Upstairs vs Downstairs: an EPIC Conundrum

April 19, 2013 by  
Filed under All Updates, ICU, Resus

A new breed, and new terminology

USAflagb&WResusScott Weingart MD and colleagues have published a discussion paper [1] outlining the role of emergency physicians who have completed additional critical care training – ED intensivists – and the potential benefits these individuals might bring to patients, emergency departments, and their emergency physician colleagues.

The paper also introduces a glossary of new terms which might help clarify future discussion of this practice area:

Emergency medicine critical care a subspecialty of emergency medicine dealing with the care of the critically ill both in the ED and in the rest of the hospital
EP intensivist a physician who has completed a residency in emergency medicine and a fellowship in critical care
ED critical care emergency medicine critical care practiced specifically in the ED
ED intensivist (EDI) EPIs who practice ED critical care as a portion of their clinical time
Resuscitationists EPs who have additional knowledge, training, and interest in the care of the critically ill patient
EDICU a unit within an ED with the same or similar staffing, monitoring, and capability for therapies as an ICU
RED-ICU a hybrid resuscitation area and EDICU allowing a department to adopt the ED intensive care model with minimal cost and no changes to the physical plant

Potential benefits of ED-intensivists – and associated adequately staffed areas within ED that facilitate ongoing critical care delivery – include:

Full intensive care provided to patients unable to be moved to ICU (usually due to bed unavailability)
Development of protocols and care pathways that allow other EPs to deliver enhanced critical care
Gaining of advanced skills for ED nurses
Removal of need for ICU bed for conditions that can be improved in a few hours (eg. some overdoses, DKA, acute pulmonary oedema)
Cost saving due to decreased ICU stay (if the above ‘short term critical care’ patients are admitted to ICU, ward bed unavailability can make it difficult to discharge them from ICU)
Additional airway skills in ED (and training around that)
Improved invasive and non-invasive ventilatory management (and training) in ED
Gaining of ED experience in ventilator weaning and extubation
Gaining of ED experience in haemodynamic monitoring, vasoactive support, and even mechanical circulatory support (balloon pumps and ECMO)
Improved sepsis care
Improved post-cardiac arrest care
Improved trauma management
Greater exposure to invasive procedures
Improved end of life care
Better critical care exposure for trainees

Improved ED-ICU communication and shared protocols

Scott’s whole mission is about bringing ‘upstairs care downstairs’, and educating others to do that, at which he is a true master. No doubt he will singlehandedly have inspired a large cohort of emergency physicians to train in critical care. Examples of ED intensivists and their roles are listed here on the EMCrit site.

Emergency physician intensivists in the Old Country

epic__logoUKflagAs an ‘ED-intensivist’ myself, I do believe many of those advantages can be realised. In the UK when I originally trained in both EM and ICM there was a small number of similarly trained individuals and we collectively called ourselves ‘EPIC’ – ‘Emergency Physicians in Intensive Care’.

Our shared energy and enthusiasm led to a dedicated conference in 2011 and it’s possible that our proselytizing combined with publications like Terry Brown’s ‘Emergency physicians in critical care: a consultant’s experience‘[2] may have made some small contribution to the subsequent explosion in interest in dual accreditation in EM & ICM in the UK.

Disappearing upstairs

AusflagWhen I moved to Australia in 2008 I was excited to hear that emergency docs now made up the largest proportion of dual trained new intensivists. When I asked a leading member of this group whether he saw any role for an ‘EPIC’ community in Australia I was surprised and disappointed with the response:

‘Nice idea but I don’t see the point. I can’t think of anyone who dual trained who’s still working in emergency medicine’

So it seems those who were in the best position to bring upstairs care downstairs had all disappeared upstairs. Many will admit it’s not just because they find critical care more interesting than emergency medicine; the combination of a significantly higher income (through private practice) with better working conditions plays a significant role.

There are other opportunities in Australia for emergency physicians to practice critical care. Prehospital & retrieval medicine services undertake interhospital critical care transport of patients from small and often remote facilities where all of the first few hours of intensive care must be delivered by retrieval teams in often challenging environments with limited personnel and equipment. In some cases it’s these retrieval physicians who are able to fulfil the role of ED-intensivist in their own EDs.

Integrated critical care models and SuperDoctors

ChrisTIconAnother Australian example is the ‘integrated critical care’ model pioneered in some regional centres in rural New South Wales where emergency physicians with critical care training aim to provide seamless care to patients in the prehospital, ED, ICU and ward environments. I was lucky enough to do some locum shifts in one of these centres – Tamworth – where the service is delivered by some of the most highly skilled and dedicated physicians I’ve ever met. Check out their registrar job ad for a flavour of their work. This model was described in a 2003 publication[3] by my Sydney HEMS colleague Craig Hore which lists its features as follows:

Features of integrated critical care
Multiskilled critical-care specialists trained and experienced in the various aspects of critical care in rural hospitals.

Multidisciplinary critical-care teams that provide:

A more seamless interface between the various phases of critical care and between its respective disciplines;

A rapid response to, and a continuum of care for, critically ill and injured patients;

Clinical leadership in evaluating and managing critically ill and injured patients, both in the hospital (including the emergency department, critical-care unit and hospital wards) and in the community (including retrievals, and support for ambulance crews, peripheral hospitals and general practitioners); and

Training of medical students, medical staff, nursing staff and allied health professionals to recognise and provide a systematic approach to critical illness and injury.

Team members who are empowered to work beyond perceived traditional boundaries, but within the realms of their clinical expertise and credentials, to enable the best use of available resources.

So it appears the benefits to patients, hospitals, and team skills of ED-intensivists have been espoused for some years in the Anglo-Australian setting, and different practice models evolve to best serve local need.

Resuscitating the resuscitationists

UKflagIs it time to revive EPIC? I chased up my UK buddies who co-founded it, and here are extracts from their replies (note ‘CCT’ refers to certificate of completion of training – the UK equivalent of specialist accreditation or board certification):

“Interesting to hear that most Aussies leave EM, my experience of [our regional] trainees is the opposite; of 4 EM / ITU dual CCT over last 5 years, I’m the only one still doing a little bit of CCM, the rest have all ended up in full time EM posts, despite all doing periods of locum consultant work in CCM. (Although, after last 4 winter months of UK EM, I’m beginning to appreciate that I backed the wrong horse! (In the wrong country!!))”
“Having recently dropped ICU/ED 40/60 mix for full time ED i think those gravitating to ICU have a point – an error on my part. The ED represents much more intense work with fewer staff and a work load that far far exceeds resources. As such time to deliver care falls and skills with it. I have just spend 5 weeks [overseas]. I spent time with several directors who pointed out they no longer look to the UK for high quality ED docs as they manage depts as opposed to caring for patients, lack critical care skills and lack the experience to review and manage patients as they improve or deteriorate – a sad state of affairs indeed.”
“I would like to see EPIC back in force and do see an increasing role. around 1 in 4 of our trainees here are looking to joint qualify and we have 3 in their last 2 years. two are currently looking for posts but struggling to find any with a 50-50 mix and are been told to choose one or the other both by prospective ED and ICU employers.”
“I am concerned that dual trained folk here will, like in Australia gravitate to ICU. Whether that is a reflection of where EM is currently in the UK or a personal reflection I’m not sure. Where as I still have days in the ED where I come home and think ‘best job in the world’ these are overshadowed by the stresses of trying to deliver quality care in a failing system. My impression is that urgent care in the UK may well implode soon as ever decreasing workforce meets an over increasing work load. Inevitable closures of units will speed up this process. I currently have a 50/50 ICM/ED job split but that might change to become more ICU.”
“The ED/ICU community in the UK is growing and it wlll be interesting to see the effect of the ICM CCT has on this. There is sadly still a paucity of ED/ICU jobs in the UK and we probably missed a trick with the trauma centres.”
“It would be great to re-create EPIC to make it a real player for the future.”

So it appears emergency physician intensivists are growing in number, but employment prospects in both specialties are not guaranteed. If we are to recruit them to work as ED intensivists (ie. providing critical care in the ED) we have a challenge in making such posts attractive and sustainable. Emergency medicine in the UK is suffering at the moment, and we’ll have to work hard to stop those who are dual trained from disappearing upstairs.

Your comments on this are invited. Should there be more critical care- trained EPs? Shouldn’t ALL EPs have the right critical care skills to manage the first few hours of critical care? Can you call yourself an emergency physician and not be a ‘resuscitationist’? Where do retrievalists fit into this spectrum? How do we help motivate those who are dual trained to stay in the ED for some of their time? Is there a need for a body like EPIC to guide those who are considering dual training, and to provide recommendations to employers and physicians on models of care and job planning? I would love to get more of an international perspective on this issue.

1. ED intensivists and ED intensive care units
Am J Emerg Med. 2013 Mar;31(3):617-20
Full text link available from here

2. Emergency physicians in critical care: a consultant’s experience
Emerg Med J. 2004 Mar;21(2):145-8
Full text link available from here


There is a growing interest in the interface between emergency medicine and critical care medicine. Previous articles in this journal have looked at the opportunities and advantages of training in critical care medicine for emergency medicine trainees. In the UK there are a small number of emergency physicians who also have a commitment to critical care medicine. This article describes a personal experience of such a job, looking at the advantages and disadvantages. Depending upon future developments in the role of emergency medicine in the UK, together with the proposed expansion in critical care medicine, such posts may become more common.

3. Integrated critical care: an approach to specialist cover for critical care in the rural setting
Med J Aust. 2003 Jul 21;179(2):95-7


Critical care encompasses elements of emergency medicine, anaesthesia, intensive care, acute internal medicine, postsurgical care, trauma management, and retrieval. In metropolitan teaching hospitals these elements are often distinct, with individual specialists providing discrete services. This may not be possible in rural centres, where specialist numbers are smaller and recruitment and retention more difficult. Multidisciplinary integrated critical care, using existing resources, has developed in some rural centres as a more relevant approach in this setting. The concept of developing a specialty of integrated critical-care medicine is worthy of further exploration.

Comments

23 Responses to “Upstairs vs Downstairs: an EPIC Conundrum”

  1. Scott on April 19th, 2013 09:33

    Cliff,

    Amazing post! or should I say an epic one.

    The problem you have outline above, I call “Crippen’s Law” coined by David Crippen, an EP Intensivist at U Pitt. He made the statement years ago that every well-intentioned dual-trained EP always comes out of training stating that they will split their time 50/50 ED and ICU and all of them by the 5 year mark will be spending all of their time in one area or the other.

  2. Seth Trueger on April 19th, 2013 09:51

    “Crippen’s Law” was pretty much the reason I ended up not going into EM/CCM!

  3. Minh Le Cong on April 19th, 2013 11:52

    Thanks Cliff. excellent writing and insight. Its hard to keep your hand in 2 or 3 areas at once. We see this in retrieval medicine. You do EM and retrieval, or anaesthetics and retrieval but rarely do you see folks doing three areas at once like ED, ICU and retrieval. The German model of EM/prehospital prob attests to this working well, where they have mainly anaesthetists who work prehospital but spend most of their time doing their primary specialty work.
    EM/ICU is a draining mix which is why I suspect folks end up doing one or the other. All the colleagues I have seen do this end up in ICU in Australia!

    its interesting where postgraduate specialist training is going. I was reading the RANZCOG magazine that my wife gets, this week and the editorial said that the RANZCOG college now is deliberately changing its training focus on the fact that new Fellows are not expected to be good at everything and that in fact sub specialisation is the future. In other words new Fellows will be expected to continue their training into sub specialty fields. the true General obstetrician/gynaecologist will cease to exist in Australia at least.

    And perhaps thats where EM/CCM training is headed? and EM/CCM dual trained docs will be that sub specialty of EM fellowship?
    I know some colleagues in anaesthesia are already undertaking the new CICM training to dual qualify. Which goes to the philosophy that you train for life, not just one moment in your life. You get your base specialty training then cross stream into a subspecialty.

  4. roger harris on April 19th, 2013 14:32

    Great post. A big obstacle in my joint to doing both is the completely different rostering which makes a blend difficult. intensivists do 24/7 then off while EP’s do more shift type call.
    Having said that though there are some EP/ICU people out there doing both, but mostly in the regional centres.
    There’s no doubt that the ICU training can bring a lot to ED, but the same is true in reverse. I feel strongly that ED training is the perfect background for ICU, but unfortunately we lose many of our specialist EP skills the longer we are away from ED and this is to the detriment of our ICU practice. Same is true of the Anaesthesia-ICU blend where most give up the anaesthetic practice as gasing lists don’t mix easily with the 24/7 ICU rostering (Important point here as this refutes slightly the comment about salary mentioned earlier). The Anaesthesia – ICU specialists also lose valuable anaesthesia skills so that most ICU’s know don’t do regional blocks or epidurals etc to the detriment of our patients.
    There is so much shared experience across the Crit Care spectrum that ICU can bring good things to ED and visa versa. Maybe instead of “upstairs care downstairs” we need “downstairs care upstairs” or even better Critical Care anywhere?

  5. Chris Nickson (@precordialthump) on April 19th, 2013 15:35

    Important post Cliff.

    The emergency physician-intensivist might work well in a few ways ‘down under’:

    A great mix for rural and remote hospitals is the capacity to work in ED, ICU and on acute medical wards – perhaps working alongside our GP Anesthetist colleagues who provide a complementary skill set.

    Dual specialists could subspecialise within the ED as Scott has done, focusing on the Resus Room and perhaps a short stay ICU within the ED. This would be similar to toxicology becoming a subspecialty within EM, in Perth we managed our own tox inpatients on the obs ward and in the ICU.

    Another route is to follow your lead and straddle prehospital and hospital boundaries, though retrieval medicine seems to be increasingly becoming a (sub)specialty in its own right.

    But is there a role for the EP-Intensivist working in both ICU and ED in a tertiary Australasian hospital?

    This is a model that is very rare at present, if it occurs at all. As well as fostering communication and smoothing relations between the two areas, I think both areas benefit from having a mix of people with different skill sets and experiences. However, the task of maintaining skills and staying up-to-date in two specialties is formidable (as you know!).

    I blame Peter Safar’s second and twelfth laws for the Navigation of Life:
    2. When given a choice, take both.
    12. When faced without a challenge, make one.

    Chris

  6. Minh Le Cong on April 19th, 2013 16:46

    this is in fact an engaging and complex discussion topic ;-)
    Anyone remotely interested in doing a podcast on this..maybe more than one?

    On pondering, I have to say that in remote Australia, this is a very relevant training and ongoing educational dilemma.

    The fact is critically ill and injured patients cant wait to arrive at a tertiary ED/ICU. Therefore you need the skills of ED and ICU at point of contact. And this is a salient debate point as the current paradigm of rural medicine training to address this has always been anaesthesia term/training OR ED training. Occasionally trainees do both but it often is that after years of practice, most senior docs realise YOU NEED BOTH in remote medical work. And it is my growing belief that thats not enough even..you NEED ICU skills ..anaesthesia skills are not adequate substitute!
    How else are you going to manage an acute STEMI..hours from nearest PCI lab, but for your ED training? How else are you going to manage the septic flu patient in resp failure but for your ICU training? And for that difficult airway case that needs an awake intubation how else are you going to learn that but for your Anaesthesia skills?

    And this is where FOAMEd can assist the ongoing learning of remote docs because there is NO WAY ANYONE IS going to be able to attain and maintain THREE DIFFERENT FELLOWSHIPS in one lifetime!

    Probably we see and realise this more acutely at the point of the spear, in retrieval medicine. Maybe training should be vocationally based on where you are going to practice or at least intend to practice with the bulk of your time?
    Because one thing you do want to avoid is spending all that time training a skill set , then never applying those skills and in fact become DESKILLED.

  7. Tim Leeuwenburg on April 19th, 2013 19:14

    Wot Minh said.

    Also, will chip in that the lure of private billing for ICU work vs ED is a big draw card for many in the big cities, understandably

    Minh’s quote :

    The fact is critically ill and injured patients cant wait to arrive at a tertiary ED/ICU. Therefore you need the skills of ED and ICU at point of contact. And this is a salient debate point as the current paradigm of rural medicine training to address this has always been anaesthesia term/training OR ED training. Occasionally trainees do both but it often is that after years of practice, most senior docs realise YOU NEED BOTH in remote medical work. And it is my growing belief that thats not enough even..you NEED ICU skills ..anaesthesia skills are not adequate substitute!

    How else are you going to manage an acute STEMI..hours from nearest PCI lab, but for your ED training? How else are you going to manage the septic flu patient in resp failure but for your ICU training? And for that difficult airway case that needs an awake intubation how else are you going to learn that but for your Anaesthesia skills?

    And this is where FOAMEd can assist the ongoing learning of remote docs because there is NO WAY ANYONE IS going to be able to attain and maintain THREE DIFFERENT FELLOWSHIPS in one lifetime!

  8. Henry Morriss on April 20th, 2013 04:58

    Great post Cliff. Yes all EPs should have some ICU skills but in reality unless these are very regularly practiced then often lost or blunted. Hence the need for some with feet in both camps and as someone else states the benefits of ICUs having intensivists with EM training is significant. The UK is still certainly slow to adapt and I feel all ITUs should have a range of consultants including several with EM/ICU.
    Very keen on using EPIC for this.

  9. John Hinds on April 20th, 2013 06:35

    The resuscitation Venn Diagram is has much broader circles than it once did, and the “lead Resuscitationist” role at any given disaster can now equally be an anaesthetist, intensivist or EP.
    Territorialism is the only real barrier these days to role definition in the management of the acute patient.

    This wasn’t always the case. When I started, I knew from an early stage I wanted to be a Resuscitationist. In Ireland, at that time, this meant being an anaesthetist. Those days, they used to sweep into resus, and disappear off with the cool stuff. The EP generally spoke to the radiologist, or maybe put in a chest drain.
    The best anaesthetists I knew were all dual trainined intensivists; so this is the route my career took, with a diversion into Prehopsital work after seeing London Hems in action.

    Nowadays, the route to resuscitation can follow a number of pathways; all with a common set of core skills, attitudes and aptitudes – which is as it should be.

    Personally speaking, I couldn’t commit to pure ICU. I need theatre lists to keep my skills up and, more importantly, for some easy, light relief! Anaesthetics alone is no real challenge though if you’re stuck in a rut of the same lists every week.
    Similarly, I couldn’t do just prehospital work – it’s a great aside, but Prehopsital trauma care, though it has its own challenges, I wouldnt want to be doing seeing the same patient group day in, day out.

    My job is a good mix – a week is 24 hours ICU, 4 operating lists (including one emergency and one trauma), and a day Prehopsital.
    I can’t see myself dropping any of those any more than I’d want to do one alone.

    -John

  10. Minh Le Cong on April 20th, 2013 08:55

    What this boils down to is something that is well known in elite sporting and military circles. Cross training skills.
    training skills in one area to benefit another area of performance.

    There are certain skill sets that cross all areas of resuscitation and emergency care/crit care. Airway management, ultrasound for examples.

    The term resuscitationist is something that Scott espoused at SMACC 2013 and in my mind it calls for a learning that is contiguous and continuous and not bound by traditional silos of discipline and practice.

    Dare I bring up the analogy of martial arts..once again. I know Cliff is an avid pracititioner as I and I do wonder if there is a connection amongst this discussion. I cannot help but compare the transformation that traditional martial arts underwent..around the time of Bruce Lee’s life and teachings..and since then how cross fighting styles have developed and been promoted. Clearly for anyone involved in martial arts, unarmed combat and fighting styles teaching, no single style can claim to be good in all areas and for all situations.

    We see this once again in prehospital and retrieval medicine. THose who work in the industry for more than a cursory time realise the need to have different skill sets. In a single week in retrieval medicine, you might need ED procedural skills to reduce a prehospital limb dislocation, then the next day need ICU skills to initiate complex positive pressure ventilation and haemodynamic support, then the next day, need Anaesthetic skills to provide prehospital multimodal analgesia and regional anaesthesia. Throw in preterm labour or APH and you need your acute obstetric skills that you learnt as a rural GP for example.

    I also dont think that promoting a Super Doctor model of training and learning is the most pragmatic way forward. What is needed is a change in our culture as a profession to accept that our learning is cross disciplinary and more aptly directed at where we work and who we look after rather than taking a one size fits all model of vocational training.
    and this is where FOAMEd value adds to personal learning because it is self directed and tailored to user needs

    Dan INosanto, one of Bruce Lee’s senior students, once said ” You never stop learning. You keep putting yourself into the position of always being a beginner. Keep learning new things and styles. ”

    and its possible. I know of a senior anaesthetist who at age of 50yo went back and did her FRACGP training..because she wanted to learn more.

  11. Cliff on April 20th, 2013 10:52

    I’m loving this discussion. I spent 12 years post-medical school training prior to my first consultant job, as training in one specialty was not equipping me for the emergency medicine I envisaged practicing. My friend (and kung fu brother) James French and I used to make the comparison with Jeet Kune Do (JKD).

    Read this JKD definition from Wikipedia, and consider that the JKD practitioner who does not conform to a single rigid martial art style parallels how the Resuscitationist who embraces cross-specialty training supplemented by FOAM is unbound by traditional specialty approaches:

    Jeet Kune Do is an eclectic/hybrid system and philosophy of life … with direct, non classical, and straightforward movements. … The system works on the use of different ‘tools’ for different situations. .. with techniques flowing smoothly between them. It is referred to as a “style without style” … Unlike more traditional [systems]… is not fixed or patterned, and is a philosophy with guiding thoughts… Through his studies [Bruce] Lee came to believe that styles had become too rigid… and that a good martial artist should “Be like water” and move fluidly without hesitation.

    Having said that, I’ve just read ‘Mastery’ by Robert Greene thanks to Scott’s recommendation, which has made me reflect on the consequences of trying to do many things to an average level versus aiming for true mastery of a narrower area. This struggle for the right balance is an ongoing theme throughout my adult life, and undoubtedly part of the fun of it.

  12. Joseph Minardi on April 20th, 2013 13:22

    I like the idea and the term resuscitationist. I think a well trained emergency physician should be a master of resuscitation without requiring additional training. I think we owe it to our patients, our trainees and ourselves to assure that’s the case. I personally prefer an integrated approach to emergency medicine – seeing adults, children, the medically ill and injured all in the same ward on the same shift. I think we sell ourselves short if we say we aren’t capable of this. Rather than segregating care, I advocate raising the bar on the care and training we provide.
    Great discussion and luckily great resources here to improve our care of the sickest patients.

  13. David Anderson on April 20th, 2013 13:22

    Thanks Cliff, Insightful as always.

    As a trainee who still doesn’t know what I want to do with my life, I found your post particularly interesting. I think I’m a member of a fairly sizeable group of trainees who want to be resuscitationists but don’t really know what the best way is.

    I look at intensive care and see 90 year olds with metastatic cancer on ventilators. I look at anaesthesia and see a specialty that’s become the victim of it’s own success and now can probably be done safely by a sensible science graduate (see this insightful post on kevinmd: http://www.kevinmd.com/blog/2013/04/anesthesiologists-victims-success.html), I look at emergency medicine and see sunglasses and soft collars, I look at prehospital care, but still have PTSD from HUET. I’m increasingly drawn to palliative medicine but worry that I will miss the adrenaline (not epinephrine) of critical care.

    Then, on the horizon, I see ED critical care, and I think, that’s it! The one ring to rule them all. Intensive care for people like me with short attention spans who don’t really care if Mrs. Jones in bed 28 isn’t meeting her feeding target. And then I get depressed. I’ve almost finished my training. Do I really want to go back and start another training programme? Do another primary exam?

    Then I read John’s comments and think, well that sounds like the best job in the world, with a little bit of everything, but I think the days of doing 2 (or 3) specialties well are rapidly ending.

    We’ve all seen specialties being done very badly by those who treat them like a hobby rather than a vocation. It sounds like the system in UK & Ireland allows anaesthetists and intensivists to get the balance just right, but I certainly don’t think that’s the case in ANZ.

    Is there a Crippen’s law for any specialty combined with intensive care? Is it just something that you have to do full time and and accept the risk of burnout that this brings?

    Then I listen to Scott, or Rick Dutton, and think – no! They have the best job in the world! Maybe the Shock-Trauma model of seamless care from resus to OR to ICU with the same staff and no silos is the way to go. It seems like a bit of a utopia where I work though, where everyone loves criticising everyone else (always behind their back of course.)

    We’ve all seen really poor care provided by emergency physicians and anaesthetists who think that their training has prepared them to look after critically ill patients but aren’t really interested in or up-to-date with critical care. Imagine working in a system where the same doctor goes and picks the patient up in the ambulance, stabilises them in the ED, anaesthetises them, and then looks after them in the ICU. Who is this doctor? Do they really have to be an anaesthetist or an emergency physician? I don’t think so. Maybe that will never happen though. The silos seem too deep in modern medicine.

    I don’t really know what the future holds for me and the intensive care trainees like me now. It’s a bit scary and a bit exciting too. I guess it’s one of the great things about medicine – that you can one day hopefully find a job that no-one else does and that’s just what you want to do. I wonder if there will be a place in ED-ICUs for intensivists with an interest in emergency medicine, rather than the other way around? I wonder what I’m going to do next year. It’s all so confusing. But thanks again for giving me more to think about while I should be studying :)

    David.

  14. Natalie Thurtle on April 20th, 2013 18:10

    Great post and comments. One issue in some contexts is job satisfaction for ED docs working in a very flow focused model with bottom heavy or low staffing levels. There can be frustration as the expectation is to do the very basics and then hand over to ICU, as the perception of the main role of the senior ED doc is to manage dept flow. If I was dual trained in this context, I might flip to ICU to practice what I am trained for. We need to work at changing this model where it exists, both to improve patient care and to retain dual trainees.

  15. Andy Neill on April 21st, 2013 01:06

    This is a great topic Cliff. As John said, my experience in junior days was the gas men stealing all the fun patients ;-)

    That seems to have changed somewhat, and at least in my practice in Dublin, I spend a lot of time with the critically ill patients (when there’s a broken system that allows a 12 hr wait to be seen, we just spend time with what is our core work – resus of the sickies)

    Ireland is having a huge crisis of staffing (on the background of a deeply broken health service) and we’re having to explore different models of care – GP referrals to acute medical units rather than EDs for example – as we simply cannot provide “urgent care” of minor medical conditions on top of all the high acuity stuff that we see.

    Would there be a way of running an ED that was ambulance only? Like shock trauma with no front door and you only get in if you come by ambulance. A seperate urgent care centre for walk in presentations? Certainly that would let us focus on the sicker patients with the small number of emergency docs we have.

    There are a few Irish trainees doing some extra ICU training, but it’s not there’s not a clear pathway as yet.

    I’d also echo John that having a couple of different jobs is a great idea as it keeps the interest alive. Certainly having some varied practice settings allows some down time – the quiet but simple minor injuries unit versus the chaotic but fun ED.

  16. Cliff on April 21st, 2013 01:10

    I’d also echo John that having a couple of different jobs is a great idea as it keeps the interest alive. Certainly having some varied practice settings allows some down time – the quiet but simple minor injuries unit versus the chaotic but fun ED.

    Andy I think you’ve hit on one of the keys to sustainability in EM, certainly as applies to the North East Atlantic.

  17. Jonathan Evans on April 21st, 2013 03:28

    This is a great post and has (rather inevitably) set off an intriguing discussion.

    I have only been qualified as a doctor for 9 months here in the UK and while my primary interest lies in critical care, I do hope to use the critical care skills I develop in the coming years in other areas, be it the ED, the anaesthetic room or prehospital in a ditch somewhere.

    The appeal of critical care in the ED is huge but looking up from the bottom of the system, I see the ED consultants where I work circulating between the different areas ensuring staff have taken a break or working swiftly through minor injuries to prevent the worst possible outcome in the ED (if you listen to those in suits), a patient breaching the 4 hour target. Put that up against what I see of the ICU consultant coming to my surgical ward and calmly performing an emergency intubation on a rapidly deteriorating inpatient, the decision of where skills are used best is rather a simple one. Even in the context of a trauma call, the anaesthetic/ICU team are present and in my albeit limited experience, usually take the lead in the implementation of critical care in that setting.

    I had not realised that the EPIC role existed here in the UK, but would be delighted to see its return. Most importantly, hospitals here should appreciate the benefits and create posts for the physicians with such a skill set for the benefit of PATIENTS, not patient flow, not because it reduces the wait time for someone with a cold, but because it will improve patient care. Whether this will happen in a system where everyone is becoming more and more specialised remains to be seen, the commissioning board may feel that appointment of surgeon specialising in left toe surgery would be better use of resources.

    Disclaimer: I am not this cynical about everything, I promise!

  18. Valerio on April 21st, 2013 04:33

    Hi Cliff!!!!As always a Great post!!!! At present I have the reverse problem… I’d like to do more shifts in the ED but I’m stuck in OR or ICU…..In my country is easier for a cardiologist to do ED shifts rather than for an Intensivist…I know is very strange!!!!!…..In any case shifts in prehospital are always available!!!!!……..Maybe should be interesting to do some locum as Epic Physician in UK……!!!!!!!

  19. Minh Le Cong on April 21st, 2013 08:36

    quote from Wikipedia International Emergency Medicine http://en.wikipedia.org/wiki/International_emergency_medicine

    “An alternate route for developing emergency medicine is providing additional training for other specialists to equip them to practice in emergency medicine. This has the benefit of being more rapid to implement as physicians already trained in other areas can add the necessary emergency skills to their repertoire. However, after the initial expansion it is difficult for emergency medicine to progress further in nations that adopt this strategy as the retrained partitioners identify more with their original specialty and have less incentive to continue to press for continuing innovations in emergency medicine.[9]
    [edit]“

  20. Tom on April 21st, 2013 09:36

    I very recently signed up to start the first part of Emergency Medicine training (ACCS EM) in the UK. This quote from Cliff’s colleague has made me really upset:

    “ they manage depts as opposed to caring for patients, lack critical care skills and lack the experience to review and manage patients as they improve or deteriorate – a sad state of affairs indeed”

    I’d be extremely disappointed if the UK seniors of today were happy to let future UK EM physicians become glorified middle managers. As an ED doc I want to be in the thick of it. I don’t want to be an average clinician. I want to be the best. I want to be respected by my colleagues, in the UK, and internationally. I want to be the resuscitationist who has a full range of critical care skills to manage anything and everything that comes through the door. I don’t mind some management, but It’s certainly not why I signed up.

    In my very humble opinion: To solidify their status as respected resuscitationists, then all UK Emergency Medicine Registrars (senior residents) should spend a mandatory further year doing critical care (in addition to their SHO (junior resident) ICU placement requirements), with the option of further years to get full dual EM/Critical Care completion of training certification. This way, ALL EM docs will be more confident with the basics of critical care, ensuring that they aren’t so eager to let other specialties take over and do the exciting stuff. This might encourage more doctors into the specialty (which currently has a massive recruitment crisis), and might encourage more EM docs to gain dual completion of training certificates so that critical care knowledge and skills are consistently brought to the heart of EM practice, which I would like to think, would further improve patient outcomes.

    Please resuscitate EPIC: ? The savior of UK Emergency Medicine

  21. Cliff on April 21st, 2013 10:44

    Well said my friend
    Cliff

  22. Steve Jones on April 22nd, 2013 08:05

    The article that Scott et al published is a fine and important debate starter. It rightly is focussed on North America and I know the role is different everywhere with a huge degree of heterogeneity even in the UK.

    For reference I think I was the first “CCST qualified” dual trained emergency/intensive care medicine physician in the UK (although it was already an infrequently trodden path). In my job plan I clinically do on average 3 days ICM and 1 day EM per week and have done this for 7 years nearly. The other 2 chaps here who do a similar job have slightly more EM, including some on call for the adult department. I do sometimes wonder what I am and how to describe myself (pause for joke opportunity) and after consideration have decided not to try. I believe that this is the first important theme to reinforce: this is not about a title/specialty but about a set of skills, attitudes and behaviours and just as importantly the flexibility to use them as required. Of all the specialties mentioned in the debate above I know consultants (read attendings) who are terrible – sometimes disastrously so – in the role of a resuscitationist.

    The second theme that struck me is training. I was really lucky to have worked with some fantastic role models – Terry Brown and Patrick Nee – who enabled me to vision a direction which (after only a minor degree of coercion) a supportive training organisation set about creating. I was the first but have been followed by many talented dually trained folks who now are in and around the place providing great care to this group of patients. In the UK training is relatively easy to achieve as is qualification if you have the correct skills, attitudes and behaviours so come on down (for those folk in Eire it is only an interdeanery transfer away- contact me). I would however caution that this is not a lightly trodden career. As suggested by other contributors there is little scope or sanity for more than two specialty foci. I see very few children’s EM cases now and having developed a management role too am struggling to feel comfortable with being ‘average’ in too many jobs.

    The third theme that struck me was about how this role may/not work in the UK and the undercurrent that being responsible for the whole of a department’s flow – i.e. making all the patients’ journeys as good as they can be – isn’t an important one. Does a surgeon deny responsibility for his inpatient and outpatient lists because they were seen by a trainee and not him, or that they are in theatre with a single patient? Why then should we not want to make sure that our staff are hydrated/fed enough to provide good care or that the LOLinNAD is seen in a timely way. Wouldn’t you want that for your mum? UK EM is in good hands but is changing and in the future it will be a different beast. In the meantime I would like to think that as Scott suggests this is about being able to do everything – and do it bloody well, to the best of your ability. There are challenges ahead for all of us in this role – with different foci and responses for each country and person.

    I am not sure that we can fully do justice to this important topic by this mode of debate and maybe some time should be dedicated at smacc2014?? I plan to attend the next event – I was a bit miffed to miss 2013 and I squarely blame my….

  23. Craig Hore on April 26th, 2013 11:29

    Great discussion and good to see our old ‘chestnut’ Integrated Critical Care paper getting a mention.

    Some excellent points made by all. And I have to echo Roger’s thoughts about ED being a great background for ICU training and the benefits of bringing ‘downstairs care upstairs’ – I use those skills a lot in my ICU practice.

    The balance in the Australian Tertiary setting is difficult for many reasons. Despite myself mostly obeying Crippen’s law (I do keep my hand in Retrieval which offers a great opportunity to extend myself outside the ICU walls) I still believe Integrated Critical Care is one way of servicing well our regional / rural practices.

    I can’t quote any Martial Arts (though my daughter is approaching her mixed martial arts black belt assessment in a couple of months) but as a (fledgling!) mountaineer I can understand Peter Safar’s second and twelfth laws for the Navigation of Life! Thanks for quoting them Chris. :)

    Craig