Critical Care Medicine Section Newsletter - September 2012
The Double Agent - Critical Care Medicine Section Newsletter, September 2012
Ayan Sen MD, MSc
“All the world’s a stage, and all the men and women merely players”
William Shakespeare in As You Like it, Act II, Scene VII
“So do you want to be a clinician or a clinician-researcher?” A question which is invariably put forth to candidates when they appear for a critical care fellowship interview; this resurfaces when graduating fellows seek jobs post-fellowship. Positions are often offered based on whether an individual is a right fit for the program. Programs may have different profiles. Some are purely clinical with minimal research output/while others have a significant research thrust. Some are strong in all areas and expect fellows to select and follow a certain pathway. Future jobs are also designed to support a clinician/clinical-research/clinician-educator/clinician-administrator track with different levels of involvement. This may bring to the fore its own set of unique challenges, working in two clinical domains and trying to undertake high quality research that will change the paradigms of practice. Especially if we love doing both!
Purists would argue that to be a well-funded researcher, especially in these days of rapid attrition of funds, clinical research is a full-time job and patient care must get relegated to a ‘hobby.’ An interesting debate ensued in Emergency Medicine News a few months ago under the title “You’ve been served: Inappropriate Experts” 1 where the author, a practicing emergency physician, had this to say “Professor EP is likely to be less of a diagnostician than his country cousin. It's a fact of life that none of us is great at everything. A great lecturer is seldom a great bench researcher is seldom a great administrator is seldom a great clinician is seldom a great author.” If you ask me, I don’t want to believe this!
When we decide to make big strides in the world of research, do we default our clinical roles? Do we become less of a physician at that time? Is it a case of ‘East is east and West is west…and never the twain shall meet?’ The idea of a clinical-researcher is to ensure easy translation of empirically tested approaches into real-world settings. It is believed that they will have active ties to clinical domains and are a strong force who will not be easily dismissed as “academics” who “do not understand what we do.”
As our specialty matures, we certainly need a quantum leap in our research endeavors. A view from other specialties does reflect trends amongst clinician-researchers spending more time in grant writing, conducting research with less clinical time investment as they become well-funded; the balancing act proves to be difficult. This may be slightly ‘against the grain’ of a lot of us who love to work in the EDs and ICUs taking care of patients and at the same time wish to advance the science of emergency and critical care medicine by undertaking innovative research.
However, as critical care-emergency physicians, one of our unique traits is multi-tasking. Not unsurprisingly, our small world has several stalwarts who have expertly managed to ‘mind the gap’ and bridge the seemingly conflicting worlds. Did they have to make a lot of sacrifices in their personal lives? Were they one-off stars or is it possible to run with the hare and hunt with the hounds? Can we be the perfect double agent?
Or like Shakespeare’s quote above, is it a matter of playing different roles in different stages of our lives? I am interested to know your thoughts. Please email me. I look forward to carrying your responses in the next issue of this newsletter.
I am eagerly waiting to meet all of you who are planning to make it to the Critical Care Medicine Section Meeting on October 9th in Denver (See Joe Shiber’s Report below). It promises to be fun, educational and a lot more!!
Hossfeld G. You’ve been served: Inappropriate experts. Emerg Med News. 2011;33(10).
Vox Populi - Critical Care Medicine Section Newsletter, September 2012
Ayan Sen MD, MS
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 apologize for the delay in introducing the innovations in the newsletter as promised, but we are making efforts to introduce them in out next edition.
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, criticism, opinions, and letters to Ayan Sen, MD, FACEP; we are very keen to hear from ALL of you. Stay tuned!
Chair’s Report - Critical Care Medicine Section Newsletter, September 2012
Joe Shiber, MD, FACEP
As the ACEP Scientific Assembly in Denver gets closer, I want to encourage everyone to attend our Section Meeting. There are many important updates and announcements, recent developments to discuss, and professional networking opportunities at the business meeting and again this year we are including an EM-CCM Educational Symposium. The meeting will be held:
Critical Care Medicine Section
Date: Tuesday, October 9, 2012
Time: 1:00 pm – 5:00 pm
Where: Hyatt Regency Denver (HQ Hotel)
Room: Mineral Hall D-E, 3rd Level
Please check the on-site program for any last minute room changes. The business meeting is scheduled for 1–3 pm and will include updates from the American Board of Emergency Medicine (ABEM) regarding the ongoing relationship with the American Board of Internal Medicine (ABIM) for fellowship training, and important announcements concerning progress with both the American Society of Anesthesiologists (ASA) and the American College of Surgeons (ACS) regarding EM-trained physicians entering into critical care fellowships with eligibility for certification through these organizations. There will be other updates from other sections that work closely with us, such as the EM Section of the Society of Critical Care Medicine (SCCM) and the ACEP Ultrasound Section Critical Care Subcommittee. The most essential aspect of this section meeting is to not only provide information to its members but to foster discussion amongst all of us, so we need you to be there to participate in the meeting.
The EM-CCM Educational Symposium will follow from 3-5 pm and include four 30-minute presentations by EM-CCM faculty members from around the country. This year we are excited to be able, for the second time to host an event with outstanding speakers who are all trained in emergency medicine and critical care. The agenda of speakers and topics is as follows:
Julie Mayglothling, MD, FACEP
Virginia Commonwealth University
Bleeding Patient on New Anticoagulants
Scott Weingart, MD, FACEP
Mount Sinai Medical Center and Elmhurst Hospital Center
Emergency Neurologic Life Support (ENLS)
Evie Marcolini, MD, FACEP
The Yale School of Medicine
The History of EM-CCM
Isaac Tawil, MD
University of New Mexico
Organ Donation in the ICU
Immediately following the Educational Symposium, there will be a Social Hour with refreshments from 5 – 6:30 pm in an adjacent room. We would like to thank the University of Florida Network for Pancreatic Organ Donors with Diabetes for their support of the ACEP CCM Section and sponsorship of this networking opportunity. Please take this time to relax while catching-up with your colleagues and mentors since it is an excellent chance to reconnect with old friends as well as meet other section members and make new friends. I hope to see you all in Denver!
Joe Shiber, MD, FACEP
Op-Ed - Critical Care Medicine Section Newsletter, September 2012
The year 2012 can be described as a watershed year in terms of moving forward with the ongoing saga of attaining board certification for emergency physicians with fellowship training in critical care medicine. After the agreement with ABIM, new avenues are being explored through the American Board of Surgery (ABS) and American Board of Anesthesiology (ABA) for those who have trained in a surgical/anesthesiology-based critical care program. The section chairs provide you with the latest updates below:
Update on Pathways for Training and Certification Opportunities for EM-CCM
Since the last ACEP Critical Care Medicine (CCM) Section meeting in October 2011, there has been continued work and discussion between the American Board of Emergency Medicine (ABEM), ABA, and ABS to craft pathways for training and certification in Anesthesia-Critical Care (ACCM) and Surgical Critical Care (SCC). The leadership of the ACEP CCM Section and our sister section, Society of Critical Care Medicine (SCCM) Section of EM have received some updates that we would like to share with the EM-CCM community.
The leadership of the ACEP CCM Section and the SCCM Section of EM will be receiving further updates from ABEM, as these are exciting times for EM and for CCM. Our respective organizations and ABEM would like to ensure information is reaching you, our membership, the EM-CCM community at large, as quickly as possible. We hope that conversation on listservs will remain positive, thoughtful, and constructive, as we know that there are many talented physicians who will have sound educational ideas to bring to the table. As a community, we advance the practice, education, and research in critical care medicine by working collaboratively, as EM physicians always do, with multiple specialties. We also recognize that the true progress is being made by each and every one of you every day as you work alongside and between Departments of Surgery, Medicine, Anesthesia, and Emergency Medicine. The continued progress towards certification would not have been possible without your excellence as faculty or as trainees.
1. ABEM and ABA have made progress with their conversations and have submitted a “Letter of Intent” to the ABMS for emergency physicians to train in ACCM fellowships and become certified in ACCM.
This is a great step forward for access to ACCM fellowships, and could potentially become similar to the ABIM co-sponsorship agreement. We hope for continued progress and involvement of EM-CCM throughout this process.
2. ABEM and ABS have had continued conversations about access to SCC fellowships for EM graduates. As a result, the ABS has worked with the Accreditation Council for Graduate Medical Education (ACGME) Surgery Residency Review Committee (RRC) to modify existing requirements for the fellowship to include EM.
The revision of interest is:
III.A.1. Prior to appointment in the program, fellows must have completed at least three clinical years in an ACGME-accredited graduate educational program in one of the following specialties: anesthesiology, emergency medicine, neurological surgery, obstetrics and gynecology, orthopedic surgery, otolaryngology, surgery, thoracic surgery, vascular surgery, or urology.
III.A.1.a) Fellows, who have completed an emergency medicine residency, must also complete one preliminary year of education in the surgery program at the institution where they will enroll in the surgical critical care fellowship. At a minimum the preliminary year of education must include supervised clinical experience in:
III.A.1.a).(1) pre-operative evaluation, including respiratory, cardiovascular, and nutritional evaluation;
III.A.1.a).(2) pre-operative and post-operative care of surgical patients, including outpatient follow-up care;
III.A.1.a).(3) care of injured patients;
III.A.1.a).(4) care of patients requiring abdominal, breast, head and neck, endocrine, thoracic, and vascular operations;
III.A.1.a).(5) management of complex wounds; and,
III.A.1.a).(6) minor operative procedures related to critical care, such as venous access, tube thoracostomy, and tracheostomy.
The leadership of the ACEP CCM Section, SCCM Section of EM, and EMRA CCC will be providing individual organizational responses to this revision. Generally speaking, the consensus is that access to training is a step forward, however describing the year between EM residency and SCC fellowship as a “preliminary year” allows for misinterpretation and confusion on what the expected experience and competencies that year entails. A Preliminary General Surgical year with PGY1-2 level rotations, responsibilities, and educational expectations is not acceptable to any of the organizations listed above, and we will recommend increased clarity by the (ACGME).
Please know, as your Section leadership, that we welcome your comments and thoughts, especially those who are in Graduate Medical Education (GME) leadership at your institutions. For those in our community who are involved in GME, through EM or CCM, we encourage you to provide input and to recommend alternate language during this time of comment from the community of interest to the ACGME.
This is an exciting time with increasing opportunities for EM physicians, and we look forward to hearing your views on our listservs so that we can best represent the interests of the practice of EM and CCM.
We recognize that there are many educators amongst our group, and also many that are not involved in GME so we hope to clarify some of the rationale behind the language used by the ACGME.
The ACGME accredits training programs and oversees the process of graduate medical education, and is accountable to the specialty and to the public to ensure training programs meet standards set forth via peer review. The member specialty boards (ie, ABS, ABEM, ABA) of ABMS certify individual physicians in standards set forth for practice by the individual specialty and is accountable to the specialty and the public.
From the Glossary of Terms downloaded from the ACGME website:
Preliminary Positions: Designated Positions: Positions for residents who have already been accepted into another specialty, but who are completing prerequisites for that specialty (see Program Requirements for Surgery).
Program Year: Refers to the current year of education within a specific program; this designation may or may not correspond to the resident’s graduate year level.
Transitional-Year Program: A one-year educational experience in GME, which is structured to provide a program of multiple clinical disciplines; its design to facilitate the choice of and/or preparation for a specialty. The transitional year is not a complete graduate education program in preparation for the practice of medicine.
Program: A structured educational experience in graduate medical education designed to conform to the Program Requirements of a particular specialty/subspecialty, the satisfactory completion of which may result in eligibility for board certification.
Program Director: The one physician designated with authority and accountability for the operation of the residency/fellowship program.
Subspecialty Program: A structured educational experience following completion of a prerequisite specialty program in GME designed to conform to the program requirements of a particular subspecialty.
Fellow: A physician in a program of graduate medical education accredited by the ACGME who has completed the requirements for eligibility for first board certification in the specialty. The term “subspecialty residents” is also applied to such physicians. Other uses of the term “fellow” require modifiers for precision and clarity, eg, research fellow.
The difficulty with SCC as a 12 month educational program (line 59 Int.C. ACGME Program Requirements for GME in SCC) is that this additional year of training cannot be termed transitional year or program year, which left the only term and funded positions available to the Surgical RRC as the “preliminary” year. This terminology could potentially be acceptable as currently defined from the Glossary of Terms, if there were greater details on educational expectations and competencies expected from the level of a fellow preparing to train and practice in SCC and direct reporting, oversight, and mentorship from the SCC Program Director.
Joseph Shiber, MD, FACEP
Evie Marcolini, MD
Lillian Emlet, MD, MS, FACEP
Vignettes: The Surrogate - Critical Care Medicine Section Newsletter, September 2012
A poem dedicated to caregivers and surrogate decision-makers of critically ill patients (Presented at the SCCM Artistic Talent Showcase)
He had been through a lot, she knew...
He was a fighter, a commonly held view
Sepsis, surgeries, dialysis....he had aced them all
Back on his feet, he rose, every time after a fall
‘Twas different this time, the medical crew said
As he lay with tubes and lines on his ICU bed
Drugged to his eyeballs, with a bleed in his brain
Surgery, for him, would be all in vain
To stand by him in sickness and in health, she had vowed
Many a difficult furrow, together they had ploughed
Now.....they asked her to make him ‘comfort care’
Pull the plug off his life support was more than she could bear
Nothingness above, A deep abyss below
A helping hand she sought, the flicker of a candle glow
Hoping the pervading agony would cease
And the encompassing blackness ease
‘Why O Why’, she wished to weep
Drown her woes and fall asleep
The bells tolled, memories rolled
Feelings went cold, the well of tears her eyes couldn’t hold
As the children quarreled, and doctors opined
His values, reminiscences held her in a spell-bind
Until she noticed a flicker in those eyes, she thought
Reminding her, to go peacefully, he always sought
An uncertain future, the haunting tread
Decisions, she was scared, she would always dread
Free him of pain, in this world, bound in chains
She let go......... of his life’s reins
Vignettes: Tailpiece - Critical Care Medicine Section Newsletter, September 2012
Evie Marcolini MD, FACEP
Chair-Elect, ACEP Critical Care Medicine Section
I invited the family to round with us, as I usually do. Grandma had suffered a large left meddle cerebral artery (MCA) stroke. The team had been caring for her for over a week now; and the family had decided that today was the day for extubation.
The daughter-in-law, the most vocal and clearly the one in charge, said to me: “Grandma has a living will, but we didn’t show it to you until we were certain that what you told us was really true.”
What does that mean?
This made me very sad for the patient and the family. It also saddened me, on a larger scale, by bringing to light some of the limitations of patient/family-physician relationship today. The realities of trust and mistrust on both sides of the fence in the world of the critically ill.
With grandma playing the part of the vulnerable patient.
My next goal was to help the family to understand the reality of grandma’s future, including the things that we know - and the things that we don’t know.
What do we really know?
We confirmed together that with the guidance of the family who knew and loved her, we were doing exactly what the patient would have wanted us to do had she been able to express her wishes.
My thoughts: “I hope that when you walk out of this hospital for the last time, that you won’t have any doubts about what happened here – not now, not next week and not in 5 years”
The difficulty of this case for the family is that with a large left-sided MCA stroke, her future would be complicated by profound aphasia and significant motor deficits. She might show some improvement over time, but she most certainly would be bed-bound and dependent for most of her daily functions. The daughter-in-law thought about this, and then said to me, “If only she didn’t show us any signs of life, this would be so much easier to handle.” Indeed this is true. We have all seen the patient who grips a hand reflexively or opens her eyes – even if she is not tracking or recognizing, these movements remind us that she is still alive (or still seems alive). This reminder makes it extremely difficult to jump to the seemingly radical decision of terminal extubation.
From birth, facial expressions are one of the cornerstones of human interaction. If a patient lying in the ICU bed makes no apparent ‘life-like’ movements, it is easier for the family to recognize that an acceptable quality of life is not an option. And it is easier for the family to let go. But if the patient makes any movement, however slight or insignificant, hope springs eternal, and the family has a more difficult time making a decision.
As emergency and critical care physicians, we help families understand the quality of life that faces the patient, and we help them decide whether or not the patient would want all that medicine has to offer. It is our responsibility to guide the family through this new and difficult experience. At times we have to help them know which questions to ask.
If we do our job well, the family will have resolution and peace in knowing that we as the medical team, and they as the caring family did the best we could – together - to make the patient’s final days painless, dignified, and free from pain, anxiety or agitation. Many of the most satisfied families in the ICU are those whose loved ones died, but who spent some of their last days in the best way possible. Our success in this is much less about the science of medicine and much more about the art of medicine. The elbow grease in this process is hours and days spent at the bedside in the Emergency Department and the Intensive Care Unit, where we communicate with the family and the patient, help them to ask the right questions, and provide the best answers possible.
Many of my most satisfying critical care patient experiences have been the ones that we saved from disaster. But also important are the patients who were allowed to progress naturally to a dignified death when the time was right. The families weren’t ready (who is?) but we helped them understand and accept the reality, and walk away with a settled feeling in their souls. This is worth more than the paycheck to me. Even if grandma’s family didn’t trust us at first, hopefully, they will understand that we are here to help them as much as the patient.
Evie Marcolini MD, FACEP
Chair-Elect, ACEP Critical Care Medicine Section
Attend the Sections Showcase during Scientific Assembly in Denver
Find your niche.
Build your network in Emergency Medicine.
Visit the Sections Showcase!
Wells Fargo Lobby D, Colorado Convention Center
Tuesday, October 9
11:15 am - 12:15 pm
Underwritten by JDRF and the University of Florida, College of Medicine