“Critical care medicine...quo vadis?” 1 (translation: where are you going?)
- Peter Safar, MD
“Current politics preventing emergency medicine from getting additional critical care medicine subspecialty certification is wrong.”
-Dr. Peter J. Safar, Careers in Anesthesiology: An Autobiographical Memoir, 2000
Critical care is a continuum initiated by prehospital care, continues with emergency medicine (EM) resuscitation and stabilization, and culminates with intensive care unit (ICU) management.1,3 Since the formation of the Society of Critical Care Medicine in 1970, a multidisciplinary approach, including EM, has been advocated for the practice of critical care medicine (CCM).4 Today, emergency medicine physicians (EMPs) are actively pursuing formal critical care training and certification to join the existing ranks of board-certified intensivists.
EMERGENCY MEDICINE RESIDENCY TRAINING
EM and CCM require proficient acumen in treating life-threatening acute illness. EM focuses on the early hours of disease treatment while CCM is weighted toward more prolonged management within the ICU.4 Graduates of EM residency programs are unique in their training and background, making them ideal candidates for CCM training. EM residencies exist as three- (70%) and four-year (30%) training cycles. A unique strength of EM training is that the Accreditation Council for Graduate Medical Education (ACGME) Residency Review Committee (RRC) requires that the trainee receive broad exposure to the undifferentiated critical care patient (see Figure 1).6 With estimates of a 60% increase in Emergency Department (ED) critical care volume and a reported 1.4 million patients admitted to the ICU through the ED, the EMP staff is a primary portal of entry and provides the most proximal, time-sensitive care for the critically ill and injured.21 EMPs provide hundreds of patients critical care annually in this country.5 EM residency also provides a training curriculum with rotations in the ICU (basic RRC requirement of four months) and in-patient floor settings (both medical/surgical). EM residents become adept at multitasking and providing critical care for emergent cardiac failure (STEMI, heart failure, arrhythmias cardiopulmonary failure, etc.), acute neurologic events (stroke, status epilepticus, intracranial hemorrhage, etc.), respiratory failure (hypoxia, COPD, asthma, PNA, etc.), sepsis, toxicology, blunt/penetrating trauma patient, GI hemorrhage, wound care, burn injuries, metabolic derangements, and so on.6
Typical Emergency Department (ED) patient population that provides critical care experience for the EM resident.
Also expected of the EM graduate is procedural acumen with emergent airway stabilization, vascular/arterial access, thoracostomy, para/thora/cardiocentesis, and point-of-care ultrasound imaging, amongst other procedures (see Figure 2).6
Typical CCM procedures that an EM resident is expected to master during residency.
EMERGENCY MEDICINE AND CRITICAL CARE MEDICINE HISTORY
EM and CCM share multiple common historical threads, having ...