Your Residency ICU: Is it open or closed? A List.

[RMortis]

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This is a question for those upcoming applicants (like me ) interested in critical care: at your residency program are your ICUs anesthesia run (closed) or open?
You can PM me your answer and institution and I'll put it on if you want to remain private. I think this would be very helpful to people!

 

[urge]

Thread hijack>

What is it icu docs do?

Serious question.

Pt has fever: call id, pt has distended abdomen: call surgery, pt strokes out: call neuro, pt has out of control diabetes: call endo, pt is not making urine: call nephro, pt has an MI: call card, pt needs tpn: call nutrition...

That's how it looks from afar.

End hijack>

 

[RMortis]

It all depends on the doc. Some I've seen handle almost everything themselves, some consult more or less frequently.
The caricature you make could be said about any profession, that's why caricatures don't work. According to an internal med guy I worked with anesthesiologists show up for intubation, don't do anything, then came back for extubation and do even less, he told me CRNAs were better for anyone who could do math. He obviously hadn't been up close when an anesthesiologist was needed, so looking from afar doesn't give you a very good view.

 

[Idiopathic]

Thread hijack>

What is it icu docs do?

Serious question.

Pt has fever: call id, pt has distended abdomen: call surgery, pt strokes out: call neuro, pt has out of control diabetes: call endo, pt is not making urine: call nephro, pt has an MI: call card, pt needs tpn: call nutrition...

That's how it looks from afar.

End hijack>

dont be a dick

 

[Doctor4Life1769]

closed.

 

[IceMD]

Current UW resident here. All ICUs except for burns are closed. Burns is open. Neuro is almost completely anes run, as is CT. MICU is all pulm. SICU and TICU are a mix of all critical care backgrounds.

 

[deleted171991]

Be careful when you say closed. Generally only MICUs are closed; the main criterion is who calls the shots,. Many times it's still the surgeon. There are exceptions to this rule, but only in few places.

To quote one of the surgeons I overheard talking to a SICU resident: "The surgical team is primary and takes most decisions, but you are the ICU team, so you get to micromanage, based on the surgical team's plan." That's the definition of an open unit, regardless how it's officially labeled.

 

[scudrunner]

To quote one of the surgeons I overheard talking to a SICU resident: "The surgical team is primary and takes most decisions, but you are the ICU team, so you get to micromanage, based on the surgical team's plan." That's the definition of an open unit, regardless how it's officially labeled.

I've had the same thoughts to myself, which accounts for a large part of why I do not enjoy ICU. All of the surgical ICUs are "closed" at my institution... But not really.

 

[Ezekiel2517]

Thread hijack>

What is it icu docs do?

Serious question.

Pt has fever: call id, pt has distended abdomen: call surgery, pt strokes out: call neuro, pt has out of control diabetes: call endo, pt is not making urine: call nephro, pt has an MI: call card, pt needs tpn: call nutrition...

That's how it looks from afar.

End hijack>

From afar it looks like nurses can do everything you do.
If for one day you were to try and manage a busy unit with critically ill patients, you wouldn't make it to 10 am

 

[PainDrain]

The SICU at our place was closed; while most patients were trauma, the ones that weren't were treated by the ICU staff and even operated on by SICU attending surgeons who were not the initial surgeon. The CT ICU was run by a mix of anesthesia and surgery staff with direction of the operating CT surgeon. Neuro ICU was run by neurosurgery/neurology.

 

[2win]

Thread hijack>

What is it icu docs do?

Serious question.

Pt has fever: call id, pt has distended abdomen: call surgery, pt strokes out: call neuro, pt has out of control diabetes: call endo, pt is not making urine: call nephro, pt has an MI: call card, pt needs tpn: call nutrition...

That's how it looks from afar.

End hijack>

Urge - I think that I know you well enough ...and this post doesn't make sense in a way.
You are right that the dumb ICU docs will call for any type a consult - depends now of their ability and their interest....
Before to judge your post hard - are you doing ICU?
2win

 

[2win]

This is a question for those upcoming applicants (like me ) interested in critical care: at your residency program are your ICUs anesthesia run (closed) or open?
You can PM me your answer and institution and I'll put it on if you want to remain private. I think this would be very helpful to people!

Although the question seems interesting at beginning - I can tell you that doesn't matter...
Old man , old opinion.
The future is an open ICU although I really understand your pint of view.

This is a question for those upcoming applicants (like me ) interested in critical care: at your residency program are your ICUs anesthesia run (closed) or open?
You can PM me your answer and institution and I'll put it on if you want to remain private. I think this would be very helpful to people!

Who really cares?
This question is old - we , in the real world ( I hope) are past behind.
Let me know please your concerns open vs closed ICU.
2win

 

[lunaire]

Open CT ICU, SICU, NeuroICU. Closed MICU that anesthesia does not go into.

Nurses general perspective would be that we intensivist trumps the surgeons on anything non-surgical. We're just here much more than they are, and have more data to make the more intelligent decision. If our order contradicts theirs, they follow our orders, with the expectation that we will talk to the surgeons.

We are then expected to have enough interpersonal skills to make the surgeons agree with our management, when we tell them this is what the patient needs.

In the OR or the ICU, we're consultants. We need to be able to convince the service that consults us that we know more about the issue of sedative, vasoactive drugs and respiratory management that they should let us manage these issues independently. However, we would be fools to not value a cardiothoracic surgeon's perspective on the heart function, or a general surgeon's on a patient's abdominal exam. ICU's meant to be a team/multidisciplinary thing.

 

[urge]

From afar it looks like nurses can do everything you do.
If for one day you were to try and manage a busy unit with critically ill patients, you wouldn't make it to 10 am

Nurse, or doctor, there is somebody actually doing a task.

I fail to see the task done by the icu doctor other than telling the secretary to call another doctor to deal with the issues.

You guys are not helping by not shining any light into the matter. Perhaps there is nothing to see I'm afraid?

 

[urge]

From afar it looks like nurses can do everything you do.
If for one day you were to try and manage a busy unit with critically ill patients, you wouldn't make it to 10 am

BTW, I have it nailed down. Seroquel, keppra, Starbucks.

 

[Random Anesthesiologist]

Open but run by CCM pulm, Anes, surg

 

[Mman]

ICU is ICU is ICU. If a patient needs to be intubated, they need to be intubated. If they need pressors or inotropes, they need them. It doesn't really matter how the place is run, the big decisions are pretty obvious and the small decisions, well who cares which individual makes that call?

 

[deleted171991]

ICU is ICU is ICU. If a patient needs to be intubated, they need to be intubated. If they need pressors or inotropes, they need them. It doesn't really matter how the place is run, the big decisions are pretty obvious and the small decisions, well who cares which individual makes that call?

Of course one cares. Would you accept the surgeon to regularly decide and override your anesthetic management, like you were his nurse? I don't think so. Oh, wait, I forgot about cardiac anesthesiologists. 😛

Just because he's currently not busy with cutting and sewing, he's not the most competent individual to make critical care-related decisions, so he shouldn't. I continue to be unimpressed by the medical management, thinking and knowledge level of most surgeons, including those CCM-certified.

And, btw, most decisions in the ICU are "obvious" only to the surgical-minded, the knee-jerk reflexives. This is not the OR, and a bit of thinking might point out a better plan, with more comfort and fewer risks for the patient. Intubations are not a given (unless the patient is unable to protect her airway), neither are (central) pressors, which of them or the way they are given. Etc. One does not just order a few protocols there and then walk away for 12-24 hours, letting nurses or trainees "manage" them. "Call me if x changes", my behind! Critical patients need to be micromanaged by intensivists, rounding on them at bedside as frequently as they actually need it, not when the doctor has the time or inclination, and definitely not by phone and proxies. One has to see and interact with the patient and her physiology, not just apply algorithms and treat numbers in the computer.

These are sick people with labile (and different/unclear) physiologies, and not many things have been proven as cut in stone when about managing them. There is still an art to it.

 

[Stank811]

I agree, I would look for an open ICU in which the anesthesiology department is consulted to see the patients but at the same time is well respected by their surgical and medical colleagues. I have heard of academic units in which the anesthesia departments are used as scut monkeys that do all the admitting and transfer work but really don't have a say in the management....avoid such programs. If you can find a well working open unit you will get to learn from the perspective of the medical, surgical, anesthesia, ER and neuro intensivist which all think differently and have their own strengths.....broadens your thought process.

Urge, my guess your ICU is the "old" model in which the intensivist is usually consulted for vent management or once the patient has been mismanaged to the point of no return. The intensivist gets paid for the consult and probably has a patient load of 20-30 patients so consults all the other problems besides the vent just to keep up. The "old" model is being pressured by many hospitals across the country that want more from their intensivists.

 

[Mad Jack]

Thread hijack>

What is it icu docs do?

Serious question.

Pt has fever: call id, pt has distended abdomen: call surgery, pt strokes out: call neuro, pt has out of control diabetes: call endo, pt is not making urine: call nephro, pt has an MI: call card, pt needs tpn: call nutrition...

That's how it looks from afar.

End hijack>

Maybe in SICU. No decent MICU doc will bump everything off like that lol.

 

[Mman]

Of course one cares. Would you accept the surgeon to regularly decide and override your anesthetic management, like you were his nurse? I don't think so. Oh, wait, I forgot about cardiac anesthesiologists. 😛

Just because he's currently not busy with cutting and sewing, he's not the most competent individual to make critical care-related decisions, so he shouldn't. I continue to be unimpressed by the medical management, thinking and knowledge level of most surgeons, including those CCM-certified.

And, btw, most decisions in the ICU are "obvious" only to the surgical-minded, the knee-jerk reflexives. This is not the OR, and a bit of thinking might point out a better plan, with more comfort and fewer risks for the patient. Intubations are not a given (unless the patient is unable to protect her airway), neither are (central) pressors, which of them or the way they are given. Etc. One does not just order a few protocols there and then walk away for 12-24 hours, letting nurses or trainees "manage" them. "Call me if x changes", my behind! Critical patients need to be micromanaged by intensivists, rounding on them at bedside as frequently as they actually need it, not when the doctor has the time or inclination, and definitely not by phone and proxies. One has to see and interact with the patient and her physiology, not just apply algorithms and treat numbers in the computer.

These are sick people with labile (and different/unclear) physiologies, and not many things have been proven as cut in stone when about managing them. There is still an art to it.

Yeah, I call all that stuff obvious. Sorry. Deciding if someone needs to be intubated isn't a tough decision. Deciding if and when and which pressors are needed isn't too hard either. And if it was so necessary to have the intensivist micromanage every second of care, I wouldn't see so many ICU's at major medical centers with the attending either at home or asleep in the call room all night with residents and fellows at the beside.

And if you like the art of some decisions, hooray for you. That just means there is not enough evidence to support them and if someone disagrees with you it doesn't mean they are wrong.

 

[nimbus]

And if you like the art of some decisions, hooray for you. That just means there is not enough evidence to support them and if someone disagrees with you it doesn't mean they are wrong.

Some people's need to be right prevents them from ever appreciating this truth.

 

[G-Man82]

Open vs closed can matter for trainees. If the Intensivist is seen making the decisions vs catering to the surgeon even on POD 5 creates an impression on trainees and whether or not they want to go into CCM. I've been exposed to both types, and let me tell you that it's much nicer in the closed model. A strong CCM division also usually implied a stronger anesthesia department to me when in training.

However, wherever there are surgeons, there will be politics. In the end they bring the patient to the hospital. Sometimes, though, especially with CT Surgeons, they just need to see themselves fail before someone from CCM takes over and says "I told you so," in a very politically correct manner.

For us, beyond 24 hours postop, it's not really considered acutely postop anymore, and the nurses know to go through CCM for their orders.

But I agree with you, @Mman. You can disagree with us and not be wrong. But we're not just sitting there in the unit twiddling our thumbs while consultants do our work for us. There isn't always evidence for what we do, but that holds
even more true for general / cardiac anesthesia practice, too.

For the purposes of this list:
1. Internship: MICU closed, SICU run by trauma and closed.

2. Residency: MICU closed (no anesthesia involvement). SICU "closed" but still catered to the primary surgical team. CTICU same as SICU but run by Anesthesia.

3. Fellowship: NeuroICU open for Nsurg but closed for neurology patients. Run by NeuroCC. Trauma - run jointly by trauma surgery and anesthesia - closed. SICU - open unit by Trauma. VA SICU closed unit by Anesthesia. CTICU - open unit by Anesthesia.

4. Attending Job: My CT and Vascular unit open to CT (mostly for first 24 hrs), closed to all else. Run by Anesthesia and 2 other CCM docs. SICU, closed and jointly managed by CCM from Surg, Med, and anesthesia.

 

[Mman]

But I agree with you, @Mman. You can disagree with us and not be wrong. But we're not just sitting there in the unit twiddling our thumbs while consultants do our work for us. There isn't always evidence for what we do, but that holds
even more true for general / cardiac anesthesia practice, too.

I never suggested an intensivist just sits there and gets consults. That was someone else in this thread. My point was that open vs closed is mostly semantics.

 

[G-Man82]

Whoops, my apologies; that should have been directed at Urge.

I still think open vs closed makes a difference though because it explains our role more clearly, plus I still think it influences a trainee who's interested in the field. If it's an open unit at an academic center where my role is just so the surgeon can justify CCM time, we are seen as superfluous. My NeuroICU in residency was like that. We existed because it's an ICU, but the decisions were all the surgeons.

In an closed unit, my role is very different. Here, I assume more care, and the trainees see my interactions with the surgical team differently because I now run the show. That's not to say that I ignore their requests; the politics can hold true in either way, in that the surgeons still bring the business, but my opinion still counts for a lot more, and If it's a pure CCM issue, I will override the surgical team's request. So, the way I think a trainee sees our role is definitely more proactive and demystified in a closed unit.