WHy is critical care silly?

[SandP]

someone in another thread recently made a comment that the anesthesia-critical care route is for "generalists" and "interns." Thoughts? Some elaboration would be quite helpful. thanks!

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[deleted171991]

someone in another thread recently made a comment that the anesthesia-critical care route is for "generalists" and "interns." Thoughts? Some elaboration would be quite helpful. thanks!

Why don't you ask that person? Mind-reading is not part of anesthesia residency.

 

[Hork Bajir]

I don't think that is a particularly widespread belief amongst most of the posters on this forum. Anesthesiologists who choose to to CC are often a little bit on the more cerebral/nerdy side, and tend to be more interested in medicine- so maybe by "interns" the poster you are referring to meant to say "internists"? Regardless, I don't think anyone who knows what they're talking about would say critical care is easy or silly.

If you were determined to make a critique of critical care, I think it would be fair to say this:
- A large chunk of ICU management is pretty straightforward, and most anesthesiologists or "generalists" could stumble through it... We don't always have the subtleties down, but these patients will probably do fine anyway
- A decent number of ICU patients are fracked no matter what anyone does, and all we do is torture them needlessly
- A relatively small number of ICU patients are critically ill, and can be saved... But only by someone who really knows their sh**. This is where the details and the subtleties matter a lot. These are the cases where a really good intensivist will make a difference

You could say the same thing about most subspecialties of anesthesia, though. A CRNA or general anesthesiologist could probably stumble through the bread and butter cardiac cases, for example, but the extra training really makes a difference in the margins

If you are asking about critical care job prospects, though, that's a totally different question

* I should add that I am not an ICU doc, so this is just my 0.02

 

[SandP]

Why don't you ask that person? Mind-reading is not part of anesthesia residency.

I did. he/she recommended i make a new thread

 

[deleted171991]

I did. he/she recommended i make a new thread

Funny.

Who was the genius?

 

[SandP]

it was /urge

 

[deleted171991]

I don't think that is a particularly widespread belief amongst most of the posters on this forum. Anesthesiologists who choose to to CC are often a little bit on the more cerebral/nerdy side, and tend to be more interested in medicine- so maybe by "interns" the poster you are referring to meant to say "internists"? Regardless, I don't think anyone who knows what they're talking about would say critical care is easy or silly.

If you were determined to make a critique of critical care, I think it would be fair to say this:
- A large chunk of ICU management is pretty straightforward, and most anesthesiologists or "generalists" could stumble through it... We don't always have the subtleties down, but these patients will probably do fine anyway
- A decent number of ICU patients are fracked no matter what anyone does, and all we do is torture them needlessly
- A relatively small number of ICU patients are critically ill, and can be saved... But only by someone who really knows their sh**. This is where the details and the subtleties matter a lot. These are the cases where a really good intensivist will make a difference

You could say the same thing about most subspecialties of anesthesia, though. A CRNA or general anesthesiologist could probably stumble through the bread and butter cardiac cases, for example, but the extra training really makes a difference in the margins

If you are asking about critical care job prospects, though, that's a totally different question

* I should add that I am not an ICU doc, so this is just my 0.02

The art of critical care is not knowing what to do, but knowing what not to do, and especially when. All the busybody idiots who prescribe 100 meds and labs and procedures for their patients mostly just cause iatrogenic problems and unpleasantness. The value of a real intensivist is knowing when to simply just watch and assist the patient in fixing herself. The only miracles in medicine come from the human body; there are much fewer geniuses among doctors intensivists than we think.

Anybody can read Uptodate, or a good critical care book. Few can actually understand the limits and biases of what they read.

Don't just do something, stand there!

 

[urge]

Because...

Patients heal themselves with time. Or they don’t.

There is no magical therapy any intensivist can provide. It is all supportive care, rendered by nurses.

BP too low? Bring it up. BP too high? Make it low. O2 Sat too low? Bring it up. Potassium too high? Make it low. Potassium too low? Bring it up. Creatinine too high? Make it low. Platelets too low? Stop the heparin (that is an advanced one actually, you need a fellowship for that one but I’ll give it to you as a freebie). Anything not covered above, consult a specialist. While you wait for the specialist to reply you can put everyone on haldol, seroquel, or keppra, your choice. And don’t forget to put everyone on high flow nasal cannula so it looks like you are doing something for them when you really aren’t.

I just summed up your career for the next 30 years, if you chose to do it.

There is zero thought process necessary. It’s all reaction and protocols, plus following specialists recommendations.

Do you think an intern cannot do that?

And I mean intern as in fresh out of med school.

 

[ToKingdomCome]

Damn, this makes me sad. I want to a CCM fellowship. I wouldn’t do CCM full time. I’d love to do it 25% of the time. I do think it would make me a better intra op anesthesiologist even if I don’t practice CCM again

 

[urge]

Damn, this makes me sad. I want to a CCM fellowship. I wouldn’t do CCM full time. I’d love to do it 25% of the time. I do think it would make me a better intra op anesthesiologist even if I don’t practice CCM again

Which part do you plan to incorporate to your anesthetic?

The seroquel?

The high flow nasal cannula?

Other? Please explain.

 

[chocomorsel]

Because...

Patients heal themselves with time. Or they don’t.

There is no magical therapy any intensivist can provide. It is all supportive care, rendered by nurses.

BP too low? Bring it up. BP too high? Make it low. O2 Sat too low? Bring it up. Potassium too high? Make it low. Potassium too low? Bring it up. Creatinine too high? Make it low. Platelets too low? Stop the heparin (that is an advanced one actually, you need a fellowship for that one but I’ll give it to you as a freebie). Anything not covered above, consult a specialist. While you wait for the specialist to reply you can put everyone on haldol, seroquel, or keppra, your choice. And don’t forget to put everyone on high flow nasal cannula so it looks like you are doing something for them when you really aren’t.

I just summed up your career for the next 30 years, if you chose to do it.

There is zero thought process necessary. It’s all reaction and protocols, plus following specialists recommendations.

Do you think an intern cannot do that?

And I mean intern as in fresh out of med school.

While there’s a lot of this going on, there is also much more than this going on. Especially in the medical ICUs.

 

[urge]

- A relatively small number of ICU patients are critically ill, and can be saved... But only by someone who really knows their sh**. This is where the details and the subtleties matter a lot. These are the cases where a really good intensivist will make a difference

Could you give us an example that’s not an episode of Dr. House, please?

 

[CCM-MD]

OP: if you want to figure out why this poster thinks critical care is "silly" refer to the thread linked below. Looks like this person has had something against CCM for a long time.

Not a fan of critical care medicine... is that ok?

So I realize that anesthesiologists are obviously intensivists, and that we founded critical care medicine and all, but the more time I spend taking care of medical ICU patients, the more I'm realizing critical care medicine is not for me. Is it even ok for an anesthesiologist to feel that way...

forums.studentdoctor.net

 

[deleted171991]

OP: if you want to figure out why this poster thinks critical care is "silly" refer to the thread linked below. Looks like this person has had something against CCM for a long time.

Not a fan of critical care medicine... is that ok?

So I realize that anesthesiologists are obviously intensivists, and that we founded critical care medicine and all, but the more time I spend taking care of medical ICU patients, the more I'm realizing critical care medicine is not for me. Is it even ok for an anesthesiologist to feel that way...

forums.studentdoctor.net

View attachment 259932
View attachment 259933

Darn, now I'll have to put you too on ignore, so I won't see his posts again.

 

[CCM-MD]

Darn, now I'll have to put you on ignore, too, so I won't see his posts again.

 

[deleted171991]

I can't see that.
.

 

[deleted171991]

Poor OP.

"A fool can throw a stone in a pond that 100 wise men can not get out."

 

[urge]

I can't see that.
.

Ok Pinocchio.

 

[deleted547339]

Because...

Patients heal themselves with time. Or they don’t.

There is no magical therapy any intensivist can provide. It is all supportive care, rendered by nurses.

BP too low? Bring it up. BP too high? Make it low. O2 Sat too low? Bring it up. Potassium too high? Make it low. Potassium too low? Bring it up. Creatinine too high? Make it low. Platelets too low? Stop the heparin (that is an advanced one actually, you need a fellowship for that one but I’ll give it to you as a freebie). Anything not covered above, consult a specialist. While you wait for the specialist to reply you can put everyone on haldol, seroquel, or keppra, your choice. And don’t forget to put everyone on high flow nasal cannula so it looks like you are doing something for them when you really aren’t.

I just summed up your career for the next 30 years, if you chose to do it.

There is zero thought process necessary. It’s all reaction and protocols, plus following specialists recommendations.

Do you think an intern cannot do that?

And I mean intern as in fresh out of med school.

Ummm. No. I agree, patients mostly heal themselves, but zero thought process necessary? Sorry.

 

[urge]

Ummm. No. I agree, patients mostly heal themselves, but zero thought process necessary? Sorry.

I was very deliberate when I wrote “necessary”.

You can think all you want, or not.

As long as all abnormal values are corrected and specialist’s recommendations are followed, it won’t make difference.

In fact, as FFP alluded to, it might actually be detrimental. I see this fairly often, though. The specialists recommend one thing, but the intensivists think they know better and do something else, which usually leads to catastrophe.

 

[vector2]

BP too low? Bring it up. BP too high? Make it low. O2 Sat too low? Bring it up. Potassium too high? Make it low. Potassium too low? Bring it up. Creatinine too high? Make it low. Platelets too low? ..........

You realize you're also describing anesthesia here, right? The difference being that when I'm staffing the unit, I don't have to beg and plead with my subordinates to follow my orders.

 

[CCM-MD]

You realize you're also describing anesthesia here, right? The difference being that when I'm staffing the unit, I don't have to beg and plead with my subordinates to follow my orders.

yes. but no seroquel in the OR.

 

[urge]

You realize you're also describing anesthesia here, right? The difference being that when I'm staffing the unit, I don't have to beg and plead with my subordinates to follow my orders.

That’s the intern part of anesthesia. Like measuring urine output.

Devising a good anesthetic plan is another story. That’s the specialist part.

 

[urge]

You realize you're also describing anesthesia here, right? The difference being that when I'm staffing the unit, I don't have to beg and plead with my subordinates to follow my orders.

Do you mean your potassium correction orders?

 

[CCM-MD]

I devise good anesthetic plans on many of my critically ill patients every day.

 

[deleted547339]

I was very deliberate when I wrote “necessary”.

You can think all you want, or not.

As long as all abnormal values are corrected and specialist’s recommendations are followed, it won’t make difference.

In fact, as FFP alluded to, it might actually be detrimental. I see this fairly often, though. The specialists recommend one thing, but the intensivists think they know better and do something else, which usually leads to catastrophe.

It seems like you’re on the far left side of the dunning-kruger effect with respect to critically ill patients and are a casualty of selection bias. Yes, when done right, it looks like we’re not doing much, but this shows a very poor understanding of what we do, particularly in medical icus. Not just that, but the number of consults we may are quite few and usually for procedures I can’t do - GI or VIR for bleeding, renal for CRRT (which we could do alone if the hospital credentials), ophtho for dilated eye exams in candidemia and occasionally a surgeon.

 

[CCM-MD]

It seems like you’re on the far left side of the dunning-kruger effect with respect to critically ill patients and are a casualty of selection bias. Yes, when done right, it looks like we’re not doing much, but this shows a very poor understanding of what we do, particularly in medical icus. Not just that, but the number of consults we may are quite few and usually for procedures I can’t do - GI or VIR for bleeding, renal for CRRT (which we could do alone if the hospital credentials), ophtho for dilated eye exams in candidemia and occasionally a surgeon.

 

[urge]

It seems like you’re on the far left side of the dunning-kruger effect with respect to critically ill patients and are a casualty of selection bias. Yes, when done right, it looks like we’re not doing much, but this shows a very poor understanding of what we do, particularly in medical icus. Not just that, but the number of consults we may are quite few and usually for procedures I can’t do - GI or VIR for bleeding, renal for CRRT (which we could do alone if the hospital credentials), ophtho for dilated eye exams in candidemia and occasionally a surgeon.

I’m an advocate of making physician statistics public to patients. If you are correct about the Dunning-Kruger effect I’ll be the first one out.

Bring it on. I’m game.

 

[deleted547339]

I’m an advocate of making physician statistics public to patients. If you are correct about the Dunning-Kruger effect I’ll be the first one out.

Bring it on. I’m game.

What? I don’t even understand what you’re asking.

Where I did fellowship (top ivory tower institution), everyone used to get admitted under the name of the MICU medical director. For about a decade, he had the highest mortality in the state, maybe the country. He was probably the best doctor I’ve ever met but his numbers were arguably the worst, as we were the last house on the block. He was the kind of guy that could walk by a room and say “they have tularemia” “sounds like EBV-induced HLH” or stop the intern and say “go ahead and page heme, it’s going to be TTP” two sentences into a presentation - and always be right.

I get that it looks like fentanyl, propofol, low volume ventilation, seroquel, insulin, vanc/zosyn and consults to the outside world, but that’s a very myopic view.

 

[fakin' the funk]

Because...

Patients heal themselves with time. Or they don’t.

There is no magical therapy any intensivist can provide. It is all supportive care, rendered by nurses.

BP too low? Bring it up. BP too high? Make it low. O2 Sat too low? Bring it up. Potassium too high? Make it low. Potassium too low? Bring it up. Creatinine too high? Make it low. Platelets too low? Stop the heparin (that is an advanced one actually, you need a fellowship for that one but I’ll give it to you as a freebie). Anything not covered above, consult a specialist. While you wait for the specialist to reply you can put everyone on haldol, seroquel, or keppra, your choice. And don’t forget to put everyone on high flow nasal cannula so it looks like you are doing something for them when you really aren’t.

I just summed up your career for the next 30 years, if you chose to do it.

There is zero thought process necessary. It’s all reaction and protocols, plus following specialists recommendations.

Do you think an intern cannot do that?

And I mean intern as in fresh out of med school.

This is achingly stupid, or trolling, likely both.

 

[urge]

What? I don’t even understand what you’re asking.

Where I did fellowship (top ivory tower institution), everyone used to get admitted under the name of the MICU medical director. For about a decade, he had the highest mortality in the state, maybe the country. He was probably the best doctor I’ve ever met but his numbers were arguably the worst, as we were the last house on the block. He was the kind of guy that could walk by a room and say “they have tularemia” “sounds like EBV-induced HLH” or stop the intern and say “go ahead and page heme, it’s going to be TTP” two sentences into a presentation - and always be right.

I get that it looks like fentanyl, propofol, low volume ventilation, seroquel, insulin, vanc/zosyn and consults to the outside world, but that’s a very myopic view.

Specialty specific stats silly goose.

You said I must suck and that's why I think the intensivists are the ones that suck.

Run my stats against anesthesiologists doing similar cases. That's the only way to tell if you are right in my cognitive disfunction, or it's just the intesivists that suck.

We'll have intesivists stats too, don't you worry.

 

[deleted547339]

Specialty specific stats silly goose.

You said I must suck and that's why I think the intensivists are the ones that suck.

Run my stats against anesthesiologists doing similar cases. That's the only way to tell if you are right in my cognitive disfunction, or it's just the intesivists that suck.

We'll have intesivists stats too, don't you worry.

No. I have no idea if you’re a good anesthesiologist. I am suggesting you know very little about critical care (and I don’t mean anesthetizing critically ill patient, I mean running an icu). You may be excellent, average or marginal, but you don’t understand my specialty.

I can say all you do is prop, sux fentanyl and inhaled anesthetics, but the fact of the matter is there are a dozen things you actively consider and probably another 50 you subconsciously consider when you plan an anesthetic, but to an outsider, it looks like you just throw some s at a patient while someone cuts.

 

[urge]

Pent sux tube, my friend.

That is the anesthetic plan.

 

[urge]

It's getting late.

Thanks for letting me vent.

Tomorrow I'll smile to my intensivist colleagues with less baggage on me.

Until it builds up again from watching them work.

Have a good night.

 

[MoMoGesiologist]

Because...

Patients heal themselves with time. Or they don’t.

There is no magical therapy any intensivist can provide. It is all supportive care, rendered by nurses.

BP too low? Bring it up. BP too high? Make it low. O2 Sat too low? Bring it up. Potassium too high? Make it low. Potassium too low? Bring it up. Creatinine too high? Make it low. Platelets too low? Stop the heparin (that is an advanced one actually, you need a fellowship for that one but I’ll give it to you as a freebie). Anything not covered above, consult a specialist. While you wait for the specialist to reply you can put everyone on haldol, seroquel, or keppra, your choice. And don’t forget to put everyone on high flow nasal cannula so it looks like you are doing something for them when you really aren’t.

I just summed up your career for the next 30 years, if you chose to do it.

There is zero thought process necessary. It’s all reaction and protocols, plus following specialists recommendations.

Do you think an intern cannot do that?

And I mean intern as in fresh out of med school.

Who hurt you?

 

[ToKingdomCome]

How much do most academic OR/CCM gigs pay?

 

[deleted171991]

How much do most academic OR/CCM gigs pay?

Typically about the same as similar full OR gigs. That's actually advantageous, because CCM makes less money for the department.

 

[McPoyle]

I will be making more though it is due to working more. However, because of the way our base is calculated this means I will also get more vacation.

 

[psychbender]

If the CCM attendings cover a larger census, they can actually bill more than the general anesthesia attendings that are strictly covering 2:1, with topical academic speed and inefficiency. Where I did fellowship, this was true, and I remember the department chief mentioning that the Anes/CCM staff were some of the few that actually covered all of their own salary and benefits package, and then some.

 

[leviathan]

I always enjoy these specialty bashing posts. For a lot of patients in ICU their outcome is pre-determined. Nothing you do will save them. Or nothing you do will kill them, even dumping in 10 litres of normal saline to treat their low urine output. There are still patients in the middle who need a strong critical care specialist. Who also need someone that has more of a brain than to think a low BP = raise it, or a high BP = lower it. Lots of studies proving that ICUs staffed by intensivists have lower mortality, fewer days in ICU and on mechanical vent etc.

 

[deleted171991]

I always enjoy these specialty bashing posts. For a lot of patients in ICU their outcome is pre-determined. Nothing you do will save them. Or nothing you do will kill them, even dumping in 10 litres of normal saline to treat their low urine output. There are still patients in the middle who need a strong critical care specialist. Who also need someone that has more of a brain than to think a low BP = raise it, or a high BP = lower it. Lots of studies proving that ICUs staffed by intensivists have lower mortality, fewer days in ICU and on mechanical vent etc.

And who cares?

I still have to see one nurse or midlevel reprimanded for uselessly debating or not following a physician's orders. Also, nobody gets punished for dumping those 10 liters of saline in a patient, till he gets abdominal compartment syndrome. So yeah, we are very important to the hospitals, sure. That's why my contract says that I have to teach medicine to everybody, including nursing and midlevel students (i.e train my replacements).

Doctors shouldn't go into specialties/jobs where patients can't choose them. That's the recipe for becoming insignificant.

 

[dhb]

If i remember correctly JL Vincent's mixed med/surg ICU in Brussels had 1500 admitions a year with a 20% mortality and with a good 40% of surgical patients in whom mortality rates should be around 1%.
If you discount the soft admission for lack of intermediate care unit you're looking at a 50% ICU mortality for real ICU patients and you're not accounting for 1 year mortality and morbidity.
How many patients are we really saving in ICUs? Very few and at an exorbitant cost.

 

[urge]

I always enjoy these specialty bashing posts. For a lot of patients in ICU their outcome is pre-determined. Nothing you do will save them. Or nothing you do will kill them, even dumping in 10 litres of normal saline to treat their low urine output. There are still patients in the middle who need a strong critical care specialist. Who also need someone that has more of a brain than to think a low BP = raise it, or a high BP = lower it. Lots of studies proving that ICUs staffed by intensivists have lower mortality, fewer days in ICU and on mechanical vent etc.

Show me said studies, please.

 

[Section31]

I liked ICU. However, I did not like having patients die. The central conceit of anesthesia that sold me on it was that none of my patients are ever supposed to die. I’m always tasked with saving. ICU violates that principle.

 

[urge]

This is real life ICU care in the US:

ACP Journals

Setting:
123 ICUs in 100 U.S. hospitals.
Patients:
101 832 critically ill adults.

Conclusion:
In a large sample of ICU patients in the United States, the odds of hospital mortality were higher for patients managed by critical care physicians than those who were not. Additional studies are needed to further evaluate these results and clarify the mechanisms by which they might occur.

 

[urge]

This is real life ICU care in the US:

ACP Journals

Setting:
123 ICUs in 100 U.S. hospitals.
Patients:
101 832 critically ill adults.

Conclusion:
In a large sample of ICU patients in the United States, the odds of hospital mortality were higher for patients managed by critical care physicians than those who were not. Additional studies are needed to further evaluate these results and clarify the mechanisms by which they might occur.

Editors’ Notes

Context

• Critical care physicians or physicians without specialized critical care training may manage patients in intensive care units.

Contribution

• This study described 101 832 patients in 123 intensive care units in the United States. Patients managed by critical care physicians were sicker, had more procedures, and had higher hospital mortality rates than those managed by other physicians. Analyses that adjusted for severity of illness and the tendency for sicker patients to be managed by critical care specialists still showed higher mortality among patients managed by the specialists.

Caution

• Unrecognized confounders might diminish or invalidate the unexpected finding of higher mortality among patients managed by critical care specialists.

—The Editors

 

[chocomorsel]

If i remember correctly JL Vincent's mixed med/surg ICU in Brussels had 1500 admitions a year with a 20% mortality and with a good 40% of surgical patients in whom mortality rates should be around 1%.
If you discount the soft admission for lack of intermediate care unit you're looking at a 50% ICU mortality for real ICU patients and you're not accounting for 1 year mortality and morbidity.
How many patients are we really saving in ICUs? Very few and at an exorbitant cost.

This is morbid.

Problem I see is we try too hard to save the 80+ year olds with multiple comorbities and now some life threatening illness to top it off instead of focusing on the more salvageable, more robust, younger, generally healthier ones. That skews our numbers.
And costs us a ton.

It is very wasteful the things we do in the Unit.

 

[shepardsun]

Yeah, most of this discussion focuses incorrectly on the qualifications or capacities of intensivists instead on the bioethical issues concerning critically ill patients. We don't know how to let largely un-savable patients die with dignity, and we often let families run the medical plan in lieu of making hard decisions for grandma and grandpa.

 

[urge]

Yeah, most of this discussion focuses incorrectly on the qualifications or capacities of intensivists instead on the bioethical issues concerning critically ill patients. We don't know how to let largely un-savable patients die with dignity, and we often let families run the medical plan in lieu of making hard decisions for grandma and grandpa.

I see that occasionally, but far more often I see surgeons trying to convince the family to keep going, since they care more about their surgical stats than futility of care. A patient sent peg'ed and trached to an LTAC is considered successful per statistics.

 

[Dam272]

Typically about the same as similar full OR gigs. That's actually advantageous, because CCM makes less money for the department.

That sounds enough for me to pursue CCM, figuring that I wont be earning less whilst doing what I like