RAMS Critical Care Roadmap

Critical Care Care of the critically ill throughout the acute care phase in the realms of the emergency room and the intensive care unit.

MED STUDENT (MS3/4)

JUNIOR RESIDENT

background

Senior RESIDENT

Resources

AUTHOR: John Hurley Contributors: Doug Schiller, MD; Mathew Stull, MD; and Dell Simmons, MD Welcome to the Emergency Medicine Education Roadmap, your definitive step-by-step guide on how to succeed in Critical Care at every training level. Don’t know where to start? Click on “Background” or select your training level above. A full list of fellowships, conferences, publications can be found in “Resources”.

For pearls of wisdom from faculty and residents in the trenches, click on “Insider Advice.”

FELLOW

insider Advice

1 - SENIOR MEDICAL STUDENT How should I plan my M3/M4 years to set them in the right direction for the Emergency Medicine- Critical Care Medicine (EM)-CCM path?

• S tart by rotating in any of the available ICU’s. Some centers will not allow ICU rotations until 4th year. If the opportunity presents itself, don’t be afraid to venture to a smaller community program ICU. There may not be any residents in that ICU which can give you more 1:1 contact with an attending and procedural exposure. Other rotations that can help prepare you for residency are your Emergency Medicine (EM) clerkship, trauma, interventional radiology, anesthesia, etc. These rotations have high patient acuity and are all integral parts of the acute care continuum.

How to get involved in EM locally and nationally: • E mergency Medicine Interest Group (EMIG): (Local Institution) • R esidency fair and Conference attendance

• S ociety of Academic Emergency Medicine (SAEM) • E mergency Medicine Residency Association (EMRA) • A merican College of Emergency Physicians (ACEP)

Are there research mandates?

• Th is depends. Some centers focus on clinical experience. If you are looking for a pure academic center, then early research is encouraged. CC is an evidenced based, research field so getting involved in research specific to CC will obviously open doors as it shows interest in CC and advancing care.

Differences between choosing a 3 vs 4 yr residency program:

• Y ou will be learning EM your entire career. It is not all learned in 3-4 years no matter the institution. Three and four year programs all meet the requirement and will train you to be a good physician. A four-year program can give you extra time and electives to spend on your area of interest.

• I f you choose a 4- year institution, ensure that the 4th year will add to your education. This would be a good year to focus on EM administration, advising younger physicians, and developing your leadership skills. The 4th year is considered by many to be critical for the development of medical skills and maturity of the EM Physician.

Time needed in Critical Care during Residency for your Critical Care pursuit?

• K eep in mind, your first goal is emergency medicine education. Once that is being achieved the evaluate the amount of time spent in the ICUs. Residencies have a varied amount of CC rotations scheduled varying from 16-34 weeks laid into their curriculum with some allowing for more electives than others in the ICU.

2 - JUNIOR RESIDENT What are the must-complete tasks for the Junior resident in their PGY1 and or PGY2 year?

• Y our focus during your first year needs to be developing good study habits. Learning how to integrate clinical work, reading and balancing your life is a difficult task.

• I n your second year, look for leadership and research opportunities. Most hospital have multiple opportunities to contribute to patient care such as sepsis committee, Qi/QA projects, etc.

• C heck out the SAEM Fellowship Directory to familiarize yourself with the various CC fellowships available.

• R ead and familiarize yourself with a CC textbook, for example Marino’s “The ICU Book”, Vincent “Textbook of Critical Care”, etc.

• C ultivate mentors who will assist you through the process. They can teach valuable study habits, provide opportunities to support hospital projects, write you letters of recommendation and help you answer questions along the way.Consider obtaining ENLS (Emergency Neurological Life Support) Certification. Very helpful as a PGY2.

What if your program doesn’t have any EM-CCM mentorship??

• R each out to the national organizations and at conferences (listed in Section 6-Resources).

• U tilize web-based mentorship programs such as the EM-CCM web based mentorship program. Fill out the form online and be assigned a mentor. They will be able to support and direct you in your decision making process.

3 - SENIOR RESIDENT General Advice

• W e highly recommend significant proficiency with Ultrasound before entering Emergency Medicine-Critical Care Medicine (EMCCM) fellowship.

Specific Advice for Different Types of Critical Care Fellowship

Internal Medicine Critical Care Fellowships

• Th is is the most common pathway for ED physicians.

• Must have at least 6 months of Internal Medicine rotations (i.e., Cards, Nephro, General), which should be completed by the end of residency, but do not have to be completed prior to sending out your fellowship applications. Due to the ACGME mandates, some programs will include this into your first 6 months of the Fellowship so you can reach your 6-month mandate prior to advising IM residents during your fellowship.

• Start your ERAS application during the first months of your senior year. There is no official Match for IM-CCM but all information is still sent to programs through ERAS and instead of having a “Match” day, the programs will individually contact you.

• Most fellowships are 24 months, however this may be shortened to 12 months if the individual is EM/IM trained and that program has a track available.

Anesthesia Critical Care Fellowships

• S an Francisco Match: Apply for this at the start of your PGY2 year if in a 3-yr program or 18 months prior to leaving residency if you are at a 4-yr program.

Surgery Critical Care Fellowships

Neurocritical Care Fellowships

• M ost programs are 24 months in duration with the first 12 months being used as a preparatory year/advanced preliminary training.

• Apply through ERAS in your final year of training of EM residency.

• The program is significantly hospital and program dependent. First year of fellowship varies widely throughout the nation.

• F irst to accept EM to board in EM. • Time is 100% spent in a Neuro ICU.

4 - FELLOWSHIPS These have become much more standardized recently, as most Emergency Medicine-Critical Care Medicine (EM-CCM) Fellowships have become ACGME-accredited. Here’s some detailed information on expected duties during CC Fellowship, including the time spent in the ED, other mandates, moonlighting, work hours, and research: • Suggested Extracurriculars: Most fellowships have expectations that you will teach residents and/or medical students and participate in a few departmental or hospital committees.

• Moonlighting: Program dependent. All moonlighting activities are factored into your duty hours and cannot exceed 80-hr/wk restriction per ACGME. Keep in mind that if taking your board the ABEM states that you must be actively practicing emergency medicine so moonlighting while going through fellowship will be an important discussion point while interviewing.

• Salary: The vast majority will offer the PGY 4, 5, and 6 salaries, which can be located on their GME Websites.

• Work Hours: There are highly variable. Generally speaking, you should expect to work 14-24 shifts per month depending on which ICU you are rotating through and up to the ACGME limit of 80 hrs/wk. Some programs have a night float system to decrease call on their fellows.

• R esearch Requirements: ACGME requires a scholarly project in the appearance of a peer reviewed journal article, case report, etc. The program may have requirements that exceed this.

• ICU Rotations during Fellowship: Most fellowships will allow you to rotate at different ICUs within their institution, which include but are not limited to: Medical (MICU), Surgical (SICU), Cardiothoracic (CTICU), Cardiac (CICU), Neuro/Stroke (NSICU), Trauma/Burn (TICU), and Emergency Critical Care Center.

• Possible Electives: Most fellowship will also offer elective time. The electives will be highly variable among different institutions. It’s important to ask fellowships what types of elective they offer, especially if there’s a particular area of CC that you’re interested in. Some examples of electives include but are not limited to: CC Ultrasound, Pediatric ICU, Anesthesiology, Pulmonary, Nephrology, Infectious Disease, Palliative Care, Nutrition, Radiology, Acute Pain Service, and Research.

5 - BACKGROUND History:

EM-CCM was first conceived in the 1970s and 1980’s by Peter Safar and Ake Grenvik at the University of Pittsburgh as one aspect of the continuum of Critical Care (CC) spanning from the pre-hospital environment to the ICU. In the 1990’s, trauma surgeon Thomas Scalea of Shock Trauma in Baltimore, MD was the next to open doors to emergency physicians in trauma resuscitation and CC. Interest in EM-CCM has risen dramatically in the last several years as pathways to board certification for emergency physicians opened up and the number of fellowship training options increased. More history including this foundation can be found here at http://emccmfellowship.org/about_emccm.php

Information about the current demand of EM-CCM and where it is today:

As the population of the United States ages, the incidence of critical illness will increase further, leading to greater demand for critical care services. Recent evidence in the Annals of Emergency Medicine on Critical Care indicate an increase in the number of critically ill patients in the emergency department (ED) and Intensive Care Unit (ICU).

That same article went on to elaborate that 1 in 5 Americans will receive ICU services before death, and CC services account for approximately 0.56% of the gross domestic product of the United States.

Emergency Medicine’s (EM) foundation, and the care in the ICU tend to run in parallel. The amount of EM residents entering CC fellowships has been increasing. There are similar problem solving skills that are shared between the Emergency Department and the ICU. The CC field itself is thought to be becoming more unified administratively similar to an “Institute of Critical Care”, while simultaneously the clinical skills required to work in the different intensive care units are becoming more differentiated.

Why do ED physicians choose Critical Care?

For many the draw to CC is based on the desire to continue to participate in the continuum of acute care medicine. Others are drawn by the cognitive and psychological challenges of managing patients at very high risk of death or by the procedural intensity inherent in the management of critically ill patients.

What is the advantage of entering Critical Care from an ED background?

EM residents tend to have more exposure and proficiency in resuscitation and procedures commonly performed in the ICU. This experience allows for greater confidence and technical prowess during the initial 24-48 hours in the ICU when the patient will likely require these advanced skills and procedures.

Continued

Physicians may recognize this desire on their first ICU rotation when they learn how the ICU pathology is similar to the highest acuity emergency department. CC involves the application of available research evidence to clinically uncertain and dynamic situations and often requires improvisation based on physician experience and a sophisticated understanding of clinical pathophysiology.

What does Critical Care training look like?

The path to critical care through EM is still relatively new to the scene. Historically, this training was only offered to internal medicine, anesthesiology and surgery. Even without a fellowship, some emergency medicine providers still managed ICUs with the proficiency of fellowship trained intensivists. This started to change though since Neuro CC realized that the ED Physician had a permanent place in the CC setting. This was followed by Surgery and now has expanded to Internal Medicine and Anesthesiology. The path to gain access is similar for each process with a slight alteration of application timelines. With EM-CCM track having reached ACGME accreditation the path to the ICU has become more standardized.

While training as an ED physician in residency, you will spend time in the ICU learning and deciding if this is the path for you. Once you step into the fellowship, you will be rotated through the various ICU’s during your 2-year training. At the end, you will be board eligible and can sit for your critical care certification.

Is there a “set path” to get into Critical Care as an ED physician?

The path to CC is determined by which CC-ICU you would like to work in. This is discussed more in detail below in the senior resident section. How complicated the path is depends on the area of CC that one decides to work in. A broad overview is that for EM residency trained physicians, the CC fellowship is a 2-year stent where you take your boards after the second year of training. This time can be shortened for certain situations. For example, some EM/IM programs have a critical care track that allows them to receive their critical care

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training in 12 months. Several physicians have stated that EM/ IM dual residency would be the best recommendation for those going into the CC track due to the overlapping of acute and chronic care management.

What should I do if my residency doesn’t have a structured Critical Care pathway?

Use your elective time to help hone your skills in critical care, regardless of if your residency has a track for it. You can take elective time in the OR for intubations, ultrasound to increase you point-of-care skills, etc. In addition to this there are several online resources that can place you with mentors within the EM-CCM community to help guide your path. You don’t even need to be at an academic center to place yourself in a good position for a critical care track.

Are the any differences between Community based vs.

Academic Residencies when pursuing CC?

Training at a community hospital can act as a double-edge sword. With less resources and trainees, you can increase your exposure to procedures and critical cases. For example, in some centers the ICU is managed by the second year resident rather than an ICU fellow or attending there 24 hours. These centers also don’t have access to all the sub-specialty coverage that is seen within academic centers. This can force the resident to become self-educated on these topics. Where in a university based setting they would rely on the consultant or sent the patient to referral centers. One common example is in transplant medicine, since this does not occur at many community centers, so exposure to these cases are limited.

Once entering into the academic center, the fellow must be able to recognize any gaps in their education and use their subspecialist and attendings to help augment their knowledge.

6 - RESOURCES Must Attend Conferences for one’s education and networking:

• SAEM, AAEM, and ACEP have CCM subsections • Th e Society of Critical Care Medicine (SCCM): More focused on CCM without the EM component.

They also have an EM-CCM subsection as well.

Scholarships and Grants for Residents: • • • •

Society for Academic Emergency Medicine (SAEM) American College of Emergency Physicians (ACEP) Society of Critical Care Medicine (SCCM) Institutional Critical Care Division Research Director

Clubs and memberships available:

• Society for Academic Emergency Medicine (SAEM): Critical Care Interest Group • Emergency Medicine Resident Association (EMRA) • American College of Emergency Physicians (ACEP): Critical Care Committee

Journals and Publications: • • • • • • • •

Academic Emergency Medicine Academic Emergency Medicine Education and Training Critical Care Medicine Annals of Emergency Medicine Intensive Care Medicine from Europe The Journal of Critical Care Anesthesia of Critical Care Medicine (British Journal) Journal of Trauma (Surgery)

7 - INSIDER ADVICE Dr. Dell Simmons, EM-CCM Attending, Vidant Medical Center “The biggest issue with residents who are interested in CC is that they get so tied down with clinical responsibilities that they don’t keep up to speed with their specialty requirements and find themselves behind when the applications need to be submitted.”

“Get involved in Critical Care research early.”

Dr. Matthew Stull, EM-CCM Attending/Assistant Program Director, Cleveland Medical Center “[Students and Residents interested in EM-CCM] must find a mentor who is practicing both EM and CC as they are ready and willing to support you in your path. CC is the most unique pathway on how to certify and it can be very confusing.”

Dr. Doug Schiller, EM-CCM Fellow, Vidant Medical Center “Take away something from every rotation undergone. You can use all that knowledge in your EM and CC pursuit.”

Dr. Ken Dodd, Critical Care Fellow, Hennepin County Medical Center “Critical Care Medicine is a gratifying and evolving field. I was drawn to the specialty because of the complex knowledge of pathophysiology, procedural skills, and interpersonal skills that are required to care for the sickest patients in the hospital. The increasing use of extracorporeal life support (ECLS), such as extracorporeal membrane oxygenation (ECMO), and the growth of critical care subspecialties has provided many rewarding career opportunities for critical care physicians. Being dual-boarded in EM and CCM allows many physicians to bridge the gap between the two specialties clinically, administratively, and through research.”