Typical cases in critical care?

[gclax30]

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Hey everyone,

I'm wondering, what are the 'typical' cases that most folks come across in pedi critical care medicine? I am becoming interested in this field as a specialty and would just like to know more about the typical day for a pediatric intensivist (if there is one of course!). Does this vary highly between academic and community hospital settings?

Also, I was chatting with an adult intensivist in my lab recently and he mentioned that adult CC is more evidence-based whereas peds is more empirical or individualized I guess. Is this generally true and if so, why?

 

[gclax30]

Oops, one more: Why do most peds residency programs make you wait until PGY-2 to do PICU? How does one get exposure to the field in order to apply for fellowships if they have to wait so long? That's kind of annoying.

 

[oldbearprofessor]

Also, I was chatting with an adult intensivist in my lab recently and he mentioned that adult CC is more evidence-based whereas peds is more empirical or individualized I guess. Is this generally true and if so, why?

As much as I'd like to defend pedi and say that this isn't true, I'm afraid it probably is. When it comes to interventions, there simply have been more trials, especially of medications used for CV support, in adults than in children. Children present a very heterogeneous group of patients and smaller numbers of patients in any one center making clinical trials difficult, expensive and challenging to generalize. There are several efforts ongoing to improve this, but it'll probably always be the case that for most interventions, we need to rely more than we'd like to on data from adults and less evidence-based approaches.

Maybe you can help fix this!👍

Oops, one more: Why do most peds residency programs make you wait until PGY-2 to do PICU? How does one get exposure to the field in order to apply for fellowships if they have to wait so long? That's kind of annoying.

The reason is that if they put PL-1s in the PICU in their first month as interns, they wouldn't have any second month interns.😎. Seriously, the PICU is a challenging environment and both the resident and the PICU benefit from having second year, not first year, residents there. This is a bit different than NICU where a mixture of first years and advanced years seems to work well. Regardless, you are correct that this is very problematic (both PICU and NICU) for fellowship decisions. There is no simple answer to this other than asking to have PICU early in your second year if you're interested. PICU is not very competitive although that doesn't help in your deciding if you want to do it...

 

[edmadison]

I agree with oldbear about the evidence based practice in pediatrics, my response to the adult intensivist would be to ask him what are the value of studies which helping prolong life in mostly dead people anyway ("By using this $58,000 drug we'll be able to keep you 104 year-old demented great-great uncle alive for another 6 days!!!"). Do they ever look at QALYs in their research? I cannot understand why anyone would do adult critical care. They are the doormen to the afterlife.

Regarding cases, it greatly depends on where you are. A large percentage of cases are post surgical. Alot of congenital heart defect repair, crainiofacial and scolis. I would guess this made up about 40% of my PICU patients. Beyond that, you'll see a fair number of kids with respiratory issues, especially PNA in wheelchair bound kids, also in the winter you'll have babies with RSV. You'll also see Asthma, DKA and near-SIDS cases. There will also be a mixture of other medical cases like spesis and heart failure. Depending on the institution, there will also be a trauma. You'll get a fair number of zebras along the way. My most interesting Zebra was a kid with sudden onset paralysis turned out to be a thrombosed spinal AVM!!!

I'd love to recommend PICU to you, but I can't unless you change your Avitar.

Ed

 

[CrazyPeds527]

Oops, one more: Why do most peds residency programs make you wait until PGY-2 to do PICU? How does one get exposure to the field in order to apply for fellowships if they have to wait so long? That's kind of annoying.

There are some programs out there (at this point, I can't remember which ones; my program does not) that do allow you to do PICU as a first year, towards the end of the year. One thing PICU fellowship programs have done to remedy this situation is to place the application season for PICU in July-September of your PGY-3 year, allowing you to have at minimum 1, if not 2 or 3 months of the unit under your belt before application season. The match for PICU, if you apply straight from residency, occurs in October of your PGY-3 year.

Congential heart disease, complex medical patients (trach/g-tube dependent), acute renal failure, sepsis, neuro trauma, subdural bleeds from non-accidental trauma, DKA, asthma, RSV, pulmonary HTN, ECMO, and lots of other good stuff await you in the unit; these are all things I saw in my one month there as a med student.

There are a lot of SDN-ers interested in peds-CCM, so I think you might get some good responses here. 🙂

 

[oldbearprofessor]

One thing PICU fellowship programs have done to remedy this situation is to place the application season for PICU in July-September of your PGY-3 year, allowing you to have at minimum 1, if not 2 or 3 months of the unit under your belt before application season. The match for PICU, if you apply straight from residency, occurs in October of your PGY-3 year.

The late match helps, but doesn't really solve the problem since OTHER fields have early matches. Even with the late match specialties, most folks have to fundamentally decide by early spring of their PL-2 year, which is, IMHO, too early to make an optimal informed decision. I'd be surprised if too many programs had more than one month of PICU prior to the PL-3 year, but would be willing to hear otherwise.

 

[BigRedBeta]

Congential heart disease, complex medical patients (trach/g-tube dependent), acute renal failure, sepsis, neuro trauma, subdural bleeds from non-accidental trauma, DKA, asthma, RSV, pulmonary HTN, ECMO, and lots of other good stuff await you in the unit; these are all things I saw in my one month there as a med student.

There are a lot of SDN-ers interested in peds-CCM, so I think you might get some good responses here. 🙂

I've seen most of those things during my the two weeks of my away rotation in the PICU so far. Throw in transplant patients, short gut (with complication like TPN cholestasis), s/p CT-surgery patients, and some congenital lung conditions. Overall, there's been a really, really wide variety of pathology that I've gotten to see. It's been an awesome rotation so far.

 

[gclax30]

Wow, thanks everyone for your great posts!

Since there appears to be a lot of interest in this area on SDN, does anyone care to comment about lifestyle of a peds CCM doc? Hours, call, 'thinking' vs. 'doing', academics vs. private, opportunities for research and teaching, you know the usual 🙂

 

[elr1983]

Hey everyone,

I'm wondering, what are the 'typical' cases that most folks come across in pedi critical care medicine? I am becoming interested in this field as a specialty and would just like to know more about the typical day for a pediatric intensivist (if there is one of course!). Does this vary highly between academic and community hospital settings?

Also, I was chatting with an adult intensivist in my lab recently and he mentioned that adult CC is more evidence-based whereas peds is more empirical or individualized I guess. Is this generally true and if so, why?

I've only done NICU, so that's the only "critical care" area I can speak to. A lot of our patients are premies (duh) with typical pre mature baby problems....ie RDS/BPD, NEC, ROP, IVH, etc. Most of the discussions are about nutrition (how much fluid they're getting, calories, electrolytes in TPN) and respiratory status (vent settings, O2 requirements, weaning settings). 3/5 of the patients I personally carried were there before I came and were still there when I left, and the other 2 I admitted will be there for the long haul. One came and went within a week. One died about 3 hours after I finished the H and P. A handful have various birth defects, like omphalocele, TEF, PDA (PDA's requiring closure are the main babies we follow....cards follows most everyone with more exotic defects), etc.

I actually thought I wanted to maybe do NICU until I did my rotation...I was expecting a little more variety and a little faster pace...I hear PICU has more variety, but I haven't been there so can't say.

As far as lifestyle, I've heard NICU is better. At our hospital, a big children's hospital, PICU attendings are in house overnight. NICU attendings take home call and I guess they'd come in if necessary, but I never saw one come in on my 4 week rotation (including the night our ECMO baby decannulated himself). Could be different at different hospitals, so not sure if this is the norm. Salary wise, I think it's on the higher end of peds salaries (>200K). As far as procedures, the attendings didn't do many at our hospital, since there were residents/fellosw/NNP's/PA's...this would probably be different in private practice. As far as research, all my attendings do some sort of research project, and rotate who is on service, giving them time for research. As far as teaching, the attendings at our hospital teach the fellows,residents, and students. I woudl think that if you want to do research/teach, you could choose an academic position.

Again, just the experience/perspective of a 4th year student, who obviously doesn't know a lot, so take it with a grain of salt! Good luck! 🙂

 

[jocg27]

I've only done NICU, so that's the only "critical care" area I can speak to. A lot of our patients are premies (duh) with typical pre mature baby problems....ie RDS/BPD, NEC, ROP, IVH, etc. Most of the discussions are about nutrition (how much fluid they're getting, calories, electrolytes in TPN) and respiratory status (vent settings, O2 requirements, weaning settings). 3/5 of the patients I personally carried were there before I came and were still there when I left, and the other 2 I admitted will be there for the long haul. One came and went within a week. One died about 3 hours after I finished the H and P. A handful have various birth defects, like omphalocele, TEF, PDA (PDA's requiring closure are the main babies we follow....cards follows most everyone with more exotic defects), etc.

I actually thought I wanted to maybe do NICU until I did my rotation...I was expecting a little more variety and a little faster pace...I hear PICU has more variety, but I haven't been there so can't say.

As far as lifestyle, I've heard NICU is better. At our hospital, a big children's hospital, PICU attendings are in house overnight. NICU attendings take home call and I guess they'd come in if necessary, but I never saw one come in on my 4 week rotation (including the night our ECMO baby decannulated himself). Could be different at different hospitals, so not sure if this is the norm. Salary wise, I think it's on the higher end of peds salaries (>200K). As far as procedures, the attendings didn't do many at our hospital, since there were residents/fellosw/NNP's/PA's...this would probably be different in private practice. As far as research, all my attendings do some sort of research project, and rotate who is on service, giving them time for research. As far as teaching, the attendings at our hospital teach the fellows,residents, and students. I woudl think that if you want to do research/teach, you could choose an academic position.

Again, just the experience/perspective of a 4th year student, who obviously doesn't know a lot, so take it with a grain of salt! Good luck! 🙂

My impression of my home program has always been the reverse. Any other perspectives?

 

[CrazyPeds527]

Everything is highly dependent on the institution.

Places with fellows around have attendings with home call only, and they usually come in only when the crap hits the fan. Other places may have attendings all night. Some places even have one attending in house covering the PICU and NICU!! Yikes!

For salary, this was discussed in another forum; on average NICU takes the $ cake, with PICU coming in 4th amongst peds subspecialities behind Peds Cards and Peds GI. Most salaries i have seen advertised for academic start around $150-200k and private $200-250k and more; although it is highly, highly dependent on your benefits package and your location.

The "thinking vs doing" is also dependent on your hospital and who is in charge of chest tubes, etc (surg vs peds), but in general, critical care is a "doing" specialty that also involves complex thinking and care coordination.

The impression of PICUs I have seen for more than one interview day personally (N=4) is that it is really variable and you can really tailor your choices professionally if you are willing to be flexible on location.