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Critical Care Medicine Section Newsletter - September 2008, Vol 9, #3

circle_arrowFrom the Chair
circle_arrowFrom the Chair Elect
circle_arrowFrom the Newsletter Editor
circle_arrowThe Emergency Traumatologist: The Next Step in the Evolution of the Emergency Intensivist
circle_arrowSAEM Update: The Role of CPR in Cardiac Resuscitation
circle_arrowThe EM-CCM Job Search: One Physicians Perspective

From the Chair

Critical Care Medicine Section
September 2008, Vol 9, #3

CCM Section Guideline Updates
Todd L. Slesinger, MD, FACEP

slesingerI hope everyone is getting excited about our annual meeting, we have a packed agenda. This has been a very busy year for all of us, and I must say we have made a lot of progress, meeting most of our goals for the year. After much work, we have updated our operational guidelines, which have been sent out to the elist for comment. During the meeting we will have to vote on the adoption of these updated guidelines, requiring a two-thirds majority vote of those present. I doubt there will be any controversy.

I am very excited to have Harold Thomas, MD, FACEP, the President of the American Board of Emergency Medicine (ABEM), and Mary Ann Reinhart, PhD, the Executive Director of ABEM join us for the meeting to update us on all of their progress. ABEM has truly made great strides this year for our cause and we are grateful for all they have done to bring us closer to board certification in this country.

I am proud to announce that our section was awarded an ACEP section grant for our proposal: "Defining Curricula for Emergency Medicine-Critical Care Medicine Fellowship Training Programs." Led by Lillian Emlet, MD, our chair-elect, and with the support of Dr. Ellender and Dr. Huang, I know this will be a successful project. Dr. Emlet will discuss this further at the meeting.

We will update the section on the EM/CCM Physician census that Dr. Mayglothling has worked on and the Fellowship List that Dr. Simmons updated. There will be updates from EMRA and SCCM as well. We will also discuss the issues involving the Surviving Sepsis Campaign (SSC) and ACEP’s role, this section’s role, and the SSC Task Force being established.

I was proud to have the opportunity to represent this section and ACEP at the Acute Care Congress on the Future of Emergency Surgical Care in the United States. This was a meeting of 16 different groups of trauma surgeons, orthopedic surgeons, neurosurgeons, general surgeons, nurses and emergency physicians that are trying to make a coalition that can work together to help solve some of our joint problems. We share many issues including access to care, on-call problems, reimbursement, liability and quality. This was just the first meeting hosted by the American Association for the Surgery of Trauma and the Centers for Disease Control and Prevention (CDC), with the hope that we can combine interests and resources in an effective manner. I hope that these are just the first steps that will ultimately help acute patient care in this country.

I look forward to seeing all of you in Chicago. Remember, the meeting is Tuesday, October 28, 2008, at 8:00 am in room E258 at the convention center. (Meeting room has been changed.)

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From the Chair Elect

Critical Care Medicine Section
September 2008, Vol 9, #3

Update on the Section Grant: Beginning the Organization of our Education
Lillian L. Emlet, MD

emletSince our last newsletter, we’ve been busy organizing our thoughts as to how best to define and shape the landscape of Emergency Medicine-Critical Care Medicine (EM-CCM) training. The growth of our specialty in number of interested residents and graduating fellows continues with the growth of many new fellowship programs with training pathways specifically for emergency physicians. Before we can come to consensus on defining an ideal EM-CCM curriculum, we first must define the landscape in which our training programs exist. We hope to bring together medical educators in EM-CCM, and we hope that someday our Section’s efforts will be useful to the American Board of Emergency Medicine.

In order to provide the highest quality training to emergency physicians, an assessment of the educational content of fellowship training should be performed to ensure that defined competencies are taught. As emergency medicine educational content has become well defined and structured over the past 30 or more years, so has CCM’s educational content. Fellowship training programs with dedicated EM-CCM paths should comply with Common Program Guidelines from the Accreditation Council of Graduate Medical Education (ACGME) and the American College of Critical Care Medicine (ACCM). Additionally, we will look at adherence to other countries’ comprehensive guidelines: the Royal College of Physicians and Surgeons of Canada Subspecialty Training Requirements in Adult Critical Care Medicine and the European Society of Critical Care Medicine’s Competency-Based Training in Intensive Care Medicine in Europe (CoBaTRICE).

Our primary goals of this ACEP Section Grant is to define the number and type of EM-CCM fellowship training programs that exist and assess their adherence to currently published educational guidelines for critical care medicine, as defined by the ACCM. We hope to use this Section Grant to define the current landscape of new and old EM-CCM training programs. We anticipate current fellowships will provide a variety of clinical experiences, employ common methods to cover curricular content, utilize common methods to assess competency, and have specific strengths. We anticipate some variety, but also that programs have modeled their curricula in accordance with majority of ACGME requirements and ACCM guidelines.

We hope that this project benefits the Section in multiple ways. From the perspective of the applicant seeking EM-CCM fellowships, these fellowship curricula and clinical emphases vary, and should be better defined to provide consistent quality training. From the perspective of employers, an emergency physician who completes a critical care medicine fellowship should have acquired a broad, comprehensive ability to manage any patient requiring critical care, with a defined set of skills to provide that care. This project will guide and advance the quality of training provided by EM-CCM fellowship programs.

The last goal in surveying the current EM-CCM training programs is to bring together medical educators in EM-CCM so that our next Section Grant will be to organize a task force to create a consensus document to guide fellowship curriculum development and assessment. I look forward to working with some of you in the future as we continue to organize and shape our educational initiatives in EM-CCM!

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From the Newsletter Editor

Critical Care Medicine Section
September 2008, Vol 9, #3

Parallel Paths- News from the EMRA Critical Care Committee
Timothy Ellender, MD

ellender(2)
The Society for Academic Emergency Medicine (SAEM) annual meeting, which was held this past May in our nation’s capital, offered me the chance to catch up with old friends, glimpse a view of the future of our specialty, and witness the activities of one of our sister organizations, the Emergency Medicine Residents’ Association (EMRA) Critical Care Committee.

I joined a packed room of medical students, emergency medicine residents, critical care fellows, and faculty in what was a very well organized and purpose driven meeting. Onier Villarreal, MD, committee chair, presided over a lengthy discussion that covered a variety of topics from educational resource development to further support of Emergency Medicine-Critical Care Medicine (EM-CCM) certification and career building. Several of the topics covered, I thought would be of interest to our readership:

  1. EMRA is creating a critical care pocket resource that will be offered to emergency medicine residents and interested medical students. While this guide has been in the planning stages for over a year, progress has been made in regards to resource allocation and content selection. The committee reached out to its membership for potential authors. Interested members might wish to contact Dell Simmons, MD for further information on this project. (criticalcarectte@emra.org )
  2. The emergency medicine critical care database, which is accessible from our section website, will continue to be updated and supported by EMRA. New and old fellow trainees were encouraged to share their interview experiences to further populate the database.
  3. Dr. William Chiu, MD, FACS, Fellowship Director at R. Adams Cowley Shock Trauma Center, presented data regarding emergency medicine trainee performance in trauma-critical care training programs over the past 5 years. In comparing trainees, emergency physicians continue to perform very well and match or exceed comparative trainees in formalized testing (Society of Critical Care Medicine’s Multidisciplinary Critical Care Knowledge Assessment Program -MCCKAP). According to Dr. Chiu, his data supports that our specialty can be trained effectively in trauma critical care medicine. Dr. Chiu also shared that there are a large amount of unfilled trauma critical care training positions and that emergency physicians may increasingly start to fill these roles in the future given the decline in interest in critical care from our surgical colleagues. Those interested in potential trauma fellowship training can find more information at www.east.org.
  4. Lastly, EMRA board members reported on their formal meeting with members of the American Board of Emergency Medicine (ABEM). A key topic of discussion with ABEM was the concerns regarding the lack of formalized certification of the fellowship trained EM-CCM practitioner. ABEM continues to assure the community at large that it is actively seeking a resolution to this matter. Promising discussions have resumed with the American Board of Anesthesiology and the American Board of Internal Medicine. The board members reported that formalized proposal documents had been drafted and that workgroups have been formed to address these potential avenues.

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The Emergency Traumatologist: The Next Step in the Evolution of the Emergency Intensivist

Critical Care Medicine Section
September 2008, Vol 9, #3

Marc Portner, MD
Adjunct Assistant Professor of Surgery
University of Pennsylvania School of Medicine
Associate Director, Trauma and Critical Care Fellowship
St. Luke’s Hospital and Health Care Network

portner
Societal and technological advances in the middle of the 20th century brought about changes in patient characteristics that tested the limits of the health care system in place at the time. Faster and more numerous cars along with an increase in interpersonal violence brought us more seriously injured patients that often required sophisticated care. During the same period, improved management of acute cardiac and pulmonary diseases led to fewer deaths during the acute phase leading to an increase in the number of patients requiring mechanical ventilation and other forms of ‘critical care.’ These and other changes threatened to overwhelm many physicians and hospitals, especially emergency ‘rooms’ staffed by generalists during their off-hours.

Some visionary physicians recognized the impending crisis and embraced the opportunity to institute significant changes in the health care system that would serve as the foundation for our current model. Physician leaders in medicine and surgery worked to create a new acute care model to meet the needs of the changing patient population. By the early 1980’s, emergency medicine existed as a specialty, Trauma systems were evolving, and intensive care units were staffed by physicians with training in critical care.

Thirty years later, our patient demographics are changing again. The proportion of people over the age of 65 will increase exponentially after 2010 and many will need advanced acute care. Challenges within our existing health care model, specifically those relating to recruitment and training of new physicians that can care for those requiring advanced care will limit our ability to meet the growing needs of our patients. Fewer specialists functioning in systems that are often overcrowded threaten the high standard of care our patients deserve. Once again, we’ll look to leaders in these fields to find creative solutions to these unique challenges.

Much has been written in recent years regarding the future role of emergency physician intensivists. This has prompted an interest among some leaders in the trauma community as they work through the workforce challenges that lie ahead for their specialty. A few of these leaders are now on the forefront of training emergency physicians as surgical intensivists and traumatologists.

Our future role in this specialty remains unclear, but as more of us complete formal training and begin practicing within Trauma systems, further research and dialogue may lead to a new career path for bright, motivated emergency physicians. The first research to evaluate the safety and efficacy of this practice model has been completed and submitted for peer review publication by Michael Grossman, MD of the University of Pennsylvania and St. Luke’s Regional Trauma Center. Objective data regarding process and outcome of care provided by an emergency traumatologist will be widely available soon, but suffice it to say the data are compelling.

I was fortunate to participate in this project, at least to the extent Pavlov’s dog was participating. After completing an emergency medicine residency and a Trauma and Critical Care Fellowship, I joined a group of trauma surgeons as a traumatologist. Our system is similar to many other Level I trauma centers in that the clinical work consists of critical care, trauma, and general surgery. My non-clinical contribution is similar to traumatologists in any busy trauma center and consists of education, performance improvement, and administrative responsibilities expected of many junior faculty.

My clinical contribution, of course, is limited to trauma and critical care. I provide care to our patients throughout their entire experience in our system, starting with the acute resuscitation in the trauma bay. If surgical intervention is necessary, my surgical partners are immediately available. Otherwise, I’ll continue to coordinate the care for our patients who may need sub-specialist surgical treatment, further evaluation and treatment with interventional radiology, continued resuscitation in the ICU, or admission for serial neurologic checks. After the initial evaluation and management phase, I’ll continue to care for these patients throughout their ICU or hospital stay, and even provide follow up weeks and months later as part of our outpatient practice.

Clearly, there are limitations in our role as traumatologists since surgical interventions are commonly an integral part of the treatment of severely injured patients. This will be most apparent in centers that care for an unusually high number of penetrating injuries. However, in a trauma center that predominantly cares for blunt traumatic injuries, a non-surgical physician who has timely surgical backup, is well trained in resuscitative principles, and is proficient with emergency procedures can function as an effective traumatologist.

The benefit to the system at large is not only an expanded workforce but potentially improved system efficiency and career satisfaction. My presence allows my surgical partners to focus more of their clinical time on general surgery which not only increases revenue, but also improves their overall job satisfaction. It seems clear from recent publications that job satisfaction among trauma surgeons and interest in trauma surgery among surgical residents is low, in part due to the increasing non-operative management strategies of this dynamic specialty. Solutions that allow us to safely care for patients while increasing the level of interest and job satisfaction for trauma surgeons should be at the forefront of our discussions.

The challenges imposed on our current practice model will likely lead to more diverse career options for ambitious emergency physicians. As thought leaders in these specialties engage in dialogue free of political barriers as they did 30 years earlier, the opportunities for emergency physicians with advanced training will likely increase, and will likely include an expanding role in the world of trauma and surgical critical care.

HRSA's Workforce Report Confirms Intensivist Shortage
http://sccmcms.sccm.org/SCCM/Publications/Critical+Connections/Archives/August+2006/HRSA_Aug06.htm [Accessed 5/22/08]

Making the Case for a Paradigm Shift in Trauma Surgery, Eastern Association for the Surgery of Trauma http://www.east.org/tpg/futurereview.pdf [Accessed 5/22/08]

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SAEM Update: The Role of CPR in Cardiac Resuscitation

Critical Care Medicine Section
September 2008, Vol 9, #3

Nick Mohr, MD
Resident, Indiana University

mohr
Despite the tremendous advances in resuscitation medicine over the last half-century, high-quality, timely cardiopulmonary resuscitation (CPR) is still the intervention most strongly linked to survival.

That was the message of Benjamin Abella, MD in his portion of the SAEM Annual Meeting didactic session during which he discussed the recent revisions to the American Heart Association Advanced Cardiac Life Support (AHA-ACLS) Guidelines and the data that supports their use.

He cites five attributes of quality CPR:

  1. Adequate Compression Rate – In his 2005 observational study, Abella 1 and colleagues prospectively recorded actual data on CPR performance parameters during in-hospital cardiac arrest for 97 patients in 3 hospitals over an 18-month period. When he looked at the rate of compressions during his 813 minutes of recorded CPR, compression rate complied with AHA guidelines (100 ± 10 cpm) only 31.4% of the time, and rate < 80 cpm in 36.9% of recorded segments.

    Abella then tried to correlate the rate of compressions with return of spontaneous circulation (ROSC). His observational cohort analysis revealed that mean compression rate for initial survivors was 90 ± 17 cpm, compared with 79 ± 18 cpm for nonsurvivors (p<0.005).

    Although his study was observational in nature, many of the arrests that he recorded had compression rates below the AHA Guidelines, and there seemed to be a correlation for better survival when the rate of compressions was higher.

  2. Adequate Compression Depth – Edelson 2 and colleagues performed another prospective observational study during which they recorded CPR parameters using an automated device during in-hospital and out-of-hospital cardiac arrests with a presenting rhythm of ventricular fibrillation (VF). They found that initial shock success seemed to correlate well with mean compression depth. Shock success for those patients receiving pre-defibrillation compression depth <1.5 cm was 57%, compared with 95% for those receiving compression depth >1.5 cm. Using a logistic regression analysis, Edelson calculated an adjusted odds ratio for resolution of VF to be 1.99 (1.08 – 3.66) for every 0.5 cm increase in compression depth. Again, in an observational study, many (55%) of the resuscitations were performed with chest compressions below the AHA recommended depth, and VF seemed to be significantly more responsive to therapy when deeper compressions were used.

  3. Timely Defibrillation – Edelson 2 used the same methodology to look at the time between pausing compressions and delivery of a defibrillation shock. As the time between stopping compressions and delivery of the defibrillation shock (i.e., pulse check, rhythm analysis, etc.) lengthened, investigators observed a significant decrease in the effectiveness of the shock in resolving VF. For a pause of less than 10.3 seconds, 90% of defibrillation shocks were successful, compared with 44% for shocks delivered after a 10.3 second pause, yielding an adjusted odds ratio of 1.86 (1.10 – 3.15) for every 5 seconds increased pause.
  4. Few Pauses in Compressions – There are animal data to suggest that pausing sequential chest compressions leads to a rapid and dramatic fall in aortic blood pressure, and that a prolonged sequence of compressions is required to restore that pressure. Based on these data and the observation that many bystanders fail to perform CPR even during known cardiac arrest, Hallstrom 3 and colleagues hypothesized that bystander-performed CPR utilizing a compressions-alone protocol would be superior to traditional CPR incorporating both compressions and ventilations. He performed a prospective randomized trial during which EMS dispatchers in Seattle instructed bystanders on either compression-only CPR (coCPR) or traditional CPR (tCPR). Ultimately, 520 patients were enrolled in the trial and compared in the outcome of survival to hospital discharge.

    Hallstrom found that the group instructed in coCPR has a non-significant increase in survival to hospital discharge compared with the tCPR group (14.6% vs. 10.4%, p=0.18). Several factors may have confounded the results (eg,, the increased time to instruct bystanders on tCPR, improved bystander participation, mean EMS response times of only 3.1 minutes), but Hallstrom concluded that coCPR was equivalent to tCPR, and some of that benefit likely was from timely CPR and limiting interruptions in compressions.

  5. Normoventilation – One of the most common problems with CPR performed by trained rescuers is iatrogenic hyperventilation. Aufderheide 4 and colleagues performed an observational study in Milwaukee where they recorded the ventilation rate of seven patients in out-of-hospital cardiac arrest after endotracheal intubation. They found the average rate of ventilations to be 37±4 bpm – none of the patients in the observation group survived. Aufderheide’s team then conducted an animal study on a porcine model with standardized CPR and mechanical ventilation after induced VF. They compared survival and hemodynamic parameters in pigs who were ventilated at a rate of 12 bpm compared to a rate of 30 bpm (which was still lower than that observed during human out-of-hospital resuscitations).

References

  1. Abella BS, Sandbo N, Vassilatos P, et al. Chest compression rates during cardiopulmonary resuscitation are suboptimal: A prospective study during in-hospital cardiac arrest. Circulation. 2005; 111(4):428-34.
  2. Edelson DP, Abella BS, Kramer-Johansen J, et al. Effects of compression depth and pre-shock pauses predict defibrillation failure during cardiac arrest. Resuscitation. 2006; 71(2):137-45.
  3. Hallstrom A, Cobb L, Johnson E, et al. Cardiopulmonary resuscitation by chest compressions alone or with mouth-to-mouth ventilation. NEJM. 2000; 342(21):1546-53.
  4. Aufderheide TP, Sigurdsson G, Pirrallo RG, et al. Hyperventilation-induced hypotension during cardiopulmonary resuscitation. Circulation. 2004; 109(16):1960-65.

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The EM-CCM Job Search: One Physicians Perspective

Critical Care Medicine Section
September 2008, Vol 9, #3

Jairo I. Santanilla, MD
Assistant Professor of Clinical Medicine
Emergency Medicine and Pulmonary Critical Care
LSUHSC/Oschner Health System - New Orleans

santanilla
Over the past decade there has been an increasing call for emergency medicine trained physicians to obtain additional Critical Care Medicine (CCM) training. A 2005 consensus statement by the major critical care societies endorsed the idea of CCM board certification for emergency medicine physicians [1]. However, to date there is no avenue for emergency physicians to obtain board certification within the US. This impediment has discouraged many emergency medicine residents from seeking further training in CCM [2]. There is little data on how many EM/CCM specialists currently practice or in which environment they practice. A national survey by Dr. Mayglothling (personal communication) is ongoing and may shed light on this information. In addition, there is little in the current literature about the practical issue of obtaining employment after completing CCM training. To that end, I would like to present my recent experience in the job market.

Introduction- My journey began in 2001 with my residency in a combined internal medicine/emergency medicine program. Like many residents, I loved the fast-paced nature of trauma and the difficult cases in the ICU. I felt a great sense of accomplishment from my time in the resuscitation rooms, the units, and with the families of critically ill patients. I decided to pursue a fellowship in CCM with the hopes of bridging the divide between the ICU and the ED. My fellowship training was a good experience and soon after my second year started, I began looking for a job. To retain credibility with colleagues in both specialties, I decided to seek a position in both emergency medicine and CCM. I considered continuing my internal medicine career, but felt it was too difficult to do all three. I didn’t realize how difficult it would be to just do two. The importance of my family ties mandated that I focus my search to a geographical area. With a narrowed scope, one of my biggest hurdles was finding a full time position. Moonlighting in both emergency medicine and CCM was possible, but it afforded one little, if any benefits, retirement plans, or security. Part-timers are always at risk of losing their position to a full-time employee. Thus, my search centered on a full-time position incorporating both specialties. I can honestly say that I conducted a fairly wide search, encompassing both private and academic environments as well as emergency medicine and CCM practices. The path of EM/CCM is not as clearly lit or marked as that of our colleagues on the well established, heavily traversed career path of Pulmonary/CCM. In the following sections, I discuss fellowship training, board certification, employment in private emergency medicine groups, private CCM groups, combined EM/CCM in a private setting, academic emergency medicine, academic CCM and combined EM/CCM in an academic setting.

Fellowship and Boards- There are no standard guidelines for what type or length of fellowship training an emergency medicine trained physician should complete. There are surgery, anesthesia, and medicine-based fellowships, each with their individual strengths and weaknesses. There are a few multidisciplinary fellowships in existence, and in my opinion unless one knows that they only want to be working in a specific type of ICU, a well-rounded multidisciplinary experience is best. The length of training is perhaps the most contentious question faced by residents deciding this path. While many programs offer one-year experiences, it is the opinion of many emergency medicine leaders in this field that a two-year training program should be completed. This offers several benefits. First, it places one on an equal training footage as the other specialists: surgery (5+1), anesthesia (4+1), pulmonary/CCM (3+3), medicine (3+2), emergency medicine (3 or 4+2). Second, it allows you to sit for both parts of the European Diploma of Intensive Care (EDIC) ( www.esicm.org). Most importantly, many believe that when a certification pathway for emergency medicine becomes a reality, two years will be the training standard.

Can you practice CCM without a 2-year fellowship or the EDIC? The answer is a qualified yes. Mostly it depends on the hospital and department that you wish to work for. Certain hospitals have by-laws that require board certification. There can be exceptions made to these rules, especially if the CCM director supports your employment and they have a need for coverage. Having the EDIC may help you in this situation. However, it is not a guarantee and it does not open doors into unfriendly territory. Thus, it is imperative that you determine their willingness to work with you well in advance.

Private Emergency Medicine Groups - Critical care training may improve one’s marketability to a private group, particularly groups that have a strong voice in hospital administration. It is conceivable that one could assist in creating protocols as well as education of fellow group members. This arrangement should be investigated on a case-by-case basis. To date there is little data regarding private ED groups’ hiring patterns of critical care trained emergency medicine physicians.

Academic Emergency Medicine Groups/Departments - Academic emergency medicine has recognized the benefit of having faculty with additional critical care training. There is a plethora of opportunity; research, clinical, education, and policy are simply a few. One hurdle that trainees face is the relative small number of available positions. While some programs may be interested, they simply do not have available spots with which to hire new grads. Again, it is my experience that it is easier to find a position if one is interested in only working in the ED. If one desires to also work in the ICU, there needs to be institutional backing from both departments (see below).

Critical Care Medicine Groups - Different specialty factions control patient care in most critical care units. Surgeons and anesthesiologists manage the surgical/trauma ICUs. The cardiac care units are staffed by cardiologists in a number of institutions. Likewise, the neurosurgical ICUs are staffed by neurosurgeons and the medical ICUs by pulmonary/CCM. There are a few environments were all units are directed by a Department of Critical Care Medicine which is composed of the different CCM subspecialties. However, these are few in number. As an emergency medicine intensivist, the largest hurdle to overcome in joining a critical care group is not belonging to any of the aforementioned controlling groups. Many SICU and trauma ICU groups also cover surgery call, many of the anesthesia groups cover the operating room schedules, and many of the pulmonary/CCM groups also cover in-patient pulmonary consults or out-patient pulmonary clinic. It is difficult to join groups in this paradigm because as a CCM specialist one cannot cover specialty clinics or operating room time. However, a growing number of groups have begun to recognize the importance of a CCM trained intensivist who does not have concurrent responsibilities outside of the ICU. The key to success in this sector is finding a department that recognizes the benefit of a dedicated CCM specialist. While there has been a move towards twenty-four hour ICU coverage, most private CCM practices are currently not staffed by full time intensivists. In that regard, I was surprised to find that the number of job openings for a CCM specialist was far smaller than I anticipated. The era of twenty-four hour coverage and shift work in the critical care environment has not been fully embraced and is not yet at the level of emergency department staffing, particularly in academic settings.

Dual Private Emergency Medicine/Critical Care - The largest hurdle faced in this sector is the competing needs of parallel clinical systems. The financial and logistic restraints of private practice may cause difficulty for those who wish to work in the ED and ICU. Time spent in one department is time one is not available to work in the other, thus making it necessary for partners to cover shifts or clinical hours. I found that groups viewed the scheduling logistics as being too difficult to make the effort. Most private ED groups were only interested in my working in the ED. There was little leeway in allowing me to work half time in the ICU. From their perspective, they needed someone to fill a shift. To hire me, meant they would have to hire someone else to fill the slots I was vacating while working in the ICU. The same held true for the critical care side. There are, however, a few private groups across the country that hold staffing contracts for both emergency medicine and CCM, and have worked out the staffing issues. So this model of practice is not all together impossible to establish.

Dual Academic Emergency Medicine/Critical Care- Again, I faced a dual departmental hurdle with employment within this practice model. Academic appointments are quite complex and at times very political. Who pays your salary, benefits, and retirement is of great concern. Do two departments split their commitment or do you belong to one? Who is your boss is another important sticking point. How will academic advancement take place? All are very important points, and often very difficult to negotiate. For this arrangement to work, one needs backing from both departments. Beyond contractual logistics, determining the work schedule can be quite difficult. There are very few academic CCM practices that employ shift work. These are perhaps the easiest schedules to determine (work some CCM shifts, then work some emergency medicine shifts). Some CCM groups assign a specific faculty to a service for an entire month. This can be very difficult because that would be a month that one could not contribute to the ED schedule. Those who have been responsible for making schedules can attest to the difficulties of having a person come in an out of the work pool. However, most academic CCM attendings work in 2-week blocks. This leaves 2 weeks for ED shifts which sounds simple enough. But, when does one do the non-clinical academic time? All these questions have to be sorted in a dual academic appointment. There are several programs across the country, which have worked out these details, and more who have been unsuccessful in their attempts.

In Summary - One can generate a lot of job offers if one picks either emergency medicine or CCM; however, by deciding to do both the search becomes much more difficult. For me, academic CCM was the hardest to break into despite my being board eligible by the ABIM in the United States. This was mainly due to the staffing paradigms used by many groups. Despite all the hurdles, the journey has been a great one, and one that promises to have an interesting future. EM-CCM graduates will find many opportunities out there, some that were never thought of, and some that are better than others. I encourage all to keep their options open and be diligent in their search. Know what you want and define/understand the obstacles that might stand in your way. Finally, position yourself to be on equal footing with others in the market; do a two-year CCM fellowship and take the European Diploma in Intensive Care (EDIC). Without them, I fear that the job market hurdles would multiply.

Good luck on your journey.

  1. Huang DT, Osborn TM, Gunnerson KJ, et al. Critical care medicine training and certification for emergency physicians. Ann Emerg Med. 2005;46(3):217-223.
  2. Williams JB, Weingart S, Lindsell C, et al. Emergency medicine resident interest in critical care fellowship training increases if provided United States certification pathway. Crit Care Med. 2006;34(12):3066-3067; author reply 3067.

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