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Emergentology: Critical Care Advice from an EP/Intensivist

Walker, Graham MD

doi: 10.1097/01.EEM.0000433403.31538.1c

Dr. Walker is an emergency physician at Kaiser San Francisco. He is the developer and co-creator of MDCalc, a medical calculator for clinical scores, equations, and risk stratifications, and The NNT, a number-needed-to-treat tool to communicate benefit and harm.



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Jarone Lee, MD, is an emergency physician status-post surgical ICU fellowship at Massachusetts General who now splits his time between managing Harvard's SICUs and staffing a community ED. Continuing my critical care series, I asked him about his career path and thoughts on emergency medicine and critical care.

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Why did you decide to do a critical care fellowship?

I found during residency that I had this great interest in following patients through their hospital stay, especially the ones that went to the ICUs. I loved emergency medicine, but also realized that I wanted to be able to take care of patients for a longer period of time but not long-term. More than four to six hours but less than months. Similarly, I really enjoyed thinking about complex cases, especially the medical mysteries.

The ICU in many ways is very similar to the ED, where we are able to get quick diagnostics and treat rapidly based on a quick turn-around of information. I also enjoyed speaking with families about their loved ones. We do a good amount of that in the ED, but because of all our other competing obligations, it's tough to have an unhurried family meeting.

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What was the most difficult thing about critical care fellowship coming from an emergency training background?

One major adjustment I had to make was getting used to my schedule. Instead of having a few shifts a week, I now work approximately two weeks straight in the ICU — every day, including weekends. The clinical work is completely different: I am able to spend this time in the hospital not just for direct patient care but also to teach and further my research and administrative projects.

The other major difficulty, which I expected, was that emergency medicine still has a stigma in the house of medicine. We are a very new specialty, and when I did my critical care fellowship, there was no path for certification. When I started fellowship, there were only three other EM folks who went through our fellowship. Overall, this was not much of an issue for me, but that's probably because my predecessors had already fought most of those battles for me.

You did a surgical critical care fellowship and you've recommended the same to other residents in training who are thinking about critical care. Why SICU over MICU?

Generally, I think that it doesn't matter if you go through a surgical or medical critical care fellowship. The general principles are the same; we all go to the same conferences, and listen to the same folks lecture. Also, most ICUs are mixed medical-surgical units staffed by an intensivist who could be medicine-, anesthesia-, surgery-, or emergency-trained.

For EM residents, I always ask if they want to do ICU after fellowship, and if the answer is maybe, then they should go to a fellowship that provides a path to certification. We are now able to get certified through medicine and surgery, and soon we should be able to certify through anesthesia as well. The reason that I recommend a SICU fellowship over a MICU fellowship is that I believe that EM training makes us more medicine-like physicians than surgical-physicians.

We are great at procedures, resuscitation, and such, but we know very little about post-operative care or preoperative care and stabilization. For example, we know how to stabilize a liver failure patient, but we do not optimize them for their liver transplant. In the SICU, we like to say that we have medical ICU patients with surgical issues. So, my recommendation is for the EM resident interested in critical care to greatly consider a surgical-based critical care fellowship.

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What could EPs dealing with critically ill patients going to the ICU do better?

Maybe vent management. I think the general volume control, tidal volume 500 cc, PEEP5, respiratory rate 12-14 works for most patients. However, once you put a patient on the ventilator, the ventilator can only harm the patient. So just taking a few minutes to be sure that the tidal volumes you are giving are safe and making sure you minimize the plateau pressures to <30 can help a ton.

The fine tweaking of everything else can be left to the ICU team. Additionally, to reduce the chance of ventilator-associated pneumonias, all these patients should have the head of their bed up by at least 30 degrees. So just remember 8 cc/kg maximum, based on ideal body weight (not actual), plateaus <30, and HOB >30. Simple things like that can go a long way. For the longer-term ICU boarders, remember that most of them will require GI prophylaxis, DVT prophylaxis, and chlorhexidine mouth wash.

BONUS! Read the rest of Dr. Walker's interview with Dr. Lee in the August issue of the EMN iPad app on Aug. 7 and on our website at on Aug. 13.

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