked it quite a bit, and I think it had surprisingly a very significant amount of overlap with EM. Our neuro ICU is both neurosurgery and neurology so you see a combination of bad bleeds and strokes, status, etc. Learning how to read a head CT scan is also very high yield.

PICU was the worst ICU rotation for me. I hear it is universally bad at many places though for EM residents, or at least that's what my residency admin seems to think... SICU was a close second.

Regardless, I love ICU rotations. I find critical care attendings to really enjoy working with EM residents because we eat up the critical care stuff, versus all the medicine residents many of whom can't wait to start their outpatient rheumatology practice and have no zero interest in critically ill patients. The ED unfortunately does not really lend itself well to in depth discussions/teaching on resuscitation like you can in the ICU.

Also... I know many in EM circles seem to think that longitudinal ICU care is not helpful for EM training. I wholeheartedly disagree. Working in the ICU truly convinced me that ED based interventions can have very significant (either positive or negative) long term effects on morbidity and mortality. I became way more judicious with fluid resuscitation and early initiation of lung protective ventilation in the ED (two examples of many), etc because of my ICU experiences.

 

[BringBackScrubs]

Thanks everyone for their input! Greatly appreciated.

 

[NYEMMED]

My training did MICU, PICU, SICU/TICU, CCU/CVICU

Probably adding a CCU/CVICU would be a good idea or another MICU rotation

 

[askamsky51]

Finishing PGY3 in a 4 yr program. High volume trauma and pretty sick overall population.

We do x2 MICU. Once as an intern and once as a senior. Obviously roles are very different but functioning as a "junior fellow" alongside the first-year fellow is a pretty rewarding and high yield experience. Being a senior actually managing a lot and supervising procedures is more fun than rounding and treading water as an intern.

x2 Months of trauma ICU is "meh." Overall it's a decent experience but not sure that two months is 100% necessary. I think the best parts are more chest tubes (always good) and that's about it. Frankly, the best part is making nice with the trauma fellows so when the inevitable coveted thoracotomy comes in you have a higher chance of getting to do it.

We also have a burns ICU which overlaps with PICU -- it's a mix between a true ICU and burns step-down. Decent experience but obviously not a must. Fairly niche. Done as an intern for whatever its worth.

PICU is a 4th yr rotation here, haven't done it but it's pretty well understood to be "eh." If volumes are good its a decent experience but I think PICU is really dependent on how many true sick kids you actually get. Most PICU's are basically kids on high flow hanging out.

 

[Namedmymember]

Extra MICU is more important. However, sounds like you need more ICU months overall. I found an extra trauma ICU month as a 3rd year really helpful. Did 10 months total ICU overall, would of done more if I could have.

 

[Tipsy McStagger]

I am biased but I think MICU has the most bang for your buck from an adult standpoint. PICU is meh, generally. It can vary wildly from place to place.

However if you can do an extra month in the neonatal ICU then I’d recommend that if you’ll be in the community (provided your NICU rotation didn’t suck the first time). I had a really good experience there, lots of resuscitations as we attended all high risk deliveries. A good number of intubations and lots of umbilical lines. All things an ED doc should be adept with, and in the ED it is not a common thing to be doing, so get your licks in while you can. Plus sick kids are the scariest thing in medicine.

 

[carbonizedeyesockets]

MICU for sure. Some of the sickest patients I have ever cared for were on SICU (had trauma there), and it was the only time I ever gave 40 units of blood, but the primary teams were over many of those patients like a hawk, thus I often was only putting in orders. I couldn't even look at a post liver transplant patient without running it by a person or 2. Way more autonomy and procedures when I was on MICU. The learning was best there.

 

[Mr. Vandemar]

Extra MICU is more important. However, sounds like you need more ICU months overall. I found an extra trauma ICU month as a 3rd year really helpful. Did 10 months total ICU overall, would of done more if I could have.

This is a wild number of ICU months for an EM residency. It's essentially the same amount as a CC fellowship for other specialities. Assuming this was at a four year residency, but still curious where you trained. I do wish we had another month of MICU at my 3 year residency.

 

[SamtheWise]

I would echo what everyone else says and say MICU. TICU/SICU was a good experience, lots of procedures, experience in a different critical care setting, but MICU, especially admitting and resuscitating ICU patients early in their MICU course, is probably the highest yield thing you can do in my opinion. MICUs also tend to be a little better of a learning environment whereas in SICUs often the care is so specific towards whatever operation or trauma the patient had and not evidence based, so you tend to just execute the plan the attending tells you, and put in orders for a fairly autonomous ICU where nursing, RT, PT and pharmacy do most of the heavy lifting. Burn is especially this way, and is probably the lowest yield of all ICU rotations.

PICU in my experience was fine, not stellar, not terrible, but I did it during respiratory season where most of the kids I managed were croup, bronchiolitis and asthma so I gained a fair amount of comfort with ill respiratory kids. If there isn't a high volume of these bread and butter sick patients, and you do PICU in a large tertiary network you could potentially get stuck managing the chronic care rocks and heme onc trainwrecks, which amounts to basically copy forwarding a 30 paragraph note and wrangling 15 different consults all day.

 

[SamtheWise]

This is a wild number of ICU months for an EM residency. It's essentially the same amount as a CC fellowship for other specialities. Assuming this was at a four year residency, but still curious where you trained. I do wish we had another month of MICU at my 3 year residency.

Oof yeah 10 months is a lot. Remember, at some point you gotta get out of the unit and into the ED during residency, or you risk being one of those people who writes letters to EMCRIT about pressor physiology but is unable to discharge a dizzy 80 year old with normal vital signs in less than 5 hours or compassionately explain a SAB to a non english speaking woman over an interpreter phone.

 

[Old_Mil]

Hey everyone,

Wanted to ask what ICU rotations you felt helped contribute to your EM training the most?

Currently, my program has a Medical ICU in 1st year. Pediatric and Trauma ICU 2nd year. And we're adding another Trauma ICU 3rd year.

This is all about scutting you out to do notes for the trauma service. Emergency medicine, particularly the emergency medical management of trauma patients, is learned in the emergency department.

TICU was one of my least useful rotations aside from OB.

MICU and to a lesser extent PICU was one of my most useful off service rotations because you will see stuff and gain pattern matching skills there that you wouldn’t anywhere else in the hospital...but we only had one of them.

 

[Epinephreus]

My program by year:
- 1: MICU
- 2: PICU (worthless IMO, but necessary by ACEP)
- 3: MICU, SICU (Most high-yield since you are senioring both months, SICU very procedural, MICU very complex patients)
- 4: None, but opportunity to do MICU/CCU/SICU as an elective if considering CC fellowship

I felt like this was more than adequate as far as gaining the "crossover" skills needed for the ER.
There are programs that do 8+ months of ICU and I really do not understand the benefit.

 

[SamtheWise]

Opinions on Burn ICU? Not all programs do rotations in them, and the programs that do rotate residents through Burn ICUs tend to aggressively advertise them as a selling point, whereas honestly I found it to be mostly menial order entry and note forwarding. Very little truly interesting resuscitation or critical care. 'Wow they're septic, again, let me look through 4 months of cultures and then give up and just start vanc/cefepime and call pharmacy and see what the least devastating IV anti-fungal I can order is"

 

[Siggy]

This is a wild number of ICU months for an EM residency. It's essentially the same amount as a CC fellowship for other specialities. Assuming this was at a four year residency, but still curious where you trained. I do wish we had another month of MICU at my 3 year residency.

I did 24 months of ICU during my 24 month IM critical care fellowship...

 

[Lexdiamondz]

I did 24 months of ICU during my 24 month IM critical care fellowship...

Yeah but remember that anesthesia and gen surg CCM is only one year, so 8/12 mos isn't that far off

 

[Namedmymember]

This is a wild number of ICU months for an EM residency. It's essentially the same amount as a CC fellowship for other specialities. Assuming this was at a four year residency, but still curious where you trained. I do wish we had another month of MICU at my 3 year residency.

Lol 3 year program, but I think they did split each year into 13 4wk blocks and we have no IM floor blocks. WMU/Kalamazoo.

The usual for that program is:
Intern: two trauma, two MICU
2nd: 1 PICU, 1 MICU
3rd: 1 MICU

I volunteered for an extra MICU block 2nd and 3rd year, and an extra trauma block 3rd year.

It's great experience. No ICU fellows and small surgical program, so lots of procedures and independent decision making. I honestly feel like the more ICU you do the better. You want to be as comfortable as possible with the super sick patients.