EM resident applying to CC programs here. Ironically torn between medicine, anesthesia, and (gasp) surgery pathways. I know the latter two can provide significantly more exposure to cardiac ICUs, but am not sure what it is like working in these units. Can anyone shed light on the environment? Seems like you'll spend a lot of time coordinating care between cardiologists, CT surgeons, and anesthesiologists and will have less "ownership" over your patients. Is that a fair assumption? Are patients rocks that get lined and tubed in the OR and sit on your service without much going on? I've heard these are some of the "sickest" patients, but would like to know how this translates into practice, and how beneficial it would be to my training as an intensivist. Appreciate anyone's thoughts, especially EM-CC folks.
What is CTICU all about?
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Transplant CTICU can be pretty darn tricky
And the CTICU at a university hospital will also be very interesting very often
In the community however, so most jobs, things will usually be more straightforward. The stupid sick will be the exception not the rule but will still happen often enough. Your job will be to do push ups at the bedside so the surgeons can operate and generate those sweet sweet DRGs for the hospital. You’ll be expected to shovel a lot of dog**** but will also be a valuable member of the team. CT surgeons often can’t help themselves and will do stuff to the patients because they have a hard time sitting still and very aggressively doing nothing.
I don’t think *I’d* like that job in the community all that much but I’d do it for the right price.
Most of your future job opportunities will be in the MICU. I’d suggest finding a program that you think will give you most exposure to the MICU but also a good percentage of time in the CTICU if it is something you think you’ll find interesting.
My $0.02
And the CTICU at a university hospital will also be very interesting very often
In the community however, so most jobs, things will usually be more straightforward. The stupid sick will be the exception not the rule but will still happen often enough. Your job will be to do push ups at the bedside so the surgeons can operate and generate those sweet sweet DRGs for the hospital. You’ll be expected to shovel a lot of dog**** but will also be a valuable member of the team. CT surgeons often can’t help themselves and will do stuff to the patients because they have a hard time sitting still and very aggressively doing nothing.
I don’t think *I’d* like that job in the community all that much but I’d do it for the right price.
Most of your future job opportunities will be in the MICU. I’d suggest finding a program that you think will give you most exposure to the MICU but also a good percentage of time in the CTICU if it is something you think you’ll find interesting.
My $0.02
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Try to find a multidisciplinary program, that’s the best option. If you want to work in academics then pick the fellowship based on what population you want to treat after finishing. For community, if you can’t get a multidis program, go for a medicine based one fellowship. I am IM-CCM so I’m obviously biased but large proportion of community practice is critical medical patients. Surgical ICUs have a major problem: surgeons. And for the SCC path I believe you are essentially a surgical intern for one year so that is probably the worst option. I believe everyone probably evens out after some years in practice as long as one keeps an open mind and keeps reading.
Which programs open to EM would you consider "multidisciplinary?" Pitt, WashU, Stanford, UNM are some that come to mind.. Any others?
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UNM has a CCM fellowship? What? Since when? Marinaro runs it? Last I heard they kicked all the anesthesiologists out of the TSICU. MICU was a much more pleasant experience. No more neurosurgery residency which is sad for the area as isolated as it is.
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Its been a bit since I interviewed. Any program that spreads your experience across a variety of units would be good. If you can get faculty from varied backgrounds, even better.
Fellowships | Pulmonary, Critical Care & Sleep Medicine | UNM School of Medicine | School of Medicine
info online is pretty scant/hard to find.. most I know is word of mouth. Sounds pretty cowboy and EM friendly.. also have a spot for surgery i just found out exists recently:
Surgical Critical Care Fellowship | School of Medicine
have you trained/worked there? Thoughts?
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CT ICU community jobs can be best summed up as baby sitter for the cardiac surgeons.
there is a reason none of us want these jobs as attendings. I personally think the CT ICU is the worse place to be, unless you’re sadistic, love having a surgeon slap you around or their midlevel giving you instruction from said surgeon.
there is a reason none of us want these jobs as attendings. I personally think the CT ICU is the worse place to be, unless you’re sadistic, love having a surgeon slap you around or their midlevel giving you instruction from said surgeon.
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There is a place worse than the CTICU: the neuro ICU. Not only does this place require baby sitting for the neurosurgeons, it also has horrible outcomes.
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I trained there a decade ago. As an anesthesia department we had no faculty that practiced CCM so therefore were treated like crap by the ER guys (Marinaro really) who ran the TSICU and the surgical residents. After I left two people from the class above me came back and were hired as CCM/Anesthesia. The anesthesia department slowly tried to be more involved and have better standing in the TSICU but were promptly pushed out by someone. Guess people were protecting their territory. Apparently the MICU and I think NICU took the anesthesia residents to help them meet their requirements. From what I hear from a friend who did locums out there during Covid last fall, there are no anesthesia residents in the TSICU still. It's all drama, political BS, protecting turf with I am sure Marinaro at the helm as he has been in charge for ever. If you are EM then I am sure you will be treated great.
The NICU used to be run by the Neuro and NSG residents but the NSG lost accreditation so no more residents. Great place to learn and had I more time I would have done a NICU rotation. Huge catchment area and lots of neuro and trauma.
MICU was great, drama free, and I remember promptly getting in trouble for saying that out loud when I was a resident. That I preferred the MICU over the required TSICU. You know, egos and all. I did my senior rotation in the MICU instead of the TSICU as I refused to set foot in there again because of drama.
Like I said as an EM person you will probably be treated dandy. Unless you are a surgeon, I would stay away from their fellowship and do the IM one instead. You get elective time to do other non MICU rotations.
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I have had much better rapport with neurosurgeons than with cardiac surgeons. I feel like the neurosurgeons really just want to operate and not want to run the ICU as well unlike CV surgeons. And I love the NICU. Hate cardiac in general from the OR to the ICU.
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I keep thinking neonatal ICU when you say NICU. I agree with you about many neurosurgeons not interfering with ICU management but PITA neurosurgeons who think they know better are definitely out there. We have a couple that consistently give families an unreasonably positive prognosis. This turns the neuro ICU into a plantation of patients getting salt water that cannot come off the vent because they don't wake up enough to protect their airway. Having patients there is a nice break from the med surg disasters that need constant intervention, so I guess because of that I kinda love the neuro ICU too.
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PEG, trach, transfer to nursing home, and move on. Used to have a problem w trachs in fellowship but that changed after a few months of the NICU.
Patient families can be unreasonable as we already know, so let them have their veggies and move on.
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Yes neonatal icu worse, neuro icu not so bad.
choco, I think we had great exposure for our training in neuro icu. In fact, I would take a Neuro icu job in a heart beat, as she stated above there basically are only a few moves to be had. I enjoyed Neuro icu a ton !
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Most of it will be straightforward stuff. Early extubation, wean the drips, resuscitate, watch the bleeding, etc. And as another poster said... facilitate getting these patients out to the ward in such a way that they can leave the hospital ASAP.
As for the sickest patients... these are the ECMO patients, the multiple comorbidity redo multi valve, ESRD/low EF cabg + mitral, thoracoabdominal aortic aneurysms, etc. All of these patients are at the university hospital, and the only coordination is really between you and the surgeon/surgeons representative (may be a PA in some places, more likely the adult cardiac fellow at a university program). In the adult CTICU, there's not much cardiologist input in my experience but but it may be different at different places. Anesthesia is involved to the extent that many adult CTICU attendings seem to be anesthesia/cardiac anesthesia/CCM pathways folks. Like the anesthesiologist from the case isn't going to come to the bedside 3 days later and recommend some drip changes.
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Reading the phrase "CTICU community jobs" made me shudder
CT always had the coolest toys and most resources, and generally positive patient outcomes but the surgeons were nightmares. Any adverse event got blamed on the ICU RNs/MDs, and the surgeons had unreasonable pull within the hospital. At one community hospital, the CV surgeon threw a fit after a fatal PE went unrecognized in a post-CABG on the floor, and the hospital changed the policy so that pts stayed in the CTICU for the entirety of their stay! Could you imagine a CC doc making such a demand??
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And you wonder why none of us like CT icu?
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To answer the thread title—the cticu is all about rapid discharge so the surgeons can do more elective hearts and print enormous piles of money. Anything that runs counter to that or the surgeon thinks might run counter to that will not happen.
If your dream was to be a well paid mid level who shields the surgeon from pages but then gets chewed out because you executed some cognitive function and titrated the Milrinone down when their index was 4 24 hrs postop in order to facilitate discharge out of the icu then it will fulfill all of your life goals and probably a lot more.
If your dream was to be a well paid mid level who shields the surgeon from pages but then gets chewed out because you executed some cognitive function and titrated the Milrinone down when their index was 4 24 hrs postop in order to facilitate discharge out of the icu then it will fulfill all of your life goals and probably a lot more.
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AdventHealth Orlando; it's IM-CCM and very EM friendly.
(disclosure- I built the program so of course I'm biased as to how awesome it is)
Critical care is its own department so the attendings trained in EM/CCM, IM/CCM, Anes/CC, Surg/CC, etc, are all under the same department. The surg/CC primarily work in the SICU (although they do infrequent night coverage for the MICU), and the MICU attendings occasionally cover the SICU. Most of the EM/CC people are in the CVICU/ECMO unit, as are the anes/CC.
The downside is it's a newer program (the second class is just about to start) but there's 1 EM trained fellow in the first class and 2 EM trained fellows in the second class.
A bunch of our attendings trained at Pitt, I trained at WashU... both of those are solid programs as well.
