ED and ICU residency

[DaniPA]

Hi everyone, 

I hope I can get some insight as I am struggling with figuring out what is best

I am graduating from PA school in December. In the first 5 months of clinical year I really enjoyed the ED and was set on moving forward with the specialty and doing a post grad residency/fellowship. My peds rotation was in the ED and I am also set to do 10 weeks in the ED right before graduating on top of the regular core ED rotation. 

I've also recently done a trauma surgery rotation where I would round on patients in the ICU and I am currently doing an ICU rotation. I never expected to fall in love with critical care medicine. If I were to do ICU, I would definitely do a critical care residency post grad.

In an ideal world I would love to work in both specialties, but is that even common? I would love the work in the ED full time but also work per diem in an ICU, but I worry that is not common since there is no continuity of care and training a PA in the ICU when they only come a few shifts a month seems impossible. Is it more common to work in the MICU full time and then pick up shifts in the ED? If that is the case I believe doing a critical residency is best... 

In my gut, I feel like I want to do an ED residency and solidify my skills as a new grad  and hopefully build the work experience to have an easier transition to work in the MICU either full time or per diem. I am just confused on what will be the best residency and path to take... any guidance or opinions would be appreciated! 

[LT_Oneal_PAC]

It’s hard to say objectively unless you have done both. It also depends on how autonomous you will be in each. 
 

personally, I think an EM residency would be better if you want to do both. In a good EM residency, you will get ample exposure to critically ill patients and will rotate through MICU and SNICU. Critical care doesn’t rotate through the ED and doesn’t get adept at fracture reduction, arthrocentesis, elective cardioversions, peritonsollar abscess drainage, lateral canthotomy, regional blocks, and differentiating minor disease like a sore throat from a peritonsillar abscess, otitis from mastoiditis, epidydimitis from testicular torsion. 
 

not saying EM is as good at critical care, obviously not, but we are better at critical care than they are at EM. Now it really depends on the residency you’re looking at. A good CCM would be better than a crappy EM. A good 18 month EM residency is worth it’s weight in gold though.

 

after residency I can say I would have felt reasonably comfortable in the ICU, at least stabilize until a pulm CCM physician came In the AM to tell me all the weird shit he could come up with in a differential.
 

You are correct that it is easier to be full time ICU and part time ED, mainly because ED part time and PRN positions are more plentiful 

[DaniPA]

Thank you so much for your comprehensive reply! I appreciate your opinion and advice. 

[MediMike]

On 5/20/2022 at 8:29 PM, LT_Oneal_PAC said:

personally, I think an EM residency would be better if you want to do both. In a good EM residency, you will get ample exposure to critically ill patients and will rotate through MICU and SNICU. Critical care doesn’t rotate through the ED and doesn’t get adept at fracture reduction, arthrocentesis, elective cardioversions, peritonsollar abscess drainage, lateral canthotomy, regional blocks, and differentiating minor disease like a sore throat from a peritonsillar abscess, otitis from mastoiditis, epidydimitis from testicular torsion. 
 

not saying EM is as good at critical care, obviously not, but we are better at critical care than they are at EM. Now it really depends on the residency you’re looking at. A good CCM would be better than a crappy EM. A good 18 month EM residency is worth it’s weight in gold though.

 

after residency I can say I would have felt reasonably comfortable in the ICU, at least stabilize until a pulm CCM physician came In the AM to tell me all the weird shit he could come up with in a differential.

Bold claims my man.

The vast majority of ED PAs do not do elective or emergent cardioversions, intubations, chest tubes, bronchs, arterial lines, and while you'll get exposure to these in residency (if it's a good one) the likelihood of you practicing to this scope outside of a rural critical access arena is pretty slim. That is regular fodder in the ICU.  We can compare numbers someday

Critical care is a hell of a lot more than just stabilizing a patient until a physician gets there @LT_Oneal_PAC, you know that.  By saying you would have felt reasonably comfortable in the ICU do you mean you could keep them alive until someone showed up?  Because that sure isn't the same thing as being competent. I'm pretty sure I could pull enough back from my ED rotations in school, UpToDate and YouTube to manage a good chunk of ED patients, does that make me feel ready to make the statement that I'd be reasonably comfortable? Not even close. 

ED and ICU are completely different animals, and while there is some overlap (i.e. acute resuscitation) the differences are pretty glaring.  We've had people join our group from the ED world and it's been a major struggle, I've seen folks go the other way as well and the same struggle exists.  The mentality, acuity, pace and flow are all completely different.

My opinion is if you want to do ED, do an ED residency.  You want ICU do ICU.  Can you switch down the road? Sure, but I'd expect to be working full time for a significant period of time in whatever field you are transitioning to so as to gain competence.  Per diem likely won't cut it as you mentioned.

 

[LT_Oneal_PAC]

@MediMike

I’ll throw down numbers, but you forget I was in anesthesia school before being a PA, where I spent a whole rotation doing open heart surgery  still counts!

We are in agreement on al your points. To boil down my long dialogue, it really does matter how autonomous you will be. I can function in an ICU with back up and I’m certain you can function in and ED, even seeing ESI level 1 patients, if you had someone to bounce the “inbetweeners” off of.

EM and CCM are definitely different mindsets. Perhaps am I generalizing too much of my own experience to others. It’s likely that I feel much more comfortable managing in CCM given my ICU nursing and anesthesia background. I was the only PA resident to ever ask for more ICU time on my elective (probably because the schedule was brutal). Further, I may be committing a cognitive error assuming I had the IM knowledge I have now, which actually came after doing tons of Hospitalist work for the past 3 years. So I may overestimate the ability of an EM residency grad in the ICU.

I certainly agree that for the majority of people, unless you’re going to do both a EM residency and a CCM fellowship, just stick to one. Honestly working both enough to stay competent is too many hours and going to burn you out anyways.
 

I hope you didn’t take offense to the my opinion. Truly I bow in humbleness of your extensive knowledge and I really mean it when I say I’m just a dumb EM guy. This goes double in comparison to people like yourself. My only point is in EM residency you get exposure to CCM (which agreed is a lot more complicated than resuscitation and stabilization), but typically CCM residency does not give exposure to EM. So if one HAD to choose only one to practice in both, I would choose EM. Having said that, big brains come from CCM residency.

 

 

 

 

[MediMike]

Hahaha fine. You probably win the tube war. For now

As I was typing out my reply I was remembering your background as well as the hospitalist role you intermittently play now.

Now that I've thoroughly peed all over the ICU tree, puffed my hair etc etc I can agree that if one HAD to pick a residency that would help with both then yeah, a high speed quality AF EM residency would probably be best for the exposure that you'd obtain. 

At the risk of throwing out shoulders patting each other on the back I've got to say you're no dumb ED guy, your skills and knowledge are some of the most well rounded I've seen.

I'd write more sappy $&#! but just biked home from shift and heading to bed. (See? I'm pretty much an EM guy, I bike 'n stuff)

[DaniPA]

3 hours ago, MediMike said:

Bold claims my man.

The vast majority of ED PAs do not do elective or emergent cardioversions, intubations, chest tubes, bronchs, arterial lines, and while you'll get exposure to these in residency (if it's a good one) the likelihood of you practicing to this scope outside of a rural critical access arena is pretty slim. That is regular fodder in the ICU.  We can compare numbers someday

Critical care is a hell of a lot more than just stabilizing a patient until a physician gets there @LT_Oneal_PAC, you know that.  By saying you would have felt reasonably comfortable in the ICU do you mean you could keep them alive until someone showed up?  Because that sure isn't the same thing as being competent. I'm pretty sure I could pull enough back from my ED rotations in school, UpToDate and YouTube to manage a good chunk of ED patients, does that make me feel ready to make the statement that I'd be reasonably comfortable? Not even close. 

ED and ICU are completely different animals, and while there is some overlap (i.e. acute resuscitation) the differences are pretty glaring.  We've had people join our group from the ED world and it's been a major struggle, I've seen folks go the other way as well and the same struggle exists.  The mentality, acuity, pace and flow are all completely different.

My opinion is if you want to do ED, do an ED residency.  You want ICU do ICU.  Can you switch down the road? Sure, but I'd expect to be working full time for a significant period of time in whatever field you are transitioning to so as to gain competence.  Per diem likely won't cut it as you mentioned.

 

Hi @MediMike thanks for your reply! I understand your point and agree that critical care and ED are different animals. I am noticing that in my rotations now. Transitioning from ED to ICU and vice versa will pose challenges for sure. I do agree with @LT_Oneal_PACthat if I were to do an ED residency, I would have the opportunity to rotate in the ICU. Some programs that I am looking at can allow me to do up to 12 weeks if I want to. Although that is no where near the ICU experience CCM residents obtain, I have yet to see a CCM residency have an ED rotation available. So if I were to eventually switch to CCM, I will at least have someeee exposure, even if it is not as much. 

My mentally with starting off in the ED will be that I will come in contact with the run of the mill cough, cold, joint pain, STI r/o, and pediatric diagnoses sprinkled in with actual emergent and acute cases, which will allow me to establish a good foundation in primary and more acute care. Then I would want to eventually transition to acute care after several years, while still moonlighting in the ED.

My desire to do a residency stems from the fact that I just do not feel mature enough as a new provider to be completely on my own with no additional structured training. I guess my question for you, @MediMike is that are the ED PAs who come into CCM completely lost and struggle tremendously? Because that is what scares me. If so, I would maybe even do a CCM residency later down the road... I would hope that working full time in a good ED that respects PAs and allows proper autonomy after doing an ED residency would make the transition a bitttt more doable. Please let me know what you think! 

[LT_Oneal_PAC]

29 minutes ago, DaniPA said:

Hi @MediMike thanks for your reply! I understand your point and agree that critical care and ED are different animals. I am noticing that in my rotations now. Transitioning from ED to ICU and vice versa will pose challenges for sure. I do agree with @LT_Oneal_PACthat if I were to do an ED residency, I would have the opportunity to rotate in the ICU. Some programs that I am looking at can allow me to do up to 12 weeks if I want to. Although that is no where near the ICU experience CCM residents obtain, I have yet to see a CCM residency have an ED rotation available. So if I were to eventually switch to CCM, I will at least have someeee exposure, even if it is not as much. 

My mentally with starting off in the ED will be that I will come in contact with the run of the mill cough, cold, joint pain, STI r/o, and pediatric diagnoses sprinkled in with actual emergent and acute cases, which will allow me to establish a good foundation in primary and more acute care. Then I would want to eventually transition to acute care after several years, while still moonlighting in the ED.

My desire to do a residency stems from the fact that I just do not feel mature enough as a new provider to be completely on my own with no additional structured training. I guess my question for you, @MediMike is that are the ED PAs who come into CCM completely lost and struggle tremendously? Because that is what scares me. If so, I would maybe even do a CCM residency later down the road... I would hope that working full time in a good ED that respects PAs and allows proper autonomy after doing an ED residency would make the transition a bitttt more doable. Please let me know what you think! 

If you’re going to work in the ED For a few years without any inpatient work, you’re going to have a learning curve regardless of residency or not. It is definitely a perishable skill. 

[LT_Oneal_PAC]

3 hours ago, MediMike said:

Hahaha fine. You probably win the tube war. For now

As I was typing out my reply I was remembering your background as well as the hospitalist role you intermittently play now.

Now that I've thoroughly peed all over the ICU tree, puffed my hair etc etc I can agree that if one HAD to pick a residency that would help with both then yeah, a high speed quality AF EM residency would probably be best for the exposure that you'd obtain. 

At the risk of throwing out shoulders patting each other on the back I've got to say you're no dumb ED guy, your skills and knowledge are some of the most well rounded I've seen.

I'd write more sappy $&#! but just biked home from shift and heading to bed. (See? I'm pretty much an EM guy, I bike 'n stuff)

footage from the multiverse where we work at the same hospital

[ohiovolffemtp]

One thing to remember:

EM no matter where, has a big element of very minor cases that come through the door that still have to be seen.  Even of the sicker patients, for many of them the care, especially, is fairly algorithmic.  The key skill that you develop over time is the "this just doesn't seem right" that helps you not miss the less obvious but still sick or more subtly may be about to get really sick.

The stories we tell are about the really cool stuff we saw, did, etc.  It doesn't reflect the multitude of less interesting other stuff we did in between to earn our paychecks.  Some (maybe the LT and EMED) are blessed with a higher percentage of "good" cases, but many of us treat lots of straightforward stuff along the way.

[LT_Oneal_PAC]

3 hours ago, ohiovolffemtp said:

One thing to remember:

EM no matter where, has a big element of very minor cases that come through the door that still have to be seen.  Even of the sicker patients, for many of them the care, especially, is fairly algorithmic.  The key skill that you develop over time is the "this just doesn't seem right" that helps you not miss the less obvious but still sick or more subtly may be about to get really sick.

The stories we tell are about the really cool stuff we saw, did, etc.  It doesn't reflect the multitude of less interesting other stuff we did in between to earn our paychecks.  Some (maybe the LT and EMED) are blessed with a higher percentage of "good" cases, but many of us treat lots of straightforward stuff along the way.

 

definitely our pay comes from finding the needle in a hay stack, the sneaks, the wolf in sheep’s clothing. That’s what make our job hard. Super sick people are honestly easier to me. I know what to do when you’re dying. But that kid that probably has a virus sure is acting really fatigued. That kid with a head injury sounded like it was super minor, but he’s is really hard to wake up, but it’s 2 am. Is it normal or are they just on the cliff edge?

I definitely think the % of sick patients I see is higher than at the big academic center, but definitely the majority of my patients are quite well, but very old population, so therefor always trying to trick me. The number of times some geriatric came to see me for “mild belly pain” and unimpressive exam ended up with some wild is staggering.

 

[MediMike]

On 5/22/2022 at 8:56 AM, DaniPA said:

My mentally with starting off in the ED will be that I will come in contact with the run of the mill cough, cold, joint pain, STI r/o, and pediatric diagnoses sprinkled in with actual emergent and acute cases, which will allow me to establish a good foundation in primary and more acute care. Then I would want to eventually transition to acute care after several years, while still moonlighting in the ED.

No simple answer for you unfortunately, so much depends on where you end up post-residency.  If you end up in a high acuity EM practice, ideally high volume high acuity then maybe you'd be able to leave it and just moonlight down the road while working FT at a critical care gig? Knowledge not used is lost, and it doesn't came back as easy as skills do.  Thanks to a hard working PICC team I probably haven't tossed in more than a handful of CVCs in the last couple months, but I could drop one in a heartbeat if need be.  On the other hand I still need to grab the guidelines every time I'm working up an ILD flare or GBS or TTP. I'm assuming it's the same in the ED, if you've got a ton of volume under your belt by the time you bounce to do inpatient medicine maybe you could moonlight on the reg and be fine?

 

On 5/22/2022 at 8:56 AM, DaniPA said:

My desire to do a residency stems from the fact that I just do not feel mature enough as a new provider to be completely on my own with no additional structured training. I guess my question for you, @MediMike is that are the ED PAs who come into CCM completely lost and struggle tremendously? Because that is what scares me. If so, I would maybe even do a CCM residency later down the road... I would hope that working full time in a good ED that respects PAs and allows proper autonomy after doing an ED residency would make the transition a bitttt more doable. Please let me know what you think! 

I mean they are normally better off than a new grad entering our fellowship, but it takes a while to adjust to the major differences in workup, management, dispo (i.e. the lack thereof) diagnostics, interpretation of tests etc.  It's easy to say you may go back and do CCM (and maybe you would) but it'll be tough to take the 50%+ pay cut once you're established. I've got a very good friend, prior PM/FF for around 12+ years, faculty with the paramedic program who is extremely high functioning and motivated, left the ED after about 5 years and is currently onboarding with us, has done around 4 months of FT days and is starting her night orientation.  She wants another month or two before flying solo.  Maybe she's overly cautious but generally is safely confident, so that may be what you're looking at if you want to transition someday Good luck!