Why so much Critical Care in EM now?

[AmericaAmerica]

Apologies if this has been covered in another thread, although my research yielded nada. Please excuse my youthful ignorance and naiveté.

I am an MS4 applying to EM residencies and I wonder why there is so much emphasis on ICU months as EM residents. I think ICU experience would be very useful, but many of the places I'm applying to highlight the fact that they are ICU heavy. Many are excited about the prospect of adding even more ICU rotations. This worries me as I'm thinking I should be perfecting my EM knowledge and style before being in the ICU. I want to be a community ED doc for my entire career and am not trying to be an intensivist.

Is this a new phenomenon? Were EM residents doing 6 months out of their training in ICUs 10-20 years ago? And what is this push all about: procedure practice, resus/code management, etc? That seems to be the answer every time I ask it in person, but I was wondering what everyone on here thinks?

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[alpinism]

So back in the day (remember EM is still a relatively new specialty) there used to be way more floor months (Medicine/Surgery) instead of ICU months (especially during intern year). As time went on, more and more residencies realized how useless these months were for EM residents and switched over to ICU months (sicker patients, more procedures, etc...).

 

[Vandalia]

Well, it is more important for a "community ED" doc than it is for someone in an academic/tertiary environment. There, all you have to do is turf someone off and let others handle critical patients. In the critical access hospital we cover, you are the only physician in house at night and on weekends. During a blizzard or a hurricane (as it may be).... it can very well be up to you to keep someone alive for a significant period of time. Paradoxically, the ICU skills you hopefully will pick up are not necessarily needed in places with an ICU, but rather the places without them.

Plus, more generally, that is the entire philosophy of medical education. IM physicians spend most of their time on wards even thought the vast majority of them will work in an outpatient environment. (Others will say that there are other reasons for that, along the lines of indentured servitude.) The belief is that if you can handle the patient with a dozen problems, 50 meds and 20 lines and tubes sticking in them then the patient in the ED with a little nausea and vomiting will be a piece of cake. Any ED, almost no matter where you are, will have a vast number of patients with negligible learning value. Therefore, to maximize the "educational density" it is thought to be necessary to spend a significant amount of time during residency learning in higher acuity environments. While you may think a residency filled with only ED time might be good, a shift seeing only patients with "stomach flu" will teach you nothing more than hatred for the rest of humanity.

 

[TheComebacKid]

Also, more people are interested in Critical Care fellowships through EM, making ICU time during residency important for your fellowship application.

 

[gro2001]

Apologies if this has been covered in another thread, although my research yielded nada. Please excuse my youthful ignorance and naiveté.

I am an MS4 applying to EM residencies and I wonder why there is so much emphasis on ICU months as EM residents. I think ICU experience would be very useful, but many of the places I'm applying to highlight the fact that they are ICU heavy. Many are excited about the prospect of adding even more ICU rotations. This worries me as I'm thinking I should be perfecting my EM knowledge and style before being in the ICU. I want to be a community ED doc for my entire career and am not trying to be an intensivist.

Is this a new phenomenon? Were EM residents doing 6 months out of their training in ICUs 10-20 years ago? And what is this push all about: procedure practice, resus/code management, etc? That seems to be the answer every time I ask it in person, but I was wondering what everyone on here thinks?

I think the reason for emphasis on ICU time during residency interview season is three fold:

1) The programs are pandering to the applicants. Its what a lot of medical students are interested in and think is cool. They've bought into the mythos of EM being all about treating the critically ill (even though in reality that is likely to be <10% of your patients).

2) It actually is important. Boarding, including of critically ill patients is still an issue in many EDs across the country and you will likely need to take care of them while waiting for ICU beds to open up or for transfers to happen.

3) Some of the skills take a while to learn and are more difficult to master after residency is over.

 

[Old_Mil]

Apologies if this has been covered in another thread, although my research yielded nada. Please excuse my youthful ignorance and naiveté.

I am an MS4 applying to EM residencies and I wonder why there is so much emphasis on ICU months as EM residents. I think ICU experience would be very useful, but many of the places I'm applying to highlight the fact that they are ICU heavy. Many are excited about the prospect of adding even more ICU rotations. This worries me as I'm thinking I should be perfecting my EM knowledge and style before being in the ICU. I want to be a community ED doc for my entire career and am not trying to be an intensivist.

Is this a new phenomenon? Were EM residents doing 6 months out of their training in ICUs 10-20 years ago? And what is this push all about: procedure practice, resus/code management, etc? That seems to be the answer every time I ask it in person, but I was wondering what everyone on here thinks?

Unless you plan on doing a critical care fellowship, ICU rotations aren't very helpful in terms of learning emergency medicine. The reason why the curriculum has so many of them ranges from inertia to EM programs lacking clout and other services needing warm bodies for scutwork. There is basically nothing relevant to the practice of EM that you can learn by babysitting a guy who has been in a coma for two weeks with a bolt in his head or is undergoing CRRT. Good emergency training happens in the ED so pick a program that minimizes the amount of time you get scutted out to other services.

As far as boarding patients in the ED this happens, but you learn how to do it by taking care of patients being boarded in the ED, not rounding on someone who has been sitting in an ICU for weeks.

 

[dotcb]

ICU rotations are important. There's no question about that. Are they more important than general inpatient care? Probably not. I think the main reason floor rotations have been eliminated is that residents in emergency medicine, just like attending emergency physicians, have no attention span, and the ongoing care of hospitalized patients is not very exciting. Ward rotations tend to get complained about. We like to see the initial presentation, learn the first few steps, next patient...

In my 4 year residency there were 3 ICU months. I thought that was a good amount, along with about 1 ICU patient per shift in the ED. As an attending, I admit about 1-3 patients to the ICU per week. Some of them are just strokes or head injuries, and go to the ICU for neuromonitoring.

If people go into EM because they like taking care of critical patients, it's important to know that only about 3 to 5% of our ED patients are critically ill. I love taking care of those patients, perhaps the most, but I also love the quick fix laceration repair, reassuring the worried well, or catching the subtle presentation of something really bad. For me it's the spectrum and breadth that is most enjoyable.

 

[filhodeinferno]

Apologies if this has been covered in another thread, although my research yielded nada. Please excuse my youthful ignorance and naiveté.

I am an MS4 applying to EM residencies and I wonder why there is so much emphasis on ICU months as EM residents. I think ICU experience would be very useful, but many of the places I'm applying to highlight the fact that they are ICU heavy. Many are excited about the prospect of adding even more ICU rotations. This worries me as I'm thinking I should be perfecting my EM knowledge and style before being in the ICU. I want to be a community ED doc for my entire career and am not trying to be an intensivist.

Is this a new phenomenon? Were EM residents doing 6 months out of their training in ICUs 10-20 years ago? And what is this push all about: procedure practice, resus/code management, etc? That seems to be the answer every time I ask it in person, but I was wondering what everyone on here thinks?

As a current resident at a critical-care heavy residency, I love my ICU months. I am also interested in community EM. ICUs are a great setting to learn how to really manage vents, and it's really where I was able to grasp how a lot of the pressors worked and when to use what. You have the time with the patient and the slower pace to really see the effect of vent changes over time, and what effects the changes have on the patients. It has also been nice to be able to do lots of central lines, arterial lines, and intubations in a setting that is not as frantic as the ED. You also feel like a badass when you compare your procedural skills with your IM peers on the unit, haha.

Overall, I agree with the above that EM is best learned in the ED. However, I've found my MICU, CICU, NSICU, and SICU months to be very valuable. (Maybe not so much my PICU month, though, but that's a story for another thread).

 

[bikERdoc]

Unless you plan on doing a critical care fellowship, ICU rotations aren't very helpful in terms of learning emergency medicine. The reason why the curriculum has so many of them ranges from inertia to EM programs lacking clout and other services needing warm bodies for scutwork. There is basically nothing relevant to the practice of EM that you can learn by babysitting a guy who has been in a coma for two weeks with a bolt in his head or is undergoing CRRT. Good emergency training happens in the ED so pick a program that minimizes the amount of time you get scutted out to other services.

As far as boarding patients in the ED this happens, but you learn how to do it by taking care of patients being boarded in the ED, not rounding on someone who has been sitting in an ICU for weeks.

Sorry, but that's a load of crap. Not sure what kind of ICUs you rotated through, but if all you did was round on comatose patients and get treated like a scut monkey, then your training did you a major disservice.

I did a total of 5 months of ICU during my residency and I learned a TON during those months. The ICU months are hard, time demanding, and can be a lot of fun. It's the only time during your training that you will have a condensed version of a lot of the cool stuff we see sporadically in the ED. From bread and butter GI bleeders, to more rare stuff like crashing thyroid storm, super sick trauma patients, hyper ovarian stim syndrome in full ARDS, bad CCB overdoses, etc... and the list goes on... You get ALL sick, ALL day, for 4 weeks at a time (Ok, lots of GOMERS too... but I digress).

It's important to know what happens to your crashing patients when they enter that magical land called the hospital. Hindsight is 20/20, and knowing what needs to get done in the first 24 hours on critically ill patients from an inpatient perspective is priceless. Much of the time we set the tone for the level of care these patients need and receive, and having an understanding of what their short term course is like can be super valuable. Plus you get a chance to know and work with your inpatient colleagues from both medicine and surgery. This can also be super helpful...

On a side note, some of my favorite teachers during residency were up in the ICU. These guys are experts in resuscitation and critical care medicine, and there is a wealth of knowledge to gain from them. Take advantage of it. Residency is the only protected learning time you will have for the rest of your EM career.

 

[Hook_EM]

I'll preface this with that I'm ED trained and just completed CCM fellowship

I think more programs moving to more ICU months is important and pertinent and only makes you a better doctor. Yes, I will say that you learn EM in the ED, so there should be enough months carved out for you to adequately learn the majority of work flow, pathology, etc.

ICU months are of the highest yield for pathology, sickness, procedures, vent management and learning what sick people look like and their trajectory.

If you want to just be a triage doc in the ED, then be that doctor. There are plenty of those and, to me, they suck as ED docs. They get a dispo and forget about the patient, or they sign them out and send them up without much of a work up and/or support/lines, etc. But if you want to do the best for your patient and order the right tests, provide the appropriate support then you're going to need to know how to do some critical care (or actual medicine).

What a lot of ED docs forget is that they're still part of the spectrum of the patient's care instead of just the gateway. And they can actually make a huge impact.. even with 8-10 other patients.

 

[Old_Mil]

Sorry, but that's a load of crap. Not sure what kind of ICUs you rotated through, but if all you did was round on comatose patients and get treated like a scut monkey, then your training did you a major disservice.

I did a total of 5 months of ICU during my residency and I learned a TON during those months. The ICU months are hard, time demanding, and can be a lot of fun. It's the only time during your training that you will have a condensed version of a lot of the cool stuff we see sporadically in the ED. From bread and butter GI bleeders, to more rare stuff like crashing thyroid storm, super sick trauma patients, hyper ovarian stim syndrome in full ARDS, bad CCB overdoses, etc... and the list goes on... You get ALL sick, ALL day, for 4 weeks at a time (Ok, lots of GOMERS too... but I digress).

It's important to know what happens to your crashing patients when they enter that magical land called the hospital. Hindsight is 20/20, and knowing what needs to get done in the first 24 hours on critically ill patients from an inpatient perspective is priceless. Much of the time we set the tone for the level of care these patients need and receive, and having an understanding of what their short term course is like can be super valuable. Plus you get a chance to know and work with your inpatient colleagues from both medicine and surgery. This can also be super helpful...

On a side note, some of my favorite teachers during residency were up in the ICU. These guys are experts in resuscitation and critical care medicine, and there is a wealth of knowledge to gain from them. Take advantage of it. Residency is the only protected learning time you will have for the rest of your EM career.

Guess we will agree to disagree on that.

Very little of your ICU rotation actually consists of taking care of patients in their first 24 hours. If you are taking care of medically sick patients 10-20 hours after presenting in your ED, look for a new job. PICU is a very important rotation simply because on a percentage basis the number of really sick kids in a Peds ER shift is relatively small. A month in the MICU probably has some value. That is about it. SICU, TICU, and CCU contribute nothing to your education. You may disparage the idea of a triage doc, but that is what we are getting paid for. We specialize in the rapid identification of and immediate stabization of disease process. We really gain nothing the minute we start engaging in the downstream management of patients another physician is already treating as an inpatient

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[Vandalia]

Guess we will agree to disagree on that.

We specialize in the rapid identification of and immediate stabization of disease process. We really gain nothing the minute we start engaging in the downstream management of patients another physician is already treating as an inpatient

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Depends on where you are working. There are a fair number of community hospitals where it is completely up to you as the only physician in the hospital. More importantly, even if you are working at a much bigger place, the group contract might require coverage of critical access hospitals. These also tend to be places where transfer may take hours. Not to mention we are the specialty that is paid to think about worst case scenarios.

When my uncle was in the Marines right before WW2 -as he was literally thrown in the pool for the swimming test - his DI told him "It would be a mistake to think the Swabbies will always manage to get you to shore! You WILL learn to swim." Translating that to EM, it is a mistake to think that an intensivist will always be ready and able to immediately take care of your critical patients. It is also a mistake to think that he will be able to take care of HIS patients. As anyone who has done this for a while knows, bad things all tend to happen at the same time.

 

[Hair Police]

If I had to pick a rotation outside of the ED, it would be in an ICU. They have the highest concentration of sick patients and ED-relevant procedures outside of the ED. There's few places in the hospital where you can get experience intubating, placing CVCs and art lines, manage chest tubes, and so on. And you can argue that the learning is diluted - I know I'm not going to place TPN orders any time soon - but the floors have even less relevance to the ED. Managing Mr Jones' blood pressure meds? Scheduling Ms Smith's outpatient PT/OT? Give me the comatose and vented guy.

 

[Pons Asinorum]

I'll put a pitch in for the relationships that you develop on those months; makes for a lot more pleasant call upstairs for a consult when the resident you're calling has been in the trenches in the MICU/PICU/SICU/_ICU with you for a bit. You meet a fair chunk of the house staff pulling those months.

 

[Tenk]

If you plan to work in community medicine, especially at a smaller hospital, when you go into the bathroom and look in the mirror you're staring at the trauma team, crit care, anesthesia, and sometimes labor and delivery. You're it.

 

[The White Coat Investor]

A lot of critical care training is absolutely imperative for community emergency physicians. Consider the patient I had the other day. I intubated, placed a central line, started pressors, gave antibiotics, gave 6 liters of fluid, did at least 2 ultasounds, had long drawn out conversations with the family about prognosis etc. I claimed 120 minutes of critical care time on that patient, independent of procedures. The worst part is that it was like the oral board exams, where I had to tell the intensivist what to do with the patient.

Another benefit of all that critical care time is it helps you know what is coming next for the patient after they leave your care, help you prognosticate, help you relate better to consultants etc. It's good to know much more medicine than you actually use yourself.

 

[Old_Mil]

A lot of critical care training is absolutely imperative for community emergency physicians. Consider the patient I had the other day. I intubated, placed a central line, started pressors, gave antibiotics, gave 6 liters of fluid, did at least 2 ultasounds, had long drawn out conversations with the family about prognosis etc. I claimed 120 minutes of critical care time on that patient, independent of procedures.

If anything, this proves my point. An emergency resident working with you in the ED would have had the opportunity to learn from this and participate in the care of this patient. That same resident on an ICU rotation would get the patient after all this was done and miss out on that experience. Emergency medicine is best learned in the emergency department.

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[Hook_EM]

If anything, this proves my point. An emergency resident working with you in the ED would have had the opportunity to learn from this and participate in the care of this patient. That same resident on an ICU rotation would get the patient after all this was done and miss out on that experience. Emergency medicine is best learned in the emergency department.

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Sure, you can learn that in the ED, but the yield is going to be low. Not all EM programs are going to be hotbeds for critically ill patients rolling in like that to provide you enough learning to actually take care of them adequately.

Yes, that is going to be of high value as you're going to learn to resuscitate a sick patient all the while attempting to move the room or keeping the room from falling apart, but learning the nuances of a good resuscitation isn't the most effective in the ED. The numbers, the why, the teaching and/or learning just aren't going to be there all the while juggling other patients and looking for the next patient to pick up.

Additionally, you won't see the consequences of your actions. You just see what your attending did and hope that they did the right thing for that patient. Anyway, that's just my thoughts. Clearly, EM docs can do a great job, but I think we can always be better and the ICU just makes you much better.

 

[Aussie904]

Well said Hook_EM. Also... Depending on where your going to be practicing. There can be holds in the ER due to no ICU beds. Some places the ER docs manage the ICU PTS until they are upstairs. I've seen ICU holds in the ER for > 24 hrs. Clearly not ideal but a possibility.

 

[Doctor Bob]

If anything, this proves my point. An emergency resident working with you in the ED would have had the opportunity to learn from this and participate in the care of this patient. That same resident on an ICU rotation would get the patient after all this was done and miss out on that experience.

Well... for every patient that gets tubed and lined up in the ED, there's a patient who gets nothing in the ED then crumps in the ICU and gets all that stuff there. That same patient may get 2 or 3 lines in the ICU when they'll only get 1 in the ED.
But it's not the procedural skills that is the main benefit of the ICU. It's the exposure to the aftercare that's important. What do you do with the next hour, two hours, 4 hours, etc. EM is great at stabilization, but then what.
You could say that's someone else problem, but then what do you do when things go awry and you can't get them out of the ED?

Emergency medicine is best learned in the emergency department.

Yes but...
It's the breadth of knowledge that separates EM docs from EM NPs/PAs. The argument could be made that every specialty should only train in their lane, but then we wouldn't be much better than the midlevels we supervise.

 

[The White Coat Investor]

An ICU rotation provides more than just the medicine. At night, it's just you and the nurses. The attending is home in bed. That doesn't happen in the ED anymore. You're on your own for 30 minutes plus when all hell breaks loose.

It also concentrates critically ill patients. You've got 8 patients on a vent. ABG interpretation, vent settings, troubleshooting, learning to interact with nurses, breaking bad news to family, teamwork etc. Great learning opportunity. That concentration effect is particularly pronounced in a PICU. Consider our local children's hospital where the local EM residents do their PICU rotation. That PICU gets every really sick kid from the surrounding 4 or 5 states and our entire state. I won't see as many deathly ill kids in my entire career as they'll see in a month there.

I recently intubated a 3 month old. I hadn't intubated a kid that small since residency. And even then, I probably did 2 tubes on kids that small in the ED and 2 in the PICU.

Looking back, if I could have spent more time on anything in residency, I'd have wanted to spend more time in ICUs and on the trauma service. More ED time would have been pretty low yield, but another month of PICU, MICU, and trauma would have been helpful. You'll have your entire career to learn more about ED management and the intricacies of ED patients. If you're in a double coverage job, you'll even still have another attending there to help with that steep learning curve that first year. But you only get one shot at PICU/MICU/trauma etc. Make the most of it.

 

[Old_Mil]

No argument from me on the value of PICU. If there are EM programs that don't have enough pathology in the ED and they have to send residents to the ICU to see it...that is another issue altogether.

 

[gro2001]

No argument from me on the value of PICU. If there are EM programs that don't have enough pathology in the ED and they have to send residents to the ICU to see it...that is another issue altogether.

To echo The White Coat Investor, it's not just the amount of pathology, but the concentration. When you have 10 vented patients in the ICU at the same time, you are thinking about their vent settings 10x more frequently per day. That high intensity repetition is a great learning opportunity. For many complicated tasks, repetition is the key to learning. In the ED you may intubate a critically ill patient and manage their vent but then may not think about vent settings again until you have to do it again a few days or a week later. That is just not the same learning for a novice.

 

[deleted547339]

No argument from me on the value of PICU. If there are EM programs that don't have enough pathology in the ED and they have to send residents to the ICU to see it...that is another issue altogether.

I disagree. Kids just don't get sick that often. My program has one of the biggest children's hospital in the country; that being said, I got way more lines, tubes and exposure to significant pathology in a single month in the PICU than over many, many Peds ED shifts.

 

[HooliganSnail]

No argument from me on the value of PICU. If there are EM programs that don't have enough pathology in the ED and they have to send residents to the ICU to see it...that is another issue altogether.

I feel as if your picture is particularly telling, very Ebenezer Scrooge. ICU ! BAH HUMBUG!

Seriously dude, ICU months are critical. Instead of bashing other ED programs for supposed lack of pathology, it is clear that your ICU experience was devoid anything but scut work.

ICU months are being added to curriculum because they are essential skills to the ED physician. Everyone knows this.

I simultaneously love and hate my ICU months. I hate them because they are so much work, and long hours. I love them because I know that I gain invaluable experience during ICU time.

 

[AmericaAmerica]

Thank you to everyone who has contributed so far. You have changed my opinion on the matter. What invaluable experience do you get in ICU that you you would never be exposed to in the ED?

I feel as if your picture is particularly telling, very Ebenezer Scrooge. ICU ! BAH HUMBUG!

Seriously dude, ICU months are critical. Instead of bashing other ED programs for supposed lack of pathology, it is clear that your ICU experience was devoid anything but scut work.

ICU months are being added to curriculum because they are essential skills to the ED physician. Everyone knows this.

I simultaneously love and hate my ICU months. I hate them because they are so much work, and long hours. I love them because I know that I gain invaluable experience during ICU time.

 

[deleted547339]

Thank you to everyone who has contributed so far. You have changed my opinion on the matter. What invaluable experience do you get in ICU that you you would never be exposed to in the ED?

Better vent management for one. The addition of multiple pressors and the though process behind the pressor choice (and having the time to talk through it). Understanding the transition between resuscitation and maintenance in treatment. Seeing mistakes that have been made in the ED. Understanding the way people upstairs think about our patients and understanding ways to make their lives easier.

 

[gutonc]

Better vent management for one. The addition of multiple pressors and the though process behind the pressor choice (and having the time to talk through it). Understanding the transition between resuscitation and maintenance in treatment. Seeing mistakes that have been made in the ED. Understanding the way people upstairs think about our patients and understanding ways to make their lives easier.

From the IM side of things, this is why I always tried to be a part of the ICU bound cases when rotating in the ED as a resident.

It's a lot easier to Monday morning quarterback if you never even suit up on Sunday. But take just one snap and see that 270# linebacker crash past your tackle and you have a very different perspective.

[/tortured metaphor]

 

[HooliganSnail]

Thank you to everyone who has contributed so far. You have changed my opinion on the matter. What invaluable experience do you get in ICU that you you would never be exposed to in the ED?

Agree with other's assessments, vent managment, pressors. shock, shock, and more shock. Mainly though, it is about getting used to critical management like it is the back of your hand.

In the ED you never just have the septic shock patient, you also have the NSTEMI in room 4, the multi-trauma and T2, and the six other cough, SOB, sinus congestion, HA types. You need to be able to get your critical patients set up and managed efficiently and effectively. Once you get your lines in, fluids rolling, pressers cooking, and AB'x hung, paperwork done, discussions with CC doc, admitting doc, and all necessary consultants, then you can get back to moving your department.

Also, in the ICU the nursing staff is used to vents and sedation and pressors, but the ED nurses don't do that on a daily basis. As such, the physician has to know what needs to be done, or something will get missed.

You need a program where you will get a lot of these CC procedures, central lines, art lines, intubation, etc....Not because you might one day need to do a central line, because you WILL need to do a central line, and you do not have 45 minutes to putz around with the thing. You need to get to a point where you can throw in a sterile IJ in less than 15 minutes, and a not sterile Fem TLC or cordis on a crashing patient in like 4 minutes. This requires practice, and doing like 30+ of these suckers. I learned most of these lines in the ICU month as an intern. When interviewing ask who is doing the ICU procedures. If it is the third year IM guys doing the first central lines of their career, then you have a problem.

Another huge issue that you really learn in ICU month is family discussion. They suck, but there is an art. Basically it is thus: You need to paint a bleak picture of the seriousness of the medical situation their loved one is in, while not completely killing all hope, but simultaneously not giving any false hope. Mom has a severe anoxic brain injury. This type of injury is not recoverable........It requires empathy, and experience. It is my least favorite part of my job. As the ED doc, I often am the first to talk with the family. It is my responsibility to paint an especially bleak picture. If I fail to do so then the family arrives in the ICU with false hope, and the docs upstairs start out with a limp.

That is why ICU months are essential. They allow you the time to learn these skills where all you are focusing on are these critical patients. The ED is naturally hectic, so simply learning critical care down there is not ideal.

 

[FreddieH]

Don't mean to necro-bump this decaying discussion (no, but seriously, I do) but as an M4 mulling over his rank list, should we be wary if the majority of ICU time is spent in the SICU with little or no MICU? Does the program that offers the MVP Sampler of CICU, NeuroICU, PICU, SICU, MICU, and even a bonus week in the Neonatal ICU prepare a resident better than the straight SICU/MICU-trained resident? Thanks for the help team!

 

[DrDrummer]

Don't mean to necro-bump this decaying discussion (no, but seriously, I do) but as an M4 mulling over his rank list, should we be wary if the majority of ICU time is spent in the SICU with little or no MICU? Does the program that offers the MVP Sampler of CICU, NeuroICU, PICU, SICU, MICU, and even a bonus week in the Neonatal ICU prepare a resident better than the straight SICU/MICU-trained resident? Thanks for the help team!

It becomes relevant if you have any interest in applying to critical care fellowships. They only count months spent in certain kinds of units-- I don't think PICU counts and I can't remember if surgical ICUs count. If you're not thinking about that or know you aren't interested, then it probably doesn't matter unless you hate working with surgeons.

 

[heroesinahalfshell]

It becomes relevant if you have any interest in applying to critical care fellowships. They only count months spent in certain kinds of units-- I don't think PICU counts and I can't remember if surgical ICUs count. If you're not thinking about that or know you aren't interested, then it probably doesn't matter unless you hate working with surgeons.

Besides rotating through the MICU, PICU is probably next most important (probably more important then MICU due to how hit or miss it can be seeing sick kids in the ED). Otherwise I don't know how much value rotating through other specialty ICUs would add. I rotated through a SICU and enjoyed it, it was interesting to see how surgeons approached a problem from a different perspective, but don't think it added much to my learning besides providing additional time in the ICU. I had fellow residents who did NICU and NeuroICU rotations for elective months and really enjoyed them but didn't make huge changes to their practice.

 

[WildcatS11]

Don't mean to necro-bump this decaying discussion (no, but seriously, I do) but as an M4 mulling over his rank list, should we be wary if the majority of ICU time is spent in the SICU with little or no MICU? Does the program that offers the MVP Sampler of CICU, NeuroICU, PICU, SICU, MICU, and even a bonus week in the Neonatal ICU prepare a resident better than the straight SICU/MICU-trained resident? Thanks for the help team!

Personally I am at a program that does all of those rotations, and I think it's incredibly helpful.

SICU - tons of procedures/lines, a majority of "normal" people with acute surgical pathology which is way more interesting than the 90 year olds with Pulm HTN/COPD/Parkinsons/100 strokes/multiple myeloma etc etc.

NSICU - incredible opportunity to manage elevated ICP and status epilepticus every single day. I saw things there that might have taken a decade to see in regular ED practice

Micu - obvious important. We do 3 months over 4 years

CCU - for me, the least important. It can be useful if you pick the brains of the cardiologists often.

NICU - useful only for delivery resuscitations. If you don't go to those, don't bother.

PICU - incredibly important. I thought PICU was a required rotation for EM residents. If it isn't a rotation, I would think hard about ranking that program highly

 

[TheComebacKid]

PICU- incredibly important. I thought PICU was a required rotation for EM residents. If it isn't a rotation, I would think hard about ranking that program highly

As an EM intern, we have a PICU rotation at our institution. By and large, it's not very useful. The problem with the majority of PICUs is that they are very fellow run, with fellows doing the majority of procedures. The reason for it is simple: pediatric residents do not get the same procedural experience as EM residents do. As an intern I have more intubations (including pediatric) and central line experience than every single first year PICU fellow. When you work in the PICU, they will pretty much get dibs on everything. And to be honest, I understand it. They need their experience too. But if you are an EM resident that may mean you step aside quite a bit.

I've talked to several of my peers training at places around the country, and they share a similar sentiment as well based on their experience. There just isn't enough pediatric procedures to go around, and the fellows will always get first crack at them.

 

[WildcatS11]

As an EM intern, we have a PICU rotation at our institution. By and large, it's not very useful. The problem with the majority of PICUs is that they are very fellow run, with fellows doing the majority of procedures. The reason for it is simple: pediatric residents do not get the same procedural experience as EM residents do. As an intern I have more intubations (including pediatric) and central line experience than every single first year PICU fellow. When you work in the PICU, they will pretty much get dibs on everything. And to be honest, I understand it. They need their experience too. But if you are an EM resident that may mean you step aside quite a bit.

I've talked to several of my peers training at places around the country, and they share a similar sentiment as well based on their experience. There just isn't enough pediatric procedures to go around, and the fellows will always get first crack at them.

Agree, totally agree. We do PICU third year. I'll tell ya - procedures on kids are damned similar to procedures on adults. I had to give away about half the procedures I could have done, but I also got a handful of tubes, art lines, central lines. The mental aspect is mildly different, but the muscle memory is there.

we also do peds anesthesia so I was not completely upset about giving away the tubes

 

[TooMuchResearch]

I think decision making autonomy and volume of sick patients probably matters more than whether or not you have the potpourri ICU experience.

But my bias, as is that of many others, is based on my training.

I don't think it should affect your rank list. The ED is your home away from home in residency, not the ICU.

 

[The White Coat Investor]

You can hone skills on low acuity patients after residency, but it is very hard to get better at critical care after residency.

 

[gman33]

I trained at a critical care heavy program.

These months made me a much better doctor.
Not just procedures, but how to think about sick patients.

I wouldn't trade the experience for anything.

 

[gro2001]

As an EM intern, we have a PICU rotation at our institution. By and large, it's not very useful. The problem with the majority of PICUs is that they are very fellow run, with fellows doing the majority of procedures. The reason for it is simple: pediatric residents do not get the same procedural experience as EM residents do. As an intern I have more intubations (including pediatric) and central line experience than every single first year PICU fellow. When you work in the PICU, they will pretty much get dibs on everything. And to be honest, I understand it. They need their experience too. But if you are an EM resident that may mean you step aside quite a bit.

I've talked to several of my peers training at places around the country, and they share a similar sentiment as well based on their experience. There just isn't enough pediatric procedures to go around, and the fellows will always get first crack at them.

PICU is a rotation that on the surface seems to be incredibly useful (everyone needs to see more sick kids!) but because it is so fellow run just about everywhere, it ends up being largely useless. In my opinion this is not so much about most of the procedures going to fellows, but the routine decision making going to fellows too. It seems PICU attendings, fellows, and nurses won't let residents (EM or Peds) make almost any decisions. I get their rationale (though I don't agree with it) but it ends up stunting resident learning. You don't actually learn until you are forced to make a decision on your own about a patients, and that just does not happen in PICU.

 

[canigetawhatwhat]

3 yr program
2 Micu months
1 ticu 1 picu 1 ccu

You need those months. It took me an HOUR to do my first u/s guided IJ. I had my upper level with me the whole time. What EM rotation can support that? As an intern it made me develop comfort with sick people. As a third year it made me an expert. Picu is certainly needed.

Man im done explaining. Icu is critical to training.

If you feel different, you are wrong

 

[engineeredout]

PICU is a rotation that on the surface seems to be incredibly useful (everyone needs to see more sick kids!) but because it is so fellow run just about everywhere, it ends up being largely useless. In my opinion this is not so much about most of the procedures going to fellows, but the routine decision making going to fellows too. It seems PICU attendings, fellows, and nurses won't let residents (EM or Peds) make almost any decisions. I get their rationale (though I don't agree with it) but it ends up stunting resident learning. You don't actually learn until you are forced to make a decision on your own about a patients, and that just does not happen in PICU.

Same experience here. The only thing I learned from my PICU rotation is that the mantra of "Children aren't just little adults and we can't treat them like that" is absolute garbage.

Pediatric critical care, in terms of physiology, is far more like adult critical care than any of them want to admit. The difference is how the pediatricians do things. Had to argue with my fellow on PICU that renal dose dopamine to try and improve renal function was worthless. I was told to not ultrasound the heart/IVC of my septic pt because that should be reserved for cardiologists only and playing around with the US is "an ER thing". In trying to make a push for levophed instead of dopamine because the patient was hyper dynamic and vasodilated so more alpha squeeze would probably help the only answer I'd get was "that's not how we do things". Saying I was more impressed by the respiratory variation of the CVP waveform instead of CVP numbers was met with blank stares. And for the love of god watching a PICU fellow trying to put in a femoral line in a 10 year old child for over an hour was the most painful thing I've ever had to sit through (but everyone acted like it was a privilege for me to be allowed to watch)

PICUs would probably be better run by non pediatricians.

 

[canigetawhatwhat]

Same experience here. The only thing I learned from my PICU rotation is that the mantra of "Children aren't just little adults and we can't treat them like that" is absolute garbage.

Pediatric critical care, in terms of physiology, is far more like adult critical care than any of them want to admit. The difference is how the pediatricians do things. Had to argue with my fellow on PICU that renal dose dopamine to try and improve renal function was worthless. I was told to not ultrasound the heart/IVC of my septic pt because that should be reserved for cardiologists only and playing around with the US is "an ER thing". In trying to make a push for levophed instead of dopamine because the patient was hyper dynamic and vasodilated so more alpha squeeze would probably help the only answer I'd get was "that's not how we do things". Saying I was more impressed by the respiratory variation of the CVP waveform instead of CVP numbers was met with blank stares. And for the love of god watching a PICU fellow trying to put in a femoral line in a 10 year old child for over an hour was the most painful thing I've ever had to sit through (but everyone acted like it was a privilege for me to be allowed to watch)

PICUs would probably be better run by non pediatricians.

It sounds like you had a bad picu month. Therefore all picu experiences are worthless?

Silly.

 

[Brigade4Radiant]

It sounds like you had a bad picu month. Therefore all picu experiences are worthless?

Silly.

No that doesn't sound like a bad month I would argue that PICU being worthwhile or worthless depends on the institution. MICU, NICU, SICU you all see sick patients. PICU at my institution you see sick patients but they are usually heart kids or toxic ingestion. They will let you manage asthmatic kids but since PICUs are fellow run they get all procedures and they get to see the sick patients. Also a lot of it is just doing what toxicology, cardio-thoracic or neurosurgery wants to do.

 

[TheComebacKid]

It sounds like you had a bad picu month. Therefore all picu experiences are worthless?

Silly.

The PICU experience at my institution is similar to engineeredout. And this is the same story for EM residents at multiple programs across the country. I would argue that the PICU experience as a whole is one of the biggest weaknesses in EM education, something that probably needs to be addressed in more detail on a national level. On my PICU rotation, we are essentially just scut monkeys for the fellows. And it's all masqueraded as this whole idea that "you will get to take care of some really sick kids!". EM residency education really pushes the notion that we need to be comfortable taking care of sick kids. The truth is that there just aren't enough sick kids in our hospitals. One PICU patient is being taken care of by a PICU fellow, an EM resident, a peds resident, 7 PICU NPs and 3 peds medical students, and a PICU attending.

Anyone who has ever worked in a dedicated peds ED will tell you that it's 99% worried parents and rashes. Throw in an asthmatic or febrile kid here or there. The truly sick kids are very rare to find. Even in the ED, if you work at an institution that has a dedicated PEM fellowship, forget it, all your tubes are going to the fellows. I train at a "busy level 1 pediatric trauma center". Essentially the PEM fellows will take their pick of the sicker kids and as a resident the scraps will be thrown to you.

I had to watch a PEM fellow struggle to intubate a kid using his right hand to hold the laryngoscope and pass the tube with his left hand before an attending just stepped in. I am not saying this to sound all high and mighty that as an EM resident on the adult side we know how to take care of critically ill patients more than anyone else. I'm just trying to point out the sad but obvious truth, which is that PICU and PEM fellows are ultimately going to be tasked with taking care of these kids, and their residency training does not prepare them AT ALL to do crash intubations/lines/chest tubes etc. They have a very valid case that they NEED to get those procedures and to take care of the sicker patients.

Critical care training (SICU, MICU, CCU, NeuroICU) has it's place in EM residency training. I preferentially ranked my program higher because of the greater number of critical care months in comparison to other programs. PICU, I would argue, is important as well. But just the way PICUs are run right now, I would say by and large training on the pediatric side is severely failing at meeting the educational needs of EM residents.

 

[deleted547339]

You're right, what we really need more training in vaginal discharge, low risk chest pain, headaches, ankle sprains and copd exacerbations. Oh, wait....

 

[fahimaz7]

Apologies if this has been covered in another thread, although my research yielded nada. Please excuse my youthful ignorance and naiveté.

I am an MS4 applying to EM residencies and I wonder why there is so much emphasis on ICU months as EM residents. I think ICU experience would be very useful, but many of the places I'm applying to highlight the fact that they are ICU heavy. Many are excited about the prospect of adding even more ICU rotations. This worries me as I'm thinking I should be perfecting my EM knowledge and style before being in the ICU. I want to be a community ED doc for my entire career and am not trying to be an intensivist.

Is this a new phenomenon? Were EM residents doing 6 months out of their training in ICUs 10-20 years ago? And what is this push all about: procedure practice, resus/code management, etc? That seems to be the answer every time I ask it in person, but I was wondering what everyone on here thinks?

In the 5 months out of residency, I've had several v-fib arrests infront of me, multiple codes in the field, severe hypothermia (28C), spinal shock, countless septic shock patients requiring multiple pressors, takasubo's, multiple brain bleeds, countless trauma's.

We had:
1 mo CICU
1 mo SICU
3 mo MICU
1 mo PICU

No fellows at my program = lots of autonomy and procedures.

I'm in a community site that is single ED doc coverage. This is why we spend time in the ICU.

 

[CliveStaples]

I will say that the PICU discussion here is giving bonus points to some programs I'm looking into which don't have an in-house PICU fellowship.

 

[canigetawhatwhat]

I will say that the PICU discussion here is giving bonus points to some programs I'm looking into which don't have an in-house PICU fellowship.

You dont want your first pediatric tube to be as a new attending. Tubin kids is butthole tightening enough.

 

[TheComebacKid]

I will say that the PICU discussion here is giving bonus points to some programs I'm looking into which don't have an in-house PICU fellowship.

This is one of the biggest selling points of community programs IMO. That being said, I wouldn't make a decision on going to a program based solely on the quality of the off service rotations. Obviously the ED experience trumps all.

 

[da8s0859q]

I also had a critical care heavy residency.

I'm glad I did.

Hell, I was glad I did while I was moonlighting in residency.