- Email: [email protected]
Call for Resident Papers Annals of Emergency Medicine
RESIDENTS’ PERSPECTIVE
critical care physicians, many EDs do not have the benefit of a critical care consult. A collaborative study conducted by representatives of the Society of Critical Care Medicine, the American Thoracic Society, and the American College of Chest Physicians (the Committee on Manpower in Pulmonary and Critical Care Services [COMPACCS]) demonstrated a significant void of fellowshiptrained critical care providers. The investigators found that up to 64% of critically ill patients do not receive input from a trained intensivist at any point during their ICU stay.7 Because of the increase in the elderly population, this deficit is predicted to increase, with only 22% of the demand being met by 2020.8 Emergency medicine as a discipline has recognized the need for additional training in areas such as pediatric emergency medicine, toxicology, disaster medicine, international medicine, and emergency medical systems. Critical care should be no different. More fellowship opportunities are necessary to train a sufficient number of emergency physicians, and the issue of board certification needs clarification. The fellowship at the University of Maryland Shock Trauma Center is the only program of which we are aware that is designed and dedicated to the trauma and critical care training of emergency physicians. Its curriculum has been described elsewhere.9 Although we currently train only 1 emergency medicine fellow each year, we have decided to expand that next year to 3 and perhaps more. This year, the Shock Trauma program has 12 fellows: 8 surgeons, 2 anesthesiologists, 1 internist, and 1 emergency physician. Each contributes knowledge and expertise from his or her specialty, and all participants have benefitted from the collaborative multidisciplinary dynamic. The Shock Trauma Center admits approximately 7,000 patients annually, and the critical care fellowship trains physicians to simultaneously resuscitate, evaluate, and treat many patients and, thereby, prepares one to adapt to virtually any situation. In the resuscitation unit, emergency physicians and surgeons work side by side on one team. The emergency medicine fellow makes rounds on patients every day until hospital discharge. Gaining an understanding of the delayed ramifications of initial resuscitation decisions is an important teaching concept of the fellowship. A significant amount of time in the fellow-
MAY 2002
39:5
ANNALS OF EMERGENCY MEDICINE
ship is spent at the Shock Trauma Center and at the University of Maryland Medical Center. Fellows accumulate a significant amount of experience in procedural techniques such as bronchoscopy, placement of monitoring devices, and dialysis techniques. Some of these procedures may not be applicable to care in the ED at the present time, but they may become an integral part of patient care as ED medical practice evolves. For instance, a patient who presents with acute renal failure and life-threatening hyperkalemia requires immediate hemodialysis. Emergency physicians who are trained to provide continuous renal replacement therapy are obviously better able to care for these desperately ill patients. The average emergency physician is quite adept at intubating a patient with respiratory failure and initiating mechanical ventilation. However, the knowledge required to wean that patient off the ventilator is not in the standard armamentarium of the emergency physician. Weaning the patient to extubation may be especially valuable when no critical care beds are available and the patient is expected to reside in the ED for more than 24 hours. Successful extubation decreases the level of care necessary to monitor the patient and facilitates movement of the patient to a hospital ward bed. The critical care fellowship provides physicians with the credentials to qualify for leadership positions and the expertise to help shape policy and define research questions. Leaders in critical care—whether from medicine, surgery, and anesthesia—are all fellowship trained. If emergency physicians are to participate meaningfully in discussions about the care for critically ill or injured patients, they must be willing to take the time to accrue the same skills and experience.
Critical care is an integral part of emergency medicine, and formal critical care training is a natural extension of emergency medicine training. Emergency medicine needs leaders in critical care, both to add a new dimension to the care provided in the nation’s EDs and to provide another venue for academic leadership. The experience of critical care training is worth the added time and financial expenditure. We hope the leaders of emergency medicine and critical care embrace these ideas as both concept and reality. REFERENCES 1. Cowley RA. The resuscitation and stabilization of major multiple trauma patients in a trauma center environment. Clin Med. 1976;83:14-22. 2. Berenson RA. Intensive Care Units (ICUs): Clinical Outcomes, Costs, and Decision-Making (Health Technology Case Study 28). Prepared for the Office of Technology Assessment, US Congress, OTA-HCS-28. Washington, DC: US Government Printing Office; 1984. 3. Coursin D, Macciloi G, Murray M. Critical care and perioperative medicine: how goes the flow? Anesthesiol Clin North Am. 2000;18:527-538. 4. Lyons RA, Wareham K, Hutchings HA, et al. Population requirement for adult critical-care beds: a prospective quantitative and qualitative study. Lancet. 2000;355:595-598. 5. Reynolds HN, Haupt MT, Thill-Baharozian MC, et al. Impact of critical care physician staffing on patients with septic shock in a university hospital medical intensive care unit. JAMA. 1988;206:3446-3450. 6. Hanson CW, Deutschman CS, Anderson HL, et al. Effects of an organized critical care service on outcomes and resource utilization: a cohort study. Crit Care Med. 1999;27:270-274. 7. Pingleton SK. Committee on Manpower of Pulmonary and Critical Care Societies: a report to membership. Chest. 2001;120:327-328. 8. Angus DC, Kelley MA, Schmitz RJ, et al. Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease: can we meet the requirements of an aging population? JAMA. 2000;284:2762-2770. 9. Bozeman WP, Gaasch WR, Barish RA, et al. Trauma resuscitation/critical care fellowship for emergency physicians: a necessary step for the future of academic emergency medicine. Acad Emerg Med. 1999;6:331-333.
Call for Resident Papers Annals of Emergency Medicine The “Residents’ Perspective” is soliciting ideas from emergency medicine residents for future articles. If you have an idea, an issue, or an experience about which you would like to write, submit an abstract (limit 250 words, double-spaced) outlining your idea. Give the names of your coauthors, if any. If your idea is chosen, you will be asked to write an article for the “Residents’ Perspective” section. Submit your abstract to Amy Kaji, MD, Resident Fellow, Annals of Emergency Medicine, 1125 Executive Circle, Irving, TX 75038-2522. Fax: 972-580-0051. E-mail: [email protected].
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critical care physicians, many EDs do not have the benefit of a critical care consult. A collaborative study conducted by representatives of the Society of Critical Care Medicine, the American Thoracic Society, and the American College of Chest Physicians (the Committee on Manpower in Pulmonary and Critical Care Services [COMPACCS]) demonstrated a significant void of fellowshiptrained critical care providers. The investigators found that up to 64% of critically ill patients do not receive input from a trained intensivist at any point during their ICU stay.7 Because of the increase in the elderly population, this deficit is predicted to increase, with only 22% of the demand being met by 2020.8 Emergency medicine as a discipline has recognized the need for additional training in areas such as pediatric emergency medicine, toxicology, disaster medicine, international medicine, and emergency medical systems. Critical care should be no different. More fellowship opportunities are necessary to train a sufficient number of emergency physicians, and the issue of board certification needs clarification. The fellowship at the University of Maryland Shock Trauma Center is the only program of which we are aware that is designed and dedicated to the trauma and critical care training of emergency physicians. Its curriculum has been described elsewhere.9 Although we currently train only 1 emergency medicine fellow each year, we have decided to expand that next year to 3 and perhaps more. This year, the Shock Trauma program has 12 fellows: 8 surgeons, 2 anesthesiologists, 1 internist, and 1 emergency physician. Each contributes knowledge and expertise from his or her specialty, and all participants have benefitted from the collaborative multidisciplinary dynamic. The Shock Trauma Center admits approximately 7,000 patients annually, and the critical care fellowship trains physicians to simultaneously resuscitate, evaluate, and treat many patients and, thereby, prepares one to adapt to virtually any situation. In the resuscitation unit, emergency physicians and surgeons work side by side on one team. The emergency medicine fellow makes rounds on patients every day until hospital discharge. Gaining an understanding of the delayed ramifications of initial resuscitation decisions is an important teaching concept of the fellowship. A significant amount of time in the fellow-
MAY 2002
39:5
ANNALS OF EMERGENCY MEDICINE
ship is spent at the Shock Trauma Center and at the University of Maryland Medical Center. Fellows accumulate a significant amount of experience in procedural techniques such as bronchoscopy, placement of monitoring devices, and dialysis techniques. Some of these procedures may not be applicable to care in the ED at the present time, but they may become an integral part of patient care as ED medical practice evolves. For instance, a patient who presents with acute renal failure and life-threatening hyperkalemia requires immediate hemodialysis. Emergency physicians who are trained to provide continuous renal replacement therapy are obviously better able to care for these desperately ill patients. The average emergency physician is quite adept at intubating a patient with respiratory failure and initiating mechanical ventilation. However, the knowledge required to wean that patient off the ventilator is not in the standard armamentarium of the emergency physician. Weaning the patient to extubation may be especially valuable when no critical care beds are available and the patient is expected to reside in the ED for more than 24 hours. Successful extubation decreases the level of care necessary to monitor the patient and facilitates movement of the patient to a hospital ward bed. The critical care fellowship provides physicians with the credentials to qualify for leadership positions and the expertise to help shape policy and define research questions. Leaders in critical care—whether from medicine, surgery, and anesthesia—are all fellowship trained. If emergency physicians are to participate meaningfully in discussions about the care for critically ill or injured patients, they must be willing to take the time to accrue the same skills and experience.
Critical care is an integral part of emergency medicine, and formal critical care training is a natural extension of emergency medicine training. Emergency medicine needs leaders in critical care, both to add a new dimension to the care provided in the nation’s EDs and to provide another venue for academic leadership. The experience of critical care training is worth the added time and financial expenditure. We hope the leaders of emergency medicine and critical care embrace these ideas as both concept and reality. REFERENCES 1. Cowley RA. The resuscitation and stabilization of major multiple trauma patients in a trauma center environment. Clin Med. 1976;83:14-22. 2. Berenson RA. Intensive Care Units (ICUs): Clinical Outcomes, Costs, and Decision-Making (Health Technology Case Study 28). Prepared for the Office of Technology Assessment, US Congress, OTA-HCS-28. Washington, DC: US Government Printing Office; 1984. 3. Coursin D, Macciloi G, Murray M. Critical care and perioperative medicine: how goes the flow? Anesthesiol Clin North Am. 2000;18:527-538. 4. Lyons RA, Wareham K, Hutchings HA, et al. Population requirement for adult critical-care beds: a prospective quantitative and qualitative study. Lancet. 2000;355:595-598. 5. Reynolds HN, Haupt MT, Thill-Baharozian MC, et al. Impact of critical care physician staffing on patients with septic shock in a university hospital medical intensive care unit. JAMA. 1988;206:3446-3450. 6. Hanson CW, Deutschman CS, Anderson HL, et al. Effects of an organized critical care service on outcomes and resource utilization: a cohort study. Crit Care Med. 1999;27:270-274. 7. Pingleton SK. Committee on Manpower of Pulmonary and Critical Care Societies: a report to membership. Chest. 2001;120:327-328. 8. Angus DC, Kelley MA, Schmitz RJ, et al. Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease: can we meet the requirements of an aging population? JAMA. 2000;284:2762-2770. 9. Bozeman WP, Gaasch WR, Barish RA, et al. Trauma resuscitation/critical care fellowship for emergency physicians: a necessary step for the future of academic emergency medicine. Acad Emerg Med. 1999;6:331-333.
Call for Resident Papers Annals of Emergency Medicine The “Residents’ Perspective” is soliciting ideas from emergency medicine residents for future articles. If you have an idea, an issue, or an experience about which you would like to write, submit an abstract (limit 250 words, double-spaced) outlining your idea. Give the names of your coauthors, if any. If your idea is chosen, you will be asked to write an article for the “Residents’ Perspective” section. Submit your abstract to Amy Kaji, MD, Resident Fellow, Annals of Emergency Medicine, 1125 Executive Circle, Irving, TX 75038-2522. Fax: 972-580-0051. E-mail: [email protected].
5 6 3