Critical Care Medicine Section Newsletter - January 2012
Editorial - Who is in Charge? - Critical Care Medicine Section Newsletter, January 2012
Ayan Sen, MD, MS
Healthcare, sometimes, reminds me of the United Nations (UN).....rather the state of the current UN. A divided house where we tend to work in our sharply demarcated territories.
It was my one-off call in the Neurosciences Intensive Care Unit (ICU). A 73 year old man had suffered a hemorrhagic stroke.....he had been extubated but remained very aphasic. He had a pan-body CT as the bleed was suspicious for a metastatic lesion. He had a history of atrial fibrillation, COPD, diabetes mellitus, lumbar spinal stenosis and chronic pain. We received the results in the evening; he had malignant lesions in multiple organs. The family was waiting for news. It was a tough conversation.....they had heard so many different things from so many different doctors and nurses until then. So many different faces: one had said he should get pain medicine if he seemed to be in pain or agitated, another had mentioned that pain medicines should be avoided to prevent clouding the neurologic exam. He would be seen by many more doctors they were being told....they were confused....they had a simple question: WHO IS IN CHARGE?
As healthcare specialism has evolved, we have somehow lost our ability to see the patient as a person. We have a finely-tuned focus of treating patients through our unique lenses as cardiologists, neurosurgeons, plastic surgeons, nephrologists etc. working in our silos and once our ‘organ of interest’ gets treated, transferring care to the next group of physicians. I don’t mean to be disparaging to any of our colleagues. They do a fantastic job....but being overwhelmed with the workload and volume of patients, there is an attempt to concentrate on their field of specialization sometimes missing out on the big picture. This is a problem with modern healthcare not only in the US but in most places around the world and gives credence to Walter Cronkite’s famous saying, “America’s health care system is neither healthy, caring, nor a system.”
The under-recognized, overstressed, inaccessible state of primary care is partly to blame. With greater inability to access primary care and the advancement of emergency medicine as the point of entry into the hospital with immediate access to invasive and diagnostic tests, we have become the first line of care for many patients for a wide variety of medical problems and injuries, emergent or non-emergent. As emergency physicians with passion for critical care medicine, we perceive ourselves to be good in resuscitation medicine, good diagnosticians but also great at bringing all the specialties together; sorting, sieving, possessing the ability to communicate with everyone, and TAKING CHARGE.
Critical care medicine is a natural extension of EM because of the ability to understand every specialty’s unique needs and content to a certain extent. The addition of CCM to EM benefits us to see the world (ie, the patient’s illness) along a larger, more comprehensive spectrum. Our dexterity in balancing and communicating the language to each specialty as they need to hear it is a good prowess to coordinate all the different disciplines caring for one patient, thereby, reducing redundancy and irrelevance. Therefore, we (intensivists, similar to emergency physicians) are the natural orchestrators, the natural persons in-charge, for the critically ill. Communication and coordination goes miles from the patient’s perspective. It is no wonder we get the doctor-shopping patients disenfranchised with the medical system throughout the hospital, EDs, or ICUs.
There may be a greater role for us to play in ICU follow-ups, rapid response and outreach services due to our coordination skills, while ensuring that the ‘worst possible scenarios’ for the patient have been considered (the heuristics of EM training) and adequate attention to details on a checklist has been paid (the sine qua non of CCM training). So can we, as dual-trained physicians in EM and CCM take the lead in bringing all specialties and teams together during the patient’s trajectory of emergency and critical illness? We can perform like an ideal UN then.....Uniting Nations a.k.a. Specialties!
Happy New Year!
Vox Populi - Critical Care Medicine Section Newsletter, January 2012
Ayan Sen, MD, MS
Hope you had great holidays and have come back refreshed and recharged for the New Year. It promises to be a great 2012!!
The section leadership, as always, through the newsletter, would like to give a voice and platform to each one of us emergency physicians who are committed to a career in critical care medicine. We are hoping to introduce some changes to the newsletter and website in the coming year; John Litell has mentioned in his write-up about plans for website innovations. There will be 4 issues of the Newsletter every year. We would like to solicit your contributions for the following sections:
- Op-Ed: Your opinions on any topic related to the clinical, educational, research or political landscape of EM-CCM
- Showcase: (Invited) Showcasing different hospitals/people where EM-CCM physicians work, different practice patterns et al (This will be an invited interview but let us know if you are interested in being featured and we will attempt to include all programs over the course of the future publications)
- Tips and Tricks: Any tips/tricks of clinical practice members wish to share
- International perspectives: Similar to Showcase, an International page describing the marriage of EM-CCM in other countries and interviews with practitioners of this unique art
- Journal/Conference/Grant Watch: A list of articles of relevance to the practice of EM-CCM in varied journals in the quarter/ interesting conferences you may have attended or are scheduled to attend/grants deadlines
- Making a Mark: Anyone who wishes to publicize their research, inviting partnerships, informing us of colleagues who won awards, promotions etc. Let us know!
- Personals/Classifieds/anything else that doesn't fit in above categories....Births, Marriages, Anecdotes....any personal achievements you wish to share with the EM-CCM community! (With pictures please!!)
Put on your writing hats and start scribbling, send in your comments, criticisms, opinions, and letters; we are very keen to hear from ALL of you. Stay tuned for the new sections in the April Edition!
Chair’s Report - Critical Care Medicine Section Newsletter, January 2012
Joe Shiber, MD, FACEP
I am very excited to be the incoming Chair of the Critical Care Medicine Section and to have the opportunity to continue the work of the previous Chairs. It is important to recognize the successful leadership of this section under Lillian Emlet, Todd Slesinger, David Huang and Tiffany Osborn. During the next two years, I will strive to promote the goals of the section “to provide resources and support for emergency physicians who practice critical care medicine in the emergency department and in the intensive care unit.” I am looking forward to working with the Chair-elect Evie Marcolini, the Secretary/Newsletter Editor Ayan Sen, the Web Page Editor John Litell, and of course to continue working with our outstanding Staff Liaison, Margaret Montgomery.
I have several specific goals for these two years that I began working on during my time as Chair-elect.
- To continue promoting the increased involvement of the members of our section in EM-CCM educational events. We should be taking ownership of lectures on issues of CCM (in the ED or in the ICU) and eventually organizing our own conferences either as part of Scientific Assembly (possibly a pre-course or a CCM Track) or as a stand-alone conference such as the Pediatric Emergency Medicine Section ACEP Pediatric EM Assembly.
- To foster communication with our “sister-section” the Society of Critical Care Medicine (SCCM) Emergency Medicine Section. There are some EM-CCM physicians who practice exclusively in the ICU who may not attend Scientific Assembly (or even be an ACEP member), and there may be some who are practicing CCM in the ED and may not attend the SCCM Congress. We should unite the talents and energies of the members of these two parallel sections.
- To investigate the possibility of holding extension meetings of the section at the other national EM conferences, AAEM and SAEM. These two EM organizations hold large national meetings annually and could provide an additional opportunity in the winter and spring, respectively, for members of our section to meet.
- To increase the membership of our section and its visibility. The first Sections Showcase was held at Scientific Assembly in San Francisco, and Lillian and I represented EM-CCM. I believe if we succeed in accomplishing these first three goals, then this fourth goal will be met.
Of course the big issue remains to be the ABEM-ABIM agreement for fellowship training in CCM and the potential for certification. Although, how it is currently stipulated, it does not include many of us (myself included) but I think it is a first step in the right direction. We will have to stay involved with this issue and continue showing our value in clinical care, medical education, and research so that eventually all of us who are trained in EM and CCM will be eligible for the recognition that we deserve.
Lastly, I need to thank all of those who helped make the first EM-CCM Educational Symposium a success: Dr. Manny Rivers did an incredible overview of The Endpoints of Resuscitation; then a Challenging Case Panel Discussion was presented by Lillian Emlet, James Dargin, Jonathan Marinaro, Julie Mayglothling, H. Bryant Nguyen, and Scott Weingart. I appreciate the efforts made by the speakers to share their experience and knowledge with all of us. I also recognize that the speakers are extremely busy and that some of them travelled to San Francisco solely so that they could participate in the Symposium, and I was not able to provide any financial support for their travel or other costs. It shows how dedicated these presenters are to the section and to its members. The audio transcripts of the Symposium with the accompanying slides should be available soon on the section website.
Invited Op-Ed - Critical Care Medicine Section Newsletter, January 2012
Emergency Medicine and Critical Care: A Decade of Evidence and Evolution
Emanuel P. Rivers, MD, MPH
Vice Chairman and Research Director, Department of Emergency Medicine
Senior Attending in Surgical Critical Care and Emergency Medicine, Henry Ford Hospital
Clinical Professor, Wayne State University
Institute of Medicine, National Academy of Sciences
Improved outcomes in acute myocardial infarction, trauma, and stroke have been realized by implementing processes involving early diagnosis and timely application of therapies beginning in the emergency department (ED). In 2001, a similar approach toward a disease responsible for just as many deaths was introduced. This disease was severe sepsis and septic shock and the intervention was early goal-directed therapy (EGDT).1 One decade later, the mortality reduction and decrease in health care resource utilization has been robustly replicated and externally validated.1-6 EGDT was not an academic pursuit; it was a quality initiative to address what we all know is that waiting times in the ED for critically ill patients negatively impact outcomes.7 Furthermore, EGDT was a celebration and recognition of previous work. It was a confirmation of the vision and research of Drs. Peter Safar, Max Harry Weil and others who laid the foundation for the ED-ICU interface. Their contribution will be eternal.
The last decade also spawned the beginning of the Coalition for Critical Care Medicine in the Emergency Department (C3MED) in 2003. It began with a group of emergency medicine physicians interested in the clinical and academic practice of critical care medicine both in the emergency department and the intensive care unit. The purpose was to provide a central forum for information and communication to aid in the coordination of activities that promote the active participation of emergency medicine physicians in critical care medicine (CCM). Through this forum was a scientific and political exchange with representation from ACEP, SAEM, AAEM, EMRA, SCCM and international Emergency Medicine and Critical Care organizations. This forum not only provided a year round discussion but led to important publications to pave the way for maturing of Emergency Medicine and its role in critical care.8
The scientific evidence and the organizational efforts of numerous individuals has evolved into the recognition of emergency medicine as an equal partner for board certification in critical care medicine. While a decade represents a convenient timeline, it is not a historical representation of the contribution of all who have made this possible. Furthermore, there are many emergency medicine diplomats with critical care fellowship training who still deserve inclusion for board certification and have sacrificed for the greater good of the speciality. These are also our heroes and we should continue to advocate for them as well.
Competing Interests: None related to this publication.
- Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345:1368-77.
- Gao F, Melody T, Daniels DF, et al. The impact of compliance with 6-hour and 24-hour sepsis bundles on hospital mortality in patients with severe sepsis: a prospective observational study. Crit Care. 2005;9:R764-70.
- Kortgen A, Niederprum P, Bauer M. Implementation of an evidence-based “standard operating procedure” and outcome in septic shock. Crit Care Med. 2006;34:943-9.
- Shapiro NI, Howell MD, Talmor D, et al. Implementation and outcomes of the Multiple Urgent Sepsis Therapies (MUST) protocol. Crit Care Med. 2006;34:1025-32.
- Trzeciak S, Dellinger RP, Abate NL, et al. Translating research to clinical practice: a 1-year experience with implementing early goal-directed therapy for septic shock in the emergency department. Chest. 2006;129:225-32.
- Nguyen HB, Corbett SW, Steele R, et al. Implementation of a bundle of quality indicators for the early management of severe sepsis and septic shock is associated with decreased mortality*. Crit Care Med. 2007.
- Chalfin DB, Trzeciak S, Likourezos A, et al. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care Med. 2007;35:1477-83.
- Huang DT, Osborn TM, Gunnerson KJ, et al. Critical care medicine training and certification for emergency physicians. Crit Care Med. 2005;33:2104-9.
Chair-Elect’s Report - Critical Care Medicine Section Newsletter, January 2012
Evie Marcolini MD, FACEP
“Give me a word, any word, and I show you that the root of that word is Greek.”
-Gus Portokalos in the movie “My Big Fat Greek Wedding”
This is indeed a great time to be part of emergency medicine and critical care. After 40 long years of hard work and negotiations, we finally have the beginnings of an agreement between internal medicine and emergency medicine and the ability of emergency physicians to matriculate into Critical Care Fellowships with the ability to sit for the certification exam. What an accomplishment! Yes, there are some hidden pitfalls, and there may be some difficulties in translation; but this is indeed a significant first step, which we hope will be followed by similar steps from our colleagues in Surgery and Anesthesia.
Credit for this agreement go to the pioneers who have been working with ABEM and lobbying to make this happen. Assertiveness combined with diplomacy, perseverance and patience have been the key.
What does Gus Portokalos have to do with this?
In ancient Greece, the laurel wreath, made from the aromatically scented Laurus Nobilis leaves, was a symbol of victory and status. The Greek God Apollo wore a laurel wreath on the 2nd century BC coin. Well, part of that might have to do with the fact that Apollo was in love with the nymph, Daphne, who turned into a Bay tree just as he approached her (anything could happen if you were a Greek God). In honor of Apollo, the Greeks presented laurel wreaths to winners in the Pythian Games, which were held at Delphi every four years.
To “rest on one’s laurels” refers to one’s tendency to be satisfied with one’s past success and to consider further effort unnecessary. It might be easy to do this as we consider the great accomplishment of bringing emergency medicine to a point of recognition within the world of critical care. But we will not do that. There is much work ahead, not only to develop the relationship with internal medicine/critical care, but to continue building the relationship with surgery and anesthesia. We also have work to do in contributing to research efforts in the field, teaching emergency medicine residents and faculty about the current trends in critical care, and maintaining the high quality of emergency medicine critical care that has been accomplished by those who have gone before us.
If you are not a member of the Critical Care Medicine Section of ACEP, I encourage you to join. If you are already a member, please join with others to contribute to the efforts in education, research and practice. We are fortunate to be at the beginning of an exciting era, and will not be ‘resting on our laurels’…
By the way, the word critical has its roots in the Greek word kritikos, meaning “skilled in judging.”
Happy New Year!
Past Chair’s Report - Critical Care Medicine Section Newsletter, January 2012
Multidisciplinary: Leveraging the Power of Team Based Learning for Better Outcomes
Lillian L. Emlet MD, MS, FACEP
Multidisciplinary is defined as “composed of or combining several usually separate branches of learning or fields of expertise.1 More critical care medicine training programs around the country are labeling their program as such, leveraging the strengths of more than one discipline to provide a comprehensive training experience. As critical care training moves forward toward outcomes-based curriculum and assessment, multidisciplinary programs should have at least 3 if not 4-7 disciplines represented. The disciplines of pediatrics, internal medicine, surgery, emergency medicine, and anesthesiology have classically been described foundations for critical care medicine training, however the future now could also include the disciplines of neurology (who have a separate certification track for NeuroCritical Care), neurosurgery, and thoracic surgery. Using the strengths of each discipline and cross-training, physicians can work collaboratively within a group practice and training program and provide better service to the patient, the hospital, the health system, and the community it serves. While competition in a free market from business perspective will drive greater profits, the result of collaboration from a patient’s perspective is coordinated care that is driven by successful outcomes while minimizing variability. Fortunately, there are a few places where the power of multi-specialty practice already exists.
There are several examples of high performing organized health delivery systems, all of which rely on some degree of peer review and teamwork in an environment of continuous innovation. Overarching themes of these health care systems include: values-driven leadership, interdisciplinary teamwork, integration of care, aligned financial incentives, mutual accountability, and transparency. Rather than top-down mandates, these organizations highlight the success of patient-centered, value-driven initiatives that bring together multiple specialties that collaborate around a shared culture and pride in delivering quality and service, rather than productivity alone.2 The culture underlying these large organizations is difficult to create and maintain, especially in the time of increasing pressures on health care system accountability and shortages of care providers. Despite the growth of advanced practice nurses and physician assistants, the shortage of physicians who bring unique skills and expertise to the care of patients will impact the delivery of care, no matter how creatively staffed.3 Cross-training physicians through team-based learning may provide a novel solution to provide integrated care in an era of physician shortage.
Team-based learning is an educational technique used in many undergraduate disciplines, including medicine and nursing, to integrate problem-solving skills while imparting cognitive knowledge. Team learning is a large group peer teaching strategy that is an expert led, interactive, analytical teaching method that allows very large numbers of students to be taught with very few faculty.4-6 Critical care medicine uses the skills and knowledge that overlap between many primary disciplines, and is actually strengthened when collaboration between disciplines, clinical service lines, and educators exists. As graduate medical education seeks to move towards describing and assessing clinical knowledge, skills, and attitudes via graduated competencies via the ACGME Milestone Project,7 team-based learning may be the first opportunity for critical care medicine to teach and assess cross-discipline. Critical care medicine is one of the few disciplines that requires competency in the content across the gamut of medicine. Application of this teaching technique could be a method to begin the inter-professional collaboration necessary for a new future in health care training and delivery. Creating the environment for patient-centered critical care will require a fresh look at access to training and opportunities for practice for intensivists from all backgrounds.
- Dictionary.com. Last accessed December 18, 2011. http://dictionary.reference.com/browse/multidisciplinary
- McCarthy D, Mueller K. Organizing for Higher Performance: Case studies of organized delivery systems. The Commonwealth Fund. Last accessed December 18, 2001.
- Sargen M, Hooker RS, Cooper RA. Gaps in the supply of physicians, advance practice nurses, and physician assistants. J Am Coll Surg. 2011; 212: 991-999.
- Team Based Learning Collaborative. Last accessed December 18, 2011. http://www.teambasedlearning.org/
- McMahon K. Team Based Learning. In: An Introduction to Medical Teaching. 2010. p. 55-64.
- Michaelsen LK, Sweet M. Team-based learning. New Directions for Teaching and Learning, 2011:41–51.
- ACGME. Last accessed December 18, 2011. http://www.acgme.org/acwebsite/newsReleases/newsRel_3_23_10_1.asp.
Web-Editor Report - Critical Care Medicine Section Newsletter, January 2012
John M. Litell, DO
Section Website Editor
I hope this brief update finds you healthy and rested. I’d like to share with you a brief overview of plans for the continued evolution of our section website. We are starting from a solid foundation thanks to the work of Dr. Portner and the outgoing leadership. This, combined with superb technical and administrative support from ACEP, has resulted in a modern, visually appealing, and comprehensive website. We are at an excellent starting point from which to grow and refine.
Thanks to the recent ABMS approval of CCM board certification for a subset of emergency medicine intensivists, we expect an increase in traffic to the section website. This will probably include visitors from all positions on the training spectrum: trainees seeking program information and mentorship, program directors and department chairs seeking certification information, clinicians seeking guidelines, and potentially members of the media, among others. Our vision for the website is to effectively and efficiently meet these visitors’ needs, with a minimum of extraneous content. This will involve changes in both content and organization. I will be working closely with the section newsletter editor Ayan Sen, and the rest of the leadership, to approach these changes in a coordinated fashion. Our goal is to present both the section related content--mentorship, training, career, practice, etc--and a revitalized and dynamic newsletter, in a format that is accessible and well organized.
As we proceed, we will be eager to hear your input and feedback. All perspectives are most welcome. We have started with the basic question “Why do people come to the section website?” and are organizing from there. The web is a marvelous tool, and there are infinite possibilities available to us. Our focus will be on content that meets identifiable needs. This content will be generally organized around the following categories:
- Section info (officers, policies, section activities, meetings)
- Mentorship (pre-training, post-training, administrative)
- Training/Education (fellowship programs, CME sources, regulatory info)
- Careers (job announcements, member career profiles)
- Practice (guidelines, ACEP and CCM policies)
- Research (funding opportunities, conferences)
As always, your feedback is most welcome. Please contact me, Ayan, or any of your section officers with questions, concerns, and suggestions. This section is only as strong as the degree of engagement among the membership. We are lucky to represent this passionate and motivated group.