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Resuscitation

Authors

Jessica L. Nelson, MD
Anesthesia Critical Care Medicine Fellow
Department of Anesthesiology
University of Colorado

Yanika Wolfe, MD
Emergency Medicine Resident
Albert Einstein Medical Center

Faculty Editor

Sarah M. Perman, MD, MSCE
Assistant Professor
Department of Emergency Medicine
University of Colorado School of Medicine

Special thanks to our 1st edition writing team

Archana A. Shah, MD, MBA
Sarah M. Perman, MD, MSCE

INTRODUCTION

Description of the specialty
A resuscitation fellowship is the perfect opportunity for an emergency medicine physician to gain additional training in critical care without the inpatient responsibilities (and rounding!) that come with a critical care fellowship and working in an intensive care unit (ICU). These fellowships allow for focused clinical and scholarly training to care for the critically-ill patient in the emergency department. Some of the fellowships are research-oriented and offer mentorship and advanced degrees in order to develop fellows as clinician-scholars. Other programs have a stronger focus on building clinical resuscitation skills, especially those skills needed to work in an ED-based ICU. Resuscitation fellowships are best suited to EM physicians who want to maintain a clinical practice solely in the ED with an academic or research emphasis in resuscitation and/or ED-based critical care. The commitment varies from 1 to 2+ years depending on interest in pursuing advanced degrees. This fellowship is non-ACGME board eligible at this time.

History of the specialty/fellowship pathway
The fellowship has evolved from a need for emergency-based resuscitative care. Many EDs have long boarding times for ICU patients, and additional training is desirable to ensure that high-quality “upstairs” ICU care is available “downstairs” in the ED. The ED is also a prime location to enroll patients for resuscitation and critical care research, especially for early treatment of sepsis, cardiac arrest, and trauma. EM clinician-scholars with additional training through a resuscitation fellowship are well-suited to these research opportunities. More recently, some EDs have constructed short-term ICUs based within the department (e.g. the University of Michigan’s Emergency Critical Care Center) to care for critically-ill patients who are anticipated to have rapid improvement in their clinical status. These patients have a length of stay too long for a traditional ED visit, but can likely be “turned around” fast enough to avoid an inpatient ICU admission, with alternative disposition to the floor or even home. This fellowship provides the additional training that EM physicians need to ensure ICU-level care for these patients. 

Why residents choose to follow this career path
Residents choose to follow this career path when they desire to become a resuscitation and critical care specialist within the ED rather than working in the inpatient setting. This pathway is geared toward training to treat high-acuity patients in their initial phase of presentation, before the patient is transferred to the ICU. This is also an opportunity for mentored research focusing on critical care and resuscitation in the ED. 

How do I know if this path is right for me?
If your goal is to become better at resuscitation as an EM physician, without the option of working in an ICU, or to become a leader in resuscitation research, then this is the fellowship for you!

Career options after fellowship
Graduates of resuscitation fellowships tend to remain primarily academic and research-oriented. Clinically, graduates work in the ED and in ED-based ICUs. Some graduates take on research positions within the ED and some have administrative roles. Again, as there is no critical care board certification available after fellowship, graduates do not have opportunities to work in inpatient ICUs.   

Academic vs. community positions
There is always the option of a community position, but historically this fellowship has appealed more to residents seeking academic positions. This fellowship also has the potential for hybrid careers, such as consulting and administration. 

IN-DEPTH FELLOWSHIP INFORMATION

Number of programs
There are a limited number of fellowship programs, but the field is continuing to grow. Current programs are: 

Research focus

Clinical focus

Differences between programs
As noted above, programs generally have either a research or a clinical focus. Each program has crossover, though, and some have more than others. All programs will train you to be an excellent resuscitation clinician and scholar. There is variation in clinical curriculum among the programs in terms of the number and types of electives offered, ICU experiences available, and ED clinical shifts required. Location of the fellowship program inevitably results in some variation of patient disease processes encountered; emphasis placed on research (or particular research areas) and administrative activities will differ as well. 

Length of time required to complete fellowship 
Resuscitation fellowships are 1-2+ years in length. The duration often depends on whether or not the fellow pursues an advanced degree in research.

Skills acquired during fellowship 
Programs with a clinical focus will train you to provide high-quality care to critically-ill patients in the ED. Fellows become masters of resuscitation, capable of providing advanced life support from a patient’s initial presentation until transfer to the ICU. Through didactic sessions and clinical training, fellows obtain in-depth knowledge about the pathophysiology, clinical presentation, and treatment of disease states that lead to life-threatening illnesses. Technical skills obtained during residency are refined, and fellows learn new procedures and undergo advanced ventilator training. For those programs with research training, fellows have specialized mentoring, protected time for scholarly work, and the opportunity to pursue advanced degrees in research. Each program’s emphasis on research vs. clinical training is different, and it is important to contact each program to know where the emphasis lies in their fellowship curriculum.

Typical rotations/curriculum during fellowship
Rotations and curriculum vary by program. Programs focused on research have less clinical training, but they may offer advanced physiology/basic science or biostatistics/research methods courses. Programs focused on clinical resuscitation training have rotations in the ED and ICUs. 

Board certification afterwards?
No.

Average salary during fellowship 
Salary varies across programs. Some programs pay PGY-4, 5, and 6 salaries, and some pay adjusted attending-level salaries that are tied to ED clinical hours and responsibilities during the fellowship.

PREPARING TO APPLY

How competitive is the fellowship application process?
There is not a lot of information available about acceptance rates for specific programs or the fellowship in general. Applications are made directly to the programs themselves and there is no formal match process governing applications, thereby limiting data availability. Given the limited number of programs, the process may be fairly competitive. Theoretically, however, competition may also have dropped in recent years as increased opportunities for EM physicians to pursue critical care fellowships have likely divided the applicant pool. 

Requirements to apply
The only requirement to apply is that applicants must complete an EM residency. Most programs request a letter of interest and curriculum vitae via email to initiate the conversation with the fellowship program director. Letters from or contact information for references will likely be requested at some point in the application process as well. 

Research requirements
Research experience, especially that pertaining to critical care in the ED, is highly recommended to increase competitiveness of an application. This is especially the case for fellowships with a research focus, as prior interest, presentations, and publications are seen as predictors for future success in fellowship.  

Suggested elective rotations to take during residency
There are not any specific requirements, but critical care rotations in the medical, cardiac, surgical, or neurological/neurosurgical ICUs would be very beneficial prior to starting this fellowship. Rotations with the trauma and burn surgery services are also likely to be useful. 

Suggestions on how to excel during these elective rotations
Make sure that you are well-read about the fundamentals of critical care and are also up to date on the latest research in the field. You should plan to arrive early, stay late, and be a dependable team member. Make it a point to know all the patients on the service well, including their primary disease process and current critical care issues. During rounds, your presentations should be polished, thorough, and medically sound. Rather than just reporting information, your presentations should also include your interpretation of data and recommended management plan. You should update families without being asked and adeptly coordinate care for the patients with other specialties as indicated. Make it a point to lead the team during resuscitations in the ED and ICU, and be proficient with your procedural skills.

Should I complete an away rotation?
It may be possible to rotate at a program that has a resuscitation fellowship in order to see what the fellows do, but this is not necessary and could be logistically difficult to arrange. A discussion with current fellows (or recent graduates) via phone, email, or in person at a conference would likely be just as useful if you are considering an application to the program. 

What can I do to stand out from the crowd?
Your application should demonstrate meaningful activities in resuscitation and critical care. It is better to have a couple projects that you have significant involvement in rather than multiple projects where your role is superficial. A common theme among your activities, such as administrative, educational, or research, is recommended instead of having a smattering of projects. Show evidence of leadership and a self-starter mentality. Create strong relationships with mentors who will be able to write you robust letters of recommendation. A strong performance in residency, where you are seen as a hard and enthusiastic worker, will set you up for success as a fellow. 

Should I join a hospital committee?
If your hospital has committees that are focused on critical care, joining one is worth considering. The goal would be to have meaningful involvement in the committee with resulting positive impact on patient care, such as through a quality improvement project. These committees can potentially expose you to leaders in critical care within your hospital, and may lead you to your future letter writers. Examples of relevant committees that many hospitals have are: resuscitation, trauma, and critical care quality improvement committees.

Publications other than research
Other opportunities include, but are not limited to, book chapters, blog posts, magazine articles, and podcasts. Remember that there are avenues for publication through other disciplines beyond EM, as critical care can involve physicians from internal medicine, surgery, neurology, neurosurgery, or anesthesia, and each of these specialties has their own publications. 

How many recommendations should I get? Who should write these recommendations?
Like applications for most fellowship programs, you will need the support of your residency program director. Applications are individualized by fellowship program, however, so the application process is largely self-directed. Contact programs early to learn more about their specific application requirements and to allow for sufficient time for letter writers. 

What if I decide to work as an attending before applying? Can I still be competitive when I apply for fellowship? 
Yes, but you need to make this time after residency valuable. Get involved in writing and research in critical care and resuscitation. Join a critical care committee at your hospital. Become involved in national critical care organizations. Make sure you have a critical care mentor who will help ensure that you make this time productive and demonstrate your interest in critical care.

What if I’m a DO applicant?
There are no special requirements for DO applicants. 

What if I am an international applicant?
You will need to demonstrate the same requirements and interest as other applicants, including taking USMLE. The biggest challenge will be getting programs to support your visa. It would be best to ask programs about this prior to applying to see if accommodations could be made. 

APPLICATION PROCESS

How many applications should I submit?
There are limited programs available, but you should only apply to those places where you would honestly consider working as a fellow. 

How do I pick the right program for me?
Your goal is to find a program that has access to a critically-ill patient population, exposure to different critical care environments in which you can apply your resuscitation skills, a curriculum that matches your needs, and mentorship that suits your academic interests and goals. For research-focused programs, access to mentors in your area of interest, availability of sustained funding, and opportunities for advanced degrees are also important. 

Common mistakes during the application process
Start early! This application process is self-directed, and you will need to contact program directors and fellowship leadership to facilitate further interest. Also, be clear with yourself and with the programs about why you are seeking to do this fellowship and how you see it adding to your residency training and benefitting your future career. 

Application deadlines
As there is no match, there is no universal application deadline. However, starting in the latter half of your second-to-last year of residency will give you ample time to contact programs, develop relationships, and gather all application materials on time. 

Tips for writing your personal statement
Your personal statement should address why you are interested in resuscitation and research. The best personal statements tell a story and have something unique/interesting that sets you apart from the pack. Keep a list of interesting critical care cases during your residency, as these can serve as inspiration for your personal statement. Do not regurgitate what is already listed on your CV; rather, your personal statement should be a mature reflection on what it means to you to become a resuscitationist. Let your personality show through, and display yourself as thoughtful, intelligent, and insightful. Remember to send your personal statement to multiple people to help edit and fine-tune your masterpiece.

Is this a match process?
No. 

What happens if I don’t obtain a fellowship position?
You will need to evaluate your application, preferably with someone who is either involved in or has recently graduated from such a fellowship, to look for deficiencies. Spend the next year addressing those deficiencies and practicing your interview skills. Do not be afraid to re-apply. Consider pursuing other fellowship opportunities, such as medical education or research, which would strengthen your overall application. 

INTERVIEW PROCESS

How do I stand out from the crowd?
Your goal in the interview process is to come off as a strong candidate. You want to highlight your strengths and things you can add to the program without being too pompous, aggressive, or self-absorbed. Supply good reasons about why you want to attend that specific program. The more you know about the program, the better the impression you will make. Find out as much about the program as you can, and treat it as if it is your top choice. Articulate not only how that program can help you achieve your career goals, but also what you can bring to the program. Hold a mock interview prior to the actual interviews to ensure that you present your best self. The goal is to be yourself and let your personality shine. Show your passion for resuscitation and critical care medicine, and demonstrate what you can bring to the program of interest. Remember, these are small programs; you will need to impress upon leadership that you are a good team player who will contribute to the group.

What types of questions are typically asked?
Be prepared to discuss your interest in critical care and resuscitation within the pre-hospital setting and ED, as well as your career goals. You will likely be asked to recount specific experiences during your residency training. You will also be expected to demonstrate that you have good clinical knowledge and understanding about the field. Know some of the “hot topics” within the field, such as therapeutic hypothermia and sepsis. Additionally, know your application inside and out because questions about your leadership experience, publications, and research projects are all fair game. Be prepared to discuss your research projects as if you were presenting an oral poster presentation. Not knowing your research makes it seem as though you played a superficial role. You should be enthusiastic about your projects, critical care, and the program where you are interviewing. Have an idea about what type of position you are aiming for after fellowship (e.g. funded independent researcher or clinical resuscitation expert in an academic ED). Be prepared with a list of questions to ask about the program. These questions should be thoughtful and not something easily answered by the institution’s website.

How many interviews should I go on?
There is no recommended number of interviews that you should attend. Because of the competitive nature of this fellowship, the general advice is that the more interviews you attend, the more likely you are to obtain a position. Ideally, you should attend any interview offered at programs where you would seriously consider accepting a fellowship position. 

PREPARING FOR FELLOWSHIP

Textbooks to consider reading

  • Vincent JL, Abraham E, Kochanek P, Moore FA, Fink MP. Textbook of Critical Care. 6th ed. Philadelphia, PA: Saunders; 2011.
  • Gabrielli A, Layon AJ, Yu M. Civetta, Taylor and Kirby’s Critical Care. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008.
  • Marino PL. The ICU Book. 4th ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2014.
  • Yealy DM, Callaway C. Emergency Department Critical Care (Pittsburgh Critical Care Medicine). New York, NY: Oxford University Press; 2013.
  • Tobin MJ. Principles and Practice of Mechanical Ventilation. 2nd ed. New York, NY: McGraw-Hill; 2006.
  • Levitov A, May PH, and Slonim AD. Critical Care Ultrasonography. 2nd ed. New York, NY: McGraw-Hill; 2014.
  • Deutschman CS and Neligan PJ. Evidence-Based Practice of Critical Care. 2nd ed. Philadelphia, PA: Elsevier; 2016.

Important skills to practice while in residency to prepare for fellowship

  • Procedural skills including (but not limited to) central line insertion, arterial line placement, intubation, thoracentesis, and paracentesis
  • Ultrasound skills, especially echocardiograms and lung exams
  • Leading a team and managing multiple sick patients
  • Leading medical and trauma resuscitations, including codes
  • Ventilator management
  • Management of non-invasive positive pressure ventilation
  • Application of targeted temperature management and sepsis protocols

Tips on how to succeed as a fellow
Read to gain understanding of fundamental critical care topics as they apply to care in the ED, as well as landmark and recent articles in high-impact journals that focus on resuscitation and critical care. Work hard during your clinical shifts, and strive to be the best physician that you can possibly be. Try to build relationships with physicians and other staff members (e.g. advanced practice providers, pharmacists, and respiratory therapists) in the ED and the ICUs in order to create opportunities for mentorship and collaboration, as well as promote teamwork between disciplines.

CONCLUSION

Additional resources

Journals

  • Circulation
  • Resuscitation
  • NEJM
  • Chest
  • Journal of Trauma
  • Anesthesiology
  • Critical Care
  • Critical Care Medicine
  • Intensive Care Medicine
  • JAMA
  • Lancet
  • American Journal of Respiratory and Critical Care Medicine
  • Annals of Emergency Medicine
  • Academic Emergency Medicine
  • Shock
  • Therapeutic Hypothermia and Temperature Management

Podcasts

Clinical Resources/Websites/Blogs

National organizations
EMRA has a Critical Care Division that is a great resource, is resident- and fellow-based, and offers multiple opportunities for involvement. ACEP also has a Critical Care Section that connects EM physicians who are interested and/or trained in critical care medicine. SAEM has a growing Critical Care Interest Group as well. 

Other organizations to consider:

  • American Heart Association (3CPR Council)
  • ACCP
  • ATS
  • EAST
  • SCCM (has an EM Section)
  • European Resuscitation Council (ERC)

Many of these organizations offer discounted membership rates for residents and fellows. Often, residents and fellows are also desirable members of committees.

Conferences

The EMRA Critical Care Division has biannual meetings at ACEP and CORD. The Critical Care Section of ACEP has annual meetings during the scientific assembly. SCCM has annual meetings in the winter. There are multiple other meetings, including the following:

  • Resuscitation Science Symposium (ReSS) at the American Heart Association Scientific Sessions
  • SMACC Conference
  • University of Maryland Medical Center Critical Care Conference
  • Weil/UC San Diego Symposium on Critical Care and Emergency Medicine
  • Northern New England Critical Care Conference
  • Rocky Mountain Regional Critical Care Conference
  • Chest Annual Meeting (American College of Chest Physicians)
  • American Thoracic Society Conference
  • Extracorporeal Life Support Organization Conference. Training courses and workshops also offered.

How to find a mentor
Within your home institution, your program director will likely be able to guide you towards both local and national mentors. Establishing good relationships with the intensivists on your critical care and trauma rotations may also help facilitate introductions. Attending organized medicine conferences, such as SAEM and ACEP, and meeting people presenting resuscitation research will further help with networking. Additionally, there are young investigator events at the American Heart Association Resuscitation Science Symposium and other conferences. The Critical Care Section of ACEP and the EMRA Critical Care Division also have programs to link you with mentors in critical care. Joining relevant committees within national organizations or attending section meetings at national conferences are also opportunities to network. You should establish a mentor early during residency and do your part to foster this relationship by bringing questions and scheduling regular meetings. Search out feedback from your mentor and apply it. Given that there are few resuscitation fellowship programs, each of which only accepts 1-2 fellows annually, this is a small community. Try to reach out to program leadership or graduates of the programs to inquire about mentorship in resuscitation care and research.