Critical Care Medicine Section Newsletter - September 2010, Vol 11, #3
Brian J. Wright, MD MPH
Secretary/Newsletter Editor, ACEP Critical Care Medicine Section
Department of Emergency Medicine
North Shore University Hospital
Manhasset, New York
Greetings ACEP Critical Care Medicine Section, and welcome to a new academic year and a new newsletter. We have a lot of great contributions to the September newsletter, and I am really appreciative of all the hard work on the part of the authors.
First and foremost, I’d like to remind everyone of the upcoming ACEP Scientific Assembly at Mandalay Bay in Las Vegas, NV from September 28th to October 1st. Las Vegas is a great city, and I’m certain it will be a great conference.
If you are going to the conference be sure to remember to attend the Section business meeting on Wednesday, September 29 from 3:00 pm to 5:00 pm at Mandalay Bay in Room Tradewinds B. There will be a networking mixer following the meeting. Fortunately, as opposed to prior meetings, this year’s section meeting will be in the afternoon. And that’s important because there are a lot of great morning lectures that I’m sure I’ll see many of you at.
Starting off the newsletter we have our esteemed chair, Lillian Emlet, MD, MS highlighting the importance of developing collaboration between EM-CCM and CCM colleagues in other fields.
Next is our chair-elect, Joseph Shiber, MD, FACEP, discussing his effort to create a national EM-CCM Eductational conference to highlight our expertise as a subspecialty and provide education and training to improve the care of the critically ill patient.
As a recent fellowship graduate, I’ve provided an article on advice for new EM Critcal Care Fellows and resources that are available to them to help adjust to the new world of the ICU and help them supplement their great clinical experience.
Scott Weingart, MD, RDMS, FACEP, gives us some information about his really cool and informative “EMCRIT” blog and podcast. Dr. Weingart is helping to push the envelope on “Upstairs Care Downstairs.”
Julie Mayglothling, MD and Timothy Ellender, MD, the chair and chair-elect of our sister section of emergency medicine in the Society of Critical Care Medicine (SCCM) give us an update on the development of the section’s new mission statement. SCCM is a great organization, and if you are not already a member, you should consider joining.
Dr. Amesh Adalja provides his expertise on emerging infectious diseases and the role of the EM-CCM physician. Dr. Adalja is EM/IM trained, board certified in Infectious Diseases and recently completed his Critical Care Fellowship.
Finally Drs. Jodee Meddy and Biren Bhatt provide an update from the EMRA CC committee. Thank you again to all of the authors. I hope you enjoy the newsletter. If you have any comments, ideas for future newsletters, or would like to submit to future newsletters, please contact me . See you in Vegas!
Back to Top
Lillian L. Emlet, MD MS
Chair, ACEP Critical Care Medicine Section
Program Director, Emergency Medicine MCCTP Fellowship
University of Pittsburgh Medical Center
Now, more than ever, advancing the strength of EM-CCM will require the collaboration of many. As our sub-specialty continues to grow, development of an inclusive, multidisciplinary group will be one of the joys and strengths of EM-CCM.
When asked, what exactly is EM-CCM and what is the mission of this Section, it is twofold:
- To support EM physicians who are interested in developing an advanced practice and content expertise in critical care provided within the ED, and
- To support EM physicians who are dually trained in Critical Care Medicine and practice in a variety of critical care settings.
Previously, I have always stressed the importance of maintaining true to individual EM-CCM excellence at the clinical, educational, research, and administrative levels. Without the quality work of each individual, EM-CCM will not be able to make an impact in each of our respective practices. As we continue to increase the number of physicians interested in critical care, whether provided in the ED or in the ICU, this fulfills a needed gap in the care of patients, improves the transition from ED to ICU, and assists in addressing the intensivist shortage. In order to make this happen, sharing and collaborating is vital for the growth in numbers, interest, and knowledge.
Communication and collegiality are integral to the practice of both emergency medicine and critical care medicine. Orchestrating the care of a complex patient require us all to speak the language of multiple disciplines, no matter where the care is located. Understanding the needs of a variety of patient disease states, presentations, and specialty consultant expectations are essential to the daily practice of medicine in the ED or the ICU. One of my greatest workplace satisfactions is to work with my colleagues from different surgical and medical disciplines in the variety of venues where I work: in the Trauma ICU, in the mixed medical-surgical ICU, at codes and medical emergency team calls on the floors, or in the ED. Mutual respect has come from the teamwork necessary to care for patients together in the diversity of situations encountered. It is a pleasure to work with residents and faculty from a variety of disciplines.
Where and how do we need to collaborate?
Amongst ourselves, those who are interested in providing critical care in the ED and critical care in the ICU:
There are growing communities of physicians providing critical care within the ED that require academic and clinical support to share ideas, collaborate, and provide areas for quality improvement. Dually trained physicians can give an additional perspective on the next phase of patient care and serve as a resource to educate colleagues on the natural progression of care for some of the most interesting patients presenting in the ED. Collaborating between the ED and ICU can improve the understanding of clinical care, administrative burdens, and patient flow. ED overcrowding and hospital flow can possibly be improved when good working relationships and partnerships between these areas exist. Now that we are in many areas throughout the country, in both community and academic settings, the ability to share our experiences, strengths, and knowledge will be the next step in advancing EM-CCM. In this regard, networking, communication and sharing of knowledge and content amongst others in the Section and College will become much more important. We will be highlighting this at the Section Meeting this year in Las Vegas.
Amongst our colleagues providing critical care in the ICU from Anesthesia, Medical and Surgical Critical Care practices:
Our partners in providing critical care have trained EM physicians in many locations and serve as our colleagues in providing care for the critically ill. Strengths from each discipline are often celebrated during training, and our friendships and professional relationships with individuals in anesthesia, surgery, and medicine go forth with us as we move into different institutions and practices. Our presence and strength within the Society of Critical Care Medicine (SCCM) will become more important to support the growth of EM-CCM and improve the quality of critical care provided across the US. I urge every person in both the ACEP Section of CCM and the EMRA CC Committee to join the SCCM Section of EM. This past year has seen inclusive attestations from our critical care colleagues: the agreement between ABIM and ABEM to offer an examination to EM trained physicians after completing an IM-CCM fellowship, and the recommendations by the Surgical Critical Care Program Directors Society to consider making the Surgical Critical Care exam available to EPs.1 I am pleased to report that the Association of EM-CCM Program Directors was formed this year, comprised of Program Directors from Anesthesia, Medicine, and Surgical programs that accept EPs and newer non-accredited programs based in EM. We welcome additional Program Directors from all disciplines to join our collaborative, and more information will be discussed at the Section Meeting in Las Vegas as well.
Amongst our colleagues advancing ultrasound in both the ED and the ICU:
Critical care ultrasound has developed as a natural offshoot of non-invasive methods of monitoring, the widespread use of ultrasound for procedures, and the rapid growth of Emergency Ultrasound (EUS). Intensivists from a variety of disciplines have also begun collaborating with anesthesia and emergency medicine, where ultrasound is a core skill set during primary specialty training. As EM-CCM, we have a strong foundation of EUS from our primary specialty training that only needs additional refinement for critical care uses. As a Section, we look forward to collaborating with intensivists from a variety of backgrounds at SCCM and our EUS colleagues here at ACEP to advance critical care ultrasound education, research, and quality assurance.
I believe that the next 5 years of EM-CCM will naturally develop from the strength of our collaborations. As an emergency physician or as an intensivist, working well with others and having an appreciation of the depth and breadth of knowledge in EM and CCM serves us well at both the individual and group level. These are exciting times of cross-discipline growth and opportunity—I urge each member to reach out and make a connection and get involved at your hospital, your academic center, in your region, in research, and at SCCM and ACEP.
1. Alam HB, Chipman JG, Luchette FA, et al on behalf of the Surgical Critical Care Program Directors Society. Training and certification in surgical critical care: A position paper by the surgical critical care program directors society. J Trauma. 2010; 69:471-474.
Back to Top
Joseph Shiber, MD
Chair-elect, ACEP Critical Care Medicine Section
Director Emergency Medicine Critical Care
Baylor College of Medicine
There are numerous continuing medical education (CME) conferences across the country each year that focus on Emergency Medicine (EM), and there are also many that focus on Critical Care (CC). Additionally, there are a handful of CME conferences that are designated as either a combination of Emergency Medicine and Critical Care or covering the areas where these two fields meet and overlap. It is my goal to review the existing EM-CC conferences and to present ideas for developing a new conference series lead by the ACEP EM-CC Section.
There are currently six conferences advertised as EM-CC (if there are other conferences that I did not include, please forward me the information). They are as follows in alphabetic order:
- Annual Weil Symposium on Critical Care and Emergency Medicine sponsored by University of Southern California
- Annual Symposium on Critical Care in the Emergency Department sponsored by Florida Emergency Physicians
- Critical Points: Emergency Critical Care sponsored by EB Medicine
- Emergency and Critical Care Medicine: The Cutting Edge sponsored by Medical Symposiums, Inc.
- Emergency Department Critical Care Conference and Emergency Medicine and Critical Care Ultrasound Course sponsored by Mount Sinai School of Medicine
As you can see, some of the conferences are run by academic groups such as a University or Medical School, while some are run by independent emergency physician groups or CME companies. While not actually having a dedicated EM-CC CME event, ACEP has a group of Critical Care themed lectures each year at Scientific Assembly. For the 2010 Scientific Assembly, ACEP has 15 presentations listed under the topic heading of Critical Care.
The faculty for these six EM-CC conferences include some Critical Care Fellowship-trained speakers, but the majority of the speakers are general Emergency Physicians. These presenters are notable for their reputations as educators and expert speakers and are highly visible on the national CME circuit. As an additional example, of the 14 speakers for the Critical Care topic presentations at the 2010 ACEP Scientific Assembly, only three are fellowship trained and practice Critical Care. In no way do I want to alienate our general EM colleagues. They are going to be providing the initial critical care to the severely ill and injured patients in ED’s throughout the country. I do feel that the education of emergency physicians on care at the interface of the ED and the ICU should be led by physicians who have the training and are practicing in this area (or areas for those who continue to practice in the ED and ICU).
To support my point, consider the ACEP Advanced Pediatric Assembly. Since I am married to a Pediatric – Emergency Medicine trained physician, I have been to five of the six annual conferences. There have been a few speakers who are Pediatric sub-specialists (Cardiology, Infectious Disease, Pulmonary, etc.) who were not Emergency Physicians and very few general Emergency Physicians who were not trained in Pediatrics, with the overwhelming majority trained in both Emergency Medicine and Pediatrics. This arrangement is what I would expect of such a titled conference and I believe if our section is to organize a conference, then I would expect most of the participants to be outstanding educators and leaders in our field with training in EM and CC.
After sending out an initial email on the C3Med web list announcing the plans of our section to organize CCM educational programs, I have received a tremendous response with great suggestions for topics and many people volunteering to be involved.
The Emergency Medicine-Critical Care Section meeting at ACEP Scientific Assembly 2010 will include a discussion on educational events and speaking opportunities for its members. We will discuss the efforts to increase the participation of the section members in CME events focusing on Critical Care topics. The additional benefits to the EM-CC section will be to increase its visibility, attract more members, and encourage students and residents to consider a career in EM-CC.
We have been working with ACEP to plan for an EM-CC educational event at the 2011 Scientific Assembly. Already from the EM-CC community, we have received many suggestions on lecture topics and ideas for possible alternative formats in addition to didactic lectures (such as a Pro-Con Debate of a controversial issue or a panel discussion of a challenging case). We are also fortunate to have received numerous responses from some of the founders of EM-CC as well as young stars of our field expressing interest in being involved in the event. We certainly have a tremendous amount of knowledge, experience and talent in our section and an outstanding educational program will be valuable to anyone who cares for critically ill or injured patients in any setting. As more develops, we will keep the section members informed via email, C3MED web group, and the ACEP Critical Care Medicine Section newsletter.
Back to Top
Brian J. Wright, MD MPH
Secretary/Newsletter Editor, ACEP Critical Care Medicine Section
Department of Emergency Medicine
North Shore University Hospital
Manhasset, New York
The new academic year is an exciting and rewarding time for the Emergency Medicine (EM) graduate that is transitioning into a Critical Care Medicine (CCM) fellowship. It can also be intimidating for a few reasons. First, as a new fellow you need to adjust to a new “turf”: the Intensive Care Unit (ICU). Plenty of things may be unfamiliar and even unusual to the EM critical care fellow (EMCCF). I remember my first patient on my first day of fellowship when I walked into the SICU. He needed to be intubated. I asked for etomidate and succinylcholine. I was politely informed by the nurses that they didn’t have those medications (only anesthesia had them outside the ED). I would have to wait for anesthesia to slog up to the ICU or do it the “old fashioned” way: propofol, phenylephrine and some brutane. At that moment I really missed the ED.
Second, there will be a lot of things, as a new EMCCF that you are unfamiliar with because you haven’t participated in long term management: vasospasm after SAH, weaning from a ventilator, managing an open abdomen, or fluid management in Acute Lung Injury to name a few problems. However, there are also things that as an EMCCF you will be very good at doing: airway management, ultrasound, central lines, arrhythmia management, toxicology, and neurologic and cardiac emergencies come to mind. There is a tremendous learning curve, and it may be humbling to go from the top of your EM residency class back down to the bottom again as a new fellow, but work hard, read, and ask questions if you don’t understand something and you will get the hang of it as the year progresses. You are doing a critical care fellowship to learn this new knowledge and skill set, if you knew everything already you wouldn’t need to do a fellowship.
Finally there may be some trepidation working alongside your medicine, surgery, and anesthesia colleagues and some uncalled for skepticism on the part of your non-EM peers. “Who prepares who better” is a superfluous and political question that unfortunately you probably will have to deal with from at least one unfriendly attending—“Who are you? What are you doing? Don’t you need to do medicine to do that?” By now you probably have a standard response because you’ve heard these questions more than three times. Or you are fortunate to work in an institution where prior EM physicians have blazed a path for you and future generation of EMCCF. The truth is that taking care of critically ill patients prepares you for a career in CCM. Work hard and you will gain the respect of your fellow medicine, surgery, and anesthesia colleagues. Some won’t be swayed no matter how good you do, others will eventually “ignore” the fact that you are from the ED and accept you as a hard working and dedicated member of the team. It is important to make a good impression, because you represent all of us. You are the future of our specialty, and your good example will win allies for the EM CCM movement down the road.
As a recent fellowship graduate, I’d like to share some textbooks, journals and web based resources that I have found and continue to find useful for CCM education. You may want to consider these resources to supplement the standard textbooks, journals, conferences and didactics recommended by your fellowship program. I’d like to disclose that I am a member of ACEP and SCCM, and have written chapters for a McGraw Hill and Lippincott Williams & Wilkins. I have no editorial or financial relationships with any of these journals, textbooks, publishers, or websites. With anything in medicine, as the clinician it is your job to verify the accuracy and applicability of information that you are using. This list is by no means all inclusive, but rather my own perspective and opinion and should not be viewed as an endorsement by ACEP or the Section of CCM.
The utility of the textbook in CCM (or medicine in general) is often debated. I personally like textbooks. The critique on textbooks is that the information provided is static and potentially out of date by the time it is published and gets to your desk. They have a shelf live. Some of my fellow colleagues just read journals and review articles as they feel this keeps them more up to date with the constantly changing literature. I think there is a place for both. I believe textbooks are a great start, and give you a good background on a particular topic. You will need to supplement the chapters with original research articles published in peer reviewed journals, professional society guideline statements as well as editorial and systematic reviews.
Which Critical Care textbook should you use as a foundation? Everyone has a different opinion, and there is not one right answer. The first critical care textbook I picked up as a medical student and emergency medicine resident was Marino’s ICU Book.1 The text had great reviews of physiology with beautiful simple drawings to explain the science behind what we do, and a lot of practical algorithms to deal with clinical problems often encountered in the ICU—for example how to use your peak airway and plateau pressure to determine why your patient on the ventilator is deteriorating. It’s a classic text, a general review of critical care. One of the ways that it is different from a lot of the other texts is that it is written entirely by one author. I found that as an EMCCF, especially rotating through different subspecialty units I preferred other texts like Civetta, Taylor & Kirby’s Critical Care2 and Principles of Critical Care.3 These texts were written with the input of multiple “expert” authors, and have more depth and cover more topics.
A text that I would highly recommend is Tobin’s Principles and Practices of Mechanical Ventilation.4 Ventilator management is an important aspect of CCM, and an area where the EMCCF probably doesn’t have a tremendous amount of experience coming from an EM background, especially with advanced modes of mechanical ventilation (Pressure Control, Inverse Ratio, Airway Pressure Release Ventilation, High Frequency Oscillation Ventilation, etc.). If I had to have one textbook, especially during my time in the MICU, it would probably be this one.
Finally, consider getting a physiology textbook. I have Guyton and Hall’s Textbook of Medical Physiology5 but there are plenty others out there. One of the coolest and most intellectually rewarding aspects of a CCM fellowship is going back and learning the fundamentals of physiology and pathophysiology and how they apply to your sickest patients. You know about the Starling Curve, but can you superimpose the venous return curve to figure out how to augment cardiac output? Response of the peripheral circulation to critical illness? What happens to the right ventricle when you place patients on a ventilator? What causes hypoxemia? Why does edema develop? How does the kidney promote homeostatsis? Having a good grounding in physiology will supplement the great clinical skills that you learned in your EM residency and help you in your resuscitations and day to day care of the critically ill.
Textbooks are expensive, and you probably won’t be able to read cover to cover one of these textbooks during your fellowship, let alone all of them. Before going out and purchasing any of these textbooks, look at the online resources provided by your hospital, fellowship program, or medical school. Many of the libraries already have electronic subscriptions to multiple textbooks. AccessMedicine©6 and MDConsult7 are examples of websites that have multiple journal and textbook resources that your hospital library may have. If you don’t mind reading on a computer screen or the new electronic tablets out there, this may be a great option for you.
Journals are a great way to stay abreast of all the new advances in CCM. In addition most of them have great clinical reviews on pertinent topics. One way to stay up to date on the new literature out there is to sign up for the table of contents of your favorite journals to be delivered to your email inbox. That way you can see what does and doesn’t interest you. There is no way to go through all of the journals, but here are some non-emergency medicine based CCM journals that I really enjoy and I think that you will find helpful. In addition to the RCTs and original research presented, be sure to look at the editorials, letters to the editors, review articles, and case presentations. You can potentially learn a lot from these other pieces of literature as they will highlight some important issues and controversies they may not be readily apparent on first inspection of a research article.
NEJM8, JAMA9, Lancet10: These three are (in my opinion) the “preeminent” journals in the field of medicine, as evidenced by their high impact factors. You’ll find a lot of large randomized controlled trials in these journals, and some expert reviews. A major probem with these journals (and it really isn’t a problem) is that these journals are not CCM exclusive. It may be interesting to learn about new cancer therapeutics or how different antihypertensive medications affect long term morbidity and mortality, but these topics may not be as pertinent for helping you survive your morning rounds. Again, get the table of contents delivered to your email inbox, and screen what you think is helpful. If you go to the websites of the respective journals, they usually have the pertinent articles under a critical care medicine heading.
Critical Care Medicine11: This is a great monthly journal published by the Society of Critical Care Medicine (SCCM). They have a great mixture of basic science, clinical, administrative and quality improvement studies across multiple CCM disciplines as well as concise clinical reviews of pertinent topics. I find the supplements—recently therapeutic hypothermia, inflammation and coagulation, and echocardiography in CCM to name a few—to be very interesting.
CHEST12: Another great journal published by the American College of Chest Physicians (ACCP). Primarily a Pulmonary and Critical Care Journal, CHEST has some hard core pulmonary articles that you may or may not find useful. However, CHEST usually has some great critical care research articles, as well as editorials, review articles, and case presentations. The supplements are also very good, with some of them being landmark papers that we base a lot of clinical CCM practice on (Weaning Guidelines and Use of Anticoagulant and Antithrombotic Agents to name a few).
American Journal of Respiratory and Critical Care Medicine.13 This is the journal of the American Thoracic Society (ATS). The pulmonary crowd likes to refer to this one as the “Blue” journal, so when you are on rounds dropping an appropriate reference on your pulmonary attending and fellows, make sure you use the appropriate slang and call it “The Blue Journal”—they may even come to respect you as one of their own. Every superlative that I used to describe CHEST applies to The Blue Journal. Screen for the CCM pertinent articles as well as the editorials and clinical reviews.
The Journal of Trauma14: This is the journal of the American Association for the Surgery of Trauma. They provide the surgical critical care and trauma critical care perspective of CCM. In addition to basic science, clinical, and administrative research they provide good case series, clinical reviews, and other editorials. The Journal of Trauma also published the guidelines created by the Eastern Association for the Surgery of Trauma (EAST) an influential organization that develops helpful trauma and critical care guidelines.
There are multiple other journals worth looking into: Intensive Care Medicine15, Critical Care16, Current Opinion in Critical Care17, The Clinics of North America18. Subspecialty journals like Neurology19, Neurosurgery20, Resuscitation21, and Circulation22 are also excellent resources. This list is by no means exhaustive, but rather a good place to start.
Professional Society Guidelines
Professional society guidelines from the likes of SCCM, ACCP, ATS, EAST, and the American Heart Association (AHA) are great ways to stay abreast on important medical topics. They are usually evidenced based (when good evidence exists), and concisely put that evidence together in a clinically applicable format. In addition, it gives an idea towards what the “standard of care” is, or at least what these leading professional societies deem is the “standard of care.” You can look at each societies or respective journal website for their guideline position papers. You can also look at the National Guideline Clearinghouse,23 a clearinghouse of multiple professional society guidelines. Professional society guidelines are also an excellent place to look for research topics. If a professional society states that “more research is needed” in a particular area than that particular topic or question is probably an important area where funding may be available.
There are a lot of websites that have a lot of information out there, some good and others not so good. There are two particular websites that I think are a good starting point. The first one is SCCM’s website, www.sccm.org. On the website you will find guidelines, textbook chapters, video presentations from national and satellite conferences, and podcasts that are very pertinent to the practice of CCM. Some videos are free, while others require a fee. I urge you to go to the site and browse around, especially the Learn ICU section because there are a ton of links that you will find helpful. One particularly interesting linked site is the Pulmonary Artery Catheter Education Project www.pacep.org which provides a tutorial for the PA Catheter.
ATS also has a very useful website which can be found at www.thoracic.org. Definitely go and check it out, there are a ton of useful links. Under the Clinical Heading for CCM.24 (http://www.thoracic.org/clinical/critical-care/index.php) there are journal club articles as well as podcasts, and procedure videos. Thomas B. Stibolt MD (website editor for the ATS) and company have made a tremendous “Best of the Web” section25 (http://www.thoracic.org/clinical/best-of-the-web/index.php). Their site does a much more extensive job reviewing the great web based resources that are out there, and I strongly urge the reader to snoop around to find out all that the web has to offer.
In conclusion, enjoy your fellowship. There is a steep learning curve, and a year or two from now when you are finished you’ll be amazed at what you have learned and the new perspective that you have on CCM. Coming from an EM residency, you already know the importance of hard work. Keep some humility and patience handy. There will be a lot of things that you don’t yet know that some of your colleagues from other specialties may be more familiar with. Recognize this weakness, and use your fellowship as an opportunity to become a great intensivist by turning those weaknesses into strengths.
- Marino P. The ICU Book, 3rd Edition. Lippincott Williams & Wilkins, 2006.
- Gabrielli A, Layon AJ, Yu M. Civetta, Taylor, & Kirby’s Critical Care, 4th Edition. Lippincott Williams & Wilkins, 2009.
- Hall JB, Schmidt GA, Wood LDH. Principles of Critical Care, 3rd Edition. The McGraw-Hill Companies, Inc. 2005.
- Tobin M. Principles and Practices of Mechanical Ventilation, 2nd Edition. The McGraw-Hill Companies, Inc. 2006.
- Hall JE. Guyton and Hall Textbook of Medical Physiolgy, 12th Edition. Saunders Elsevier, Inc 2011.
- AccessMedicine, McGraw-Hill Company. www.accessmedicine.com
- MDConsult, Elsevier Health, www.mdconsult.cm
Back to Top
Scott D. Weingart, MD RDMS FACEP
Director, Division of ED Critical Care
Elmhurst Hospital Center &
Mount Sinai School of Medicine
Queens, New York
For the past year and a half I have been doing a twice monthly podcast on Emergency Department Critical Care. The main reason I started the program was to publicize the existence of our subspecialty, but it has turned into an incredibly rewarding academic pursuit. The podcast was started with the slogan, “Upstairs Care, Downstairs.” Patients should not receive one level of care when they get to the ICU, but a lower standard while awaiting their bed in the ED. Hospital geography should not determine optimal diagnosis or treatment.
Shows are approximately 20 minutes long and deal with a single topic on resuscitation, trauma, or critical care applicable to the ED. While I am an adamant proponent of evidence-based medicine, I try to leave out the quoting of studies and statistics on the show. I would rather listeners seek out the evidence to verify or refute the discussed practices and examine the literature for themselves. The show is supported by the EMCrit Webtext (www.emcrit.org) with all of the references to back up any of the conversation. The feedback for this strategy has been particularly strong; many of the listeners want to hear how we (critical care trained emergency physicians), handle situations as opposed to a summary of the latest critical care literature.
The show currently has >25,000 downloads per month, mostly from iTunes. It has listeners across the globe, including a very vocal and much appreciated group in Slovenia. Episodes have been resyndicated on EM:RAP, ERCAST, and EMCast (the three major emergency medicine podcasts).
While primarily a monologue show, I have had guests on the podcast such as Richard Dutton, former director of Shock Trauma Anesthesia and Alan Jones, author of the non-invasive sepsis study. If any of you are interested in joining me on the podcast for a guest spot, I would love to have you.
If you have not heard the podcast, give it a listen. Find it at blog.emcrit.org or search for “emcrit” on iTunes®.
Back to Top
Julie Mayglothling MD
Chair, SCCM Section of Emergency Medicine
Department of Emergency Medicine
Department of Surgery, Division of Trauma/Critical Care
Virginia Commonwealth University
Timothy J. Ellender, MD
Chair-elect, SCCM Section of Emergency Medicine
Co-director Emergency Medicine-Critical Care Fellowship
Methodist Hospital, Indiana University School of Medicine
Greetings from the Society of Critical Care Medicine’s (SCCM) Section of EM-Critical Care. During and after the last section meeting, our group spent time trying to update our Guidelines for Governance for the Emergency Medicine section. Although initially it may not sound like an overly intellectual pursuit, part of the process required that we develop a mission statement for our section. The importance of defining who we are, as well as our goals and objectives, was an interesting and challenging experience that sparked lively discussions. We discussed how to use our unique combination of training and experience as emergency physicians to promote improved care of critically ill patients, better resident and medical student education regarding critical illness, and expand training and job opportunities for EM-critical care physicians. In addition, we discussed how we might improve the education of our own critical care fellows and use our strong communities in the sections of ACEP and SCCM to help achieve these goals.
After much cutting and pasting, we finally penned this simple statement:
- Improve patient care in the continuum from the Emergency Department to the Intensive Care Unit
- Address the nationwide shortage of intensivists by promoting education, training, and a pathway to board certification in critical care by emergency physicians
- Achieve the above through communication, visibility, and organization
Unfortunately, the executive council of SCCM rejected our proposed Guidelines, stating that the wording in the mission statement was too “emergency medicine specific” and that any SCCM member from any discipline should be able to join and find purpose in a section. Though we were required to change the wording of our mission statement for the purposes of the guidelines, we still feel that our section is destined to serve emergency physicians and specialists in critical care. In fact, this word debate sparked larger questions regarding the future of our specialty. For example, what direction should EM-critical care take and what strategic plan should we follow to get there?
These questions are not easily answered nor are they to be taken lightly. As we move our focus beyond the plight of certification, we must ponder how we might influence not only our “subspecialty,” but also the evolution of emergency medicine and critical care medicine. We feel that this shift in focus is growing in importance and the SCCM Section of Emergency Medicine is committed to working with our ACEP sister section to provide more educated answers.
We encourage all EM physicians interested in critical care to join SCCM- it’s a fantastic organization with extensive resources and the annual critical care congress is always an enjoyable and educational experience. This year’s Critical Care Congress will be in San Diego, CA from January 15th to 19th, 2011, and the Emergency Medicine section will meet on Sunday, January 16th from 10-11 am. We hope to see you all in San Diego!
Back to Top
Amesh A. Adalja, MD
Departments of Critical Care Medicine and Emergency Medicine
Associate, Center for Biosecurity of UPMC
University of Pittsburgh Medical Center
Emerging infectious diseases represent a true trial for the physician. This particular class of infections has multiple implications. An emerging infectious disease often is characterized by new illness appearing in humans for which there may be no treatment, no strict delineation of the signs/symptoms, and no clear guidance on infection control measures. Also, the public and patients are often panicked.
Where do these diseases first get noticed?
When acute infectious diseases strike, patients may seek healthcare at one of several different locales. The PCP’s office, the urgent care clinic, and the emergency department are all part of the 1st tier of healthcare interaction with a new disease. There are myriad examples of new or newly emergent diseases making their initial appearance in an ED. For example, early anthrax victims in 2001 presented to EDs with non-specific flu-like symptoms, testing the ED physicians clinical acumen. For this reason, it is essential that emergency physicians from all geographic locales (urban, rural, suburban) remain engaged and current on the emerging infectious diseases that are currently circulating and forecasted to circulate. The quintessential example of an astute emergency physician sounding the alarm is the hepatitis A outbreak in Pennsylvania in 2003. The physician, at a community hospital, realized that seeing a few cases of what appeared to be hepatitis A in his town was an epidemic. With his help, the epidemic was traced to a local Mexican restaurant.
The role of the CCM physician
When emerging infections are severe enough, they will warrant admission to a critical care unit. They may be labeled with such diagnoses as ARDS, severe sepsis, or septic shock without a clear etiology. It will be left for the critical care physician to explore the diagnosis by delving into the patient’s travel history, social interactions, hobbies, eating habits and many other areas while, simultaneously, preventing irreversible organ failure from occurring. Emergency medicine trained critical care physicians are especially adept at this type of multi-tasking because it is a key skill learned while working in a busy ED where everything is occurring at once.
SARS: Severe Influenza, and other Pathogens
Recent history has provided several examples of newly emerged infections that landed in the ICU. Severe Acute Respiratory Syndrome (SARS) is one such example. This disease killed healthcare workers, including ones that were exposed to infected patients in ICUs. Severe influenza—both the pandemic H1N1 strain and the very deadly H5N1 variant—makes its presence known in ICUs under the label of “viral pneumonia” or “ARDS”. The agents of bioterrorism—anthrax, plague, botulism, and tularemia—are all characterized by often severe presentations warranting ICU admission.
CCM Physicians are Crucial to the Response
While managing these patients with novel pathogens, CCM physicians are likely to gain in-depth knowledge of the pathophysiology, clinical course, and response to therapy. They may even, in the early days of an outbreak, find themselves to be the expert on these diseases because none of the “official” experts may yet have managed actual cases, especially if this is a novel disease. Providing input to those managing the outbreak would prove to be essential in devising treatment guidelines and anticipating resource needs (eg, ventilators, etc.)
How to Anticipate an Emerging Infectious Disease
Because of their very nature, emerging infectious diseases, catch the world off-guard. But, it is not true that the physician has no defense. There are many resources to keep abreast of what new diseases are appearing and EM and CCM physicians should consult them regularly. A few are listed below:
- Emerging Infectious Diseases: a CDC journal devoted to the topic (www.cdc.gov/eid)
- Morbidity and Mortality World Report (MMWR): a CDC news bulletin (www.cdc.gov/mmwr)
- Pro-Med Mail: an email list that catalogs all the disease outbreaks worldwide real-time (www.promedmail.org)
- Clinicians’ Biosecurity Network: a bi-monthly newsletter from the Center for Biosecurity of UPMC devoted to describing infectious disease threats with specific emphasis on biosecurity, bioterrorism, and pandemic preparedness edited by me (www.upmc-cbn.org)
Back to Top
Jodee Meddy, DO
Chair, EMRA Critical Care Committee
Emergency Medicine Program
Maimonides Medical Center
Brooklyn, New York
Biren Bhatt, MD
Vice-Chair, EMRA Critical Care Committee
Resident in Emergency Medicine (PGY3)
New York, New York
The EMRA Critical Care Committee seeks to promote excellence in the care of our sickest patients through resident-led advocacy and education. We are excited to share new developments and opportunities for the residency-trained emergency physician to serve the critically ill and injured, upstairs and downstairs. Our current projects include the creation of a critical care pocket-book for emergency medicine residents, dissemination of up-to-date information on EM-friendly critical care fellowships, and publication of a regular column in EMRA's bimonthly magazine, EM Resident.
By encouraging interest and proficiency in the field, we will provide our residents with the tools to become leaders in emergency medicine AND critical care. To join the EMRA Critical Care Committee, please contact Griffin Achilles .
Back to Top
Make plans to attend the Critical Care Medicine Section Meeting at Scientific Assembly!
Wednesday, September 29, 2010
3:00 pm to 5:00 pm
Room Tradewinds B,
Mandalay Bay Resort & Casino, Las Vegas, Nevada
Come join your colleagues to discuss the issues most pertinent to critical care medicine.
A networking social session is being planned to follow the section meeting.
When: Wednesday, September 29th immediately following the CCM Section meeting – 5:00pm to 6:30pm
Where: the lounge located at THEhotel at Mandalay Bay
BYOB: (Buy your own Beverage)
EMRA CC Committee
Thursday, September 30th at 10am.
Mandalay Bay Convention Center North, Room “Tropics A”
In the April 2010 newsletter there was a Pro/Con article, “ABIM and ABEM Agreement on ABEM Co-Sponsorship in IM CCM.” The Con viewpoint written by Dr. Dell Simmons did not appear as the author intended. In the editing process, the article’s tone and intensity was subdued. The editing process, which affects all articles in all issues to varying degrees, was not intended to intentionally misrepresent the author’s intentions. We apologize for any confusion this may have caused.
Back to Top
This publication is designed to promote communication among emergency physicians of a basic informational nature only. While ACEP provides the support necessary for these newsletters to be produced, the content is provided by volunteers and is in no way an official ACEP communication. ACEP makes no representations as to the content of this newsletter and does not necessarily endorse the specific content or positions contained therein. ACEP does not purport to provide medical, legal, business, or any other professional guidance in this publication. If expert assistance is needed, the services of a competent professional should be sought. ACEP expressly disclaims all liability in respect to the content, positions, or actions taken or not taken based on any or all the contents of this newsletter.