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Surgical Critical Care

Authors

Brandon M. Parker, DO
Trauma/Surgical Critical Care Fellow
Department of Surgery
R Adams Cowley Shock Trauma Center
University of Maryland School of Medicine

Mark T. Foster, MD, MS
Trauma/Surgical Critical Care Fellow
Department of  Surgery
R Adams Cowley Shock Trauma Center
University of Maryland School of Medicine

Ashley Menne, MD
Assistant Professor
Department of Emergency Medicine
Program in Trauma
R Adams Cowley Shock Trauma Center
University of Maryland School of Medicine

Faculty Editor

Cindy H. Hsu, MD, PhD
Assistant Professor 
Division of Emergency Critical Care, Department of Emergency Medicine
Division of Acute Care Surgery, Department of Surgery
Michigan Center for Integrative Research in Critical Care
University of Michigan

Special thanks to our 1st edition writing team

Cindy H. Hsu, MD, PhD
Samuel A. Tisherman, MD, FCS, FCCM

INTRODUCTION

Description of the specialty
Critical care medicine became an ACGME-approved subspecialty for emergency physicians in 2011. In 2012, the surgical critical care fellowship (SCC) pathway was approved for emergency physicians interested in becoming board-eligible intensivists. As of 2016, emergency physicians can become board-certified intensivists by pursuing one of the three pathways: surgery, internal medicine, and anesthesia. Given the growing acuity within emergency departments, persistent shortage of intensivists nationwide, and an increased interest in ED-based Intensive Care Units (ICUs), pursuing a board-eligible critical care training pathway has become an attractive career option for emergency physicians.

History of the specialty/fellowship pathway
In 2012, the American Board of Surgery (ABS) broadened its eligibility criteria to allow ABEM diplomates board certification in SCC. This is the result of the approval by the American Board of Medical Specialties (ABMS) of a resolution submitted by the ABS. This pathway requires 2 years of training. The first year is a preparatory year during which you will gain clinical experience in the foundations of surgery, management of complex surgical conditions, and exposure to critical care training. This includes pre-operative and post-operative management of surgical patients, advanced care of injured patients, complex wound management, and procedures related to critical care. The exact composition of this year is at the discretion of the SCC program directors, and each SCC program must submit a proposal for the first-year curriculum to the ABS for approval. The second year is a traditional SCC fellowship, during which 8 months must take place in surgical ICUs.

Why residents choose to follow this career path
Emergency physicians who may want to consider additional critical care training are those who have enjoyed treating critically ill patients beyond their initial resuscitative phase in the ED. These physicians thrived in their ICU rotations during residency and are interested in improving the care of critically ill patients from the moment the patients enter the ED to their transition to (and care within) the ICU to hospital discharge. They enjoy learning about relevant critical care topics such as ventilator management, sepsis, shock, acute lung injury, extracorporeal support, parenteral nutrition, pain management and sedation, and goals-of-care discussions. Those who pursue the SCC (or anesthesia critical care) fellowship pathway rather than internal medicine programs have particularly enjoyed taking care of surgical patients, as these pathways usually put more emphasis on pre- and post-operative management and complications, trauma, and hemorrhagic shock. 

How do I know if this path is right for me?
Most EM residencies have established ICU rotations, but consider setting up additional rotations through surgical ICUs as a senior resident so you are given more responsibilities. Get in touch with current EM-trained intensivists about their careers, clinical activities, and lifestyle, to see whether this career path fits with your personal goals. A great way to meet many EM-intensivists in one setting is to attend the critical care section meetings at ACEP and SAEM, through EMRA’s mentorship program, and the emergency medicine section of the Society of Critical Care Medicine (SCCM). You may also want to follow intensive care related podcasts or blogs listed at the end of this chapter. 

Career options after fellowship
There are many career options available after SCC fellowship. Fellowship-trained intensivists will be able to work in many types of ICUs, including SICU, trauma ICU, neurosciences ICU, cardiac surgery ICU, transplant ICU, medical ICU, and mixed ICU. There is also a growing role for ED based ICUs. They may want to split time between the ED and the ICU, with varying ratios based on their interests and the institutional needs. They can work in a community setting or an academic institution. They may also want to pursue research, educational, or administrative roles in addition to their clinical duties. 

Splitting time between departments
Many fellowship-trained physicians choose to split their time between the ICU and the ED. Some spend more time in the ICU or in the ED, while others also mix in time on the trauma service. While you must have fellowship training to work in a surgical ICU, it does not have to be a SCC fellowship. Those who have trained with multi-disciplinary IM-CCM programs with adequate exposure to surgical patients have had successful careers in surgical ICUs.

Those looking for jobs in institutions without precedence of EM-intensivists may need to negotiate with two or more departments to create a suitable employment agreement. It is important to determine what each department’s full time employment means, as different departments will have different requirements. Clear expectations need to be agreed upon up front. 

Academic vs. community positions
Academic institutions tend to have more specialized ICUs, whereas community hospitals tend to have mixed units. In general, there is more research infrastructure and greater focus on education within academic institutions. 

IN-DEPTH FELLOWSHIP INFORMATION

Number of programs
As of 2018, SCC programs accepting EM applicants include:

Please refer to EMRA Critical Care Committee for an updated list of the SCC fellowships that currently accept EM applicants.

Differences between programs

There are many differences between the structure and roles of each fellowship’s first year, or “advanced preliminary resident in surgery” year, sometimes referred to as the Supplementary Education Program in Surgery for the Emergency Physician (SEPSEP). For many programs, the curriculum of the first year has evolved considerably, since this is still a very new pathway. Applicants should contact each program director to gain further insight into what the first year entails. Because the first year varies greatly between programs, prior graduates of the SCC pathway can be an excellent resource when comparing different programs.

The experience of the second year is largely similar to an institution’s SCC fellowship. As such, applicants should inquire about the diversity, volume, and role of that year’s training. It is also helpful to determine the types of jobs that the EM-SCC fellows secure after completion of the fellowship. Again, reaching out to prior graduates can be helpful in this respect.

Length of time required to complete fellowship
2 years.

Skills acquired during fellowship
You will become an expert in the critical management of all forms of shock, coagulopathy, renal failure, lung injury, ICU nutrition, infectious disease, sedation, and mechanical ventilation. 

You may also gain exposure to management of extracorporeal membrane oxygenation (ECMO) and procedures, such as the surgical airway, percutaneous gastrostomy, resuscitative endovascular balloon occlusion of the aorta (REBOA), venous cutdown, and cannulation for ECMO.

Typical rotations/curriculum
The first year consists of 12 months of intermediate-level surgical experience in the management of patients with complex surgical pathology. Services that are acceptable to the ABS for this experience include but are not limited to:

  • Emergency general surgery
  • Trauma surgery
  • Burn surgery
  • Solid organ transplantation
  • Vascular surgery
  • Cardiothoracic surgery
  • Surgical oncology
  • Surgical infections
  • Orthopedic surgery
  • Neurosurgery
  • Pediatric surgery
  • Surgical ICU - may not comprise more than 3 months of the total 12 months 

The second year focuses on exposure to various SICUs, and often includes elective and research months to further pursue academic interests within the realm of SCC.

Board certification afterwards?
The ABS SCC board certification examination is a 1-day examination consisting of approximately 200 computerized, multiple choice questions. The exam lasts 5 hours and is offered in September of each year. An examination content outline is available at SCC Certifying Examination Content Outline

To be eligible, ABEM diplomates must complete a “preparatory year as an advanced preliminary resident in surgery” prior to entering a one-year ACGME-accredited fellowship in SCC at the same institution that the preliminary year was completed. Upon successful completion of the SCC certification examination, ABEM diplomates will need to participate in the ABS maintenance of certification (MOC) program to maintain their SCC certificate. The ABS has not offered a provision (grandfathering clause) for ABEM diplomates who had completed a SCC fellowship before July 2013 to become certified in SCC. Please visit https://www.absurgery.org/default.jsp?certsccce_abem for additional details regarding SCC board certification and continuous certification. Emergency physicians will then undergo the same recertification process as other surgical intensivists through the ABS.

Average salary during fellowship
Typically, fellows will receive a salary commensurate with their PGY-level (4 or 5) depending upon whether they graduated from a 3- or 4-year EM program. 

PREPARING TO APPLY

How competitive is the fellowship application process?
The SCC fellowship application process is fairly competitive because there are relatively few programs and limited spots available.

Requirements to apply
Completion of 3- or 4-year ACGME-accredited EM residency. 

Research requirements
Research is encouraged but not required. Applicants should pursue projects they find interesting, which may include clinical or basic science research projects, clinical protocol design, or qualitative improvement projects that aim to improve the care of critically ill patients in the ED or ICU. The project should ideally lead to poster or podium presentations and/or publications. 

Suggested elective rotations to take during residency
ICU rotations with senior-resident level responsibility and additional trauma surgery outside of your required trauma months. 

Suggestions on how to excel during these rotations
To excel during these rotations, it is important that you know your patients, their pathologies, and management. As with all other rotations, be proactive in procedures, stay on top of the literature, and offer to teach junior residents and students. Above all, show interest and motivation to learn. 

Should I complete an away elective rotation?
Yes, if your home institution does not offer any of the suggested rotations. If there is a program of particular interest to you, consider completing an away rotation there.  Be sure excel during your away rotation as your performance will be reflected in your recommendation letter. 

What can I do to stand out from the crowd?
Ways to stand out include national or institutional leadership positions, research that leads to publications, continuity of interests, interest and expertise in education, and outstanding letters of recommendation, particularly from surgical intensivists. Some applicants have also completed prior fellowships such as a resuscitation or ultrasound fellowship. While the skills learned previously are helpful and may differentiate the applicant from their peers, the graduating SCC fellows will have adequate knowledge in these fields.

Should I join a hospital committee?
Yes, if your interest and time permits. Some helpful hospital committees to join include: resuscitation, critical care, transfusion, pharmacy, quality improvement, and/or palliative care. 

Publications other than research
Additional publications beyond research would potentially help and strengthen your application. These include blog posts, book chapters, reviews, case reports, podcasts, and/or videocasts.

How many recommendations should I get? Who should write these recommendations?
Three recommendation letters are generally required. In addition to soliciting a letter from your EM program director or chair, it is important that you highlight your performance in the ICU. To do so, you should solicit letters from intensivists. If your program does not already have ICU rotations built in the curriculum, doing an elective in an ICU (preferably SICU) as a senior resident will really help to demonstrate your dedication to this pathway as well as a way to secure a recommendation letter. Though not always possible, getting a letter of recommendation from someone that has trained at the location where you are applying would be helpful. An away rotation at your desired program can also help you secure a letter which will differentiate you as an applicant.   

What if I decide to work as an attending before applying? Can I still be competitive when I apply for fellowship?
Yes, but you should make the attending year(s) worthwhile by enhancing your critical care knowledge and skills. 

What if I’m a DO applicant?
The same set of rules and recommendations apply to the DO applicants as long as they are completing an allopathic residency program. 

What if I am an international applicant?
The SCC Program Requirements state that applicants must have completed an ACGME-accredited residency program. Programs accredited by the Royal College are usually acceptable, while others are often not. Find out which programs accept international applicants and the type(s) of visa they can sponsor prior to submitting your application. Once accepted to a fellowship, it is important to submit all requested documentation promptly in order to avoid delays in visa approval.

APPLICATION PROCESS

How many applications should I submit?
Similar to residency, applicants should apply to as many places as possible within their geographic preference. Do not apply to a program if you would not be willing to live in that area. 

How do I pick the right program for me?
If you decide that applying to an SCC fellowship is the right choice for you, then look closely into each fellowship’s curriculum, the EM fellows’ roles during each rotation, geography, and the alumni network. Attempt to reach out to programs and correspond with current or past fellows, if possible, to get a better feel for the program. There is significant variability in the first year curriculum across programs.

Common mistakes during the application process
The biggest mistake people make is not submitting all the required information in a timely fashion. Starting in 2015, many SCC programs have instructed applicants to go through the Surgical Critical Care and Acute Care Surgery Fellowship Application Service (SAFAS). The Surgical Critical Care Program Directors Society is strongly encouraging programs to use SAFAS for applicants. Applicants may create an account and follow the applicant instructions provided by SAFAS. The SAFAS applications open in January and are accepted through August 15 of each year. 

Most SCC programs will require applicants to submit the following items with their application:

  • Personal statement
  • 3 letters of recommendation
  • Curriculum Vitae
  • Copy of your medical school transcript
  • USMLE scores
  • Copy of ECFMG (if applicable)

Some SCC programs accept applications on a rolling basis beginning in the spring or summer in the year prior to matriculation. The process varies among programs, so it is important to check with each program individually about application requirements and deadlines. It is also important that applicants secure recommendation letters from intensivists in addition to their EM program director.

Application deadlines
August 15 if you apply through SAFAS; otherwise, aim to submit as early as possible. It is also important to reach out to programs once you have submitted your application to ensure they have received your completed application and that nothing is missing. This is also why it is important not to wait until the deadline to submit your application. 

Tips for writing your personal statement
It is important to formulate a cohesive discussion on your interest in critical care and how that will help to enhance your training in EM. Some topics of discussion may include: What got you interested in EM-CC in the first place? Why is SCC important to you? What do you plan to do with your SCC training after you are done? Who inspired you? What have you done to further your interest in SCC? 

Is this a match process?
This may be different for each program, so it is best to ask the fellowship directors to see if they are putting their EM-SCC positions into the match. As with the application, it is important to reach out early so you do not miss any deadlines. 

What happens if I don’t obtain a fellowship position?
Use the next year (or few years) to enhance your application and make yourself a better future EM-intensivist. Some examples may include, but are not limited to, another fellowship such as ultrasound, resuscitation, research, medical education, or simulation. Alternatively, you may decide to take an attending job, maybe even at the institution where you are interested in furthering your SCC training. 

INTERVIEW PROCESS

How can I stand out from the crowd?
In general, applicants who stand out are those who have shown commitment during their training to EM-CC. Examples include research, education, national awards, institutional quality improvement projects, and leadership roles, such as chief resident or service on national critical care committees. 

What types of questions are typically asked?

  • Why critical care?
  • Why SCC rather than another critical care training pathway?
  • Tell me about a challenging critically ill patient that you had.
  • What are some challenges in critical care medicine?
  • Do you have any questions about the program? It is very important to do your homework regarding the program itself, the institution, and many of the faculty before the interview.

How many interviews should I go on?
Because SCC spots are limited and fairly competitive, applicants should aim to go on as many interviews as possible until they have received an offer.

PREPARING FOR FELLOWSHIP

Textbooks to consider reading

  • Marino PL. The ICU Book. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2013.
  • Farcy DA, Chiu WC, Flaxman A, Marshall JP. Critical Care Emergency Medicine. New York, NY: McGraw Hill; 2011.
  • Mattox K, Moore E, Feliciano D. Trauma. 7th ed. New York, NY: McGraw Hill; 2012.
  • Society of Critical Care Medicine. Comprehensive Critical Care: Adult. Mount Prospect: SCCM; 2012.
  • Zanotti-Cavazzoni SL, Pino RM. Self-Assessment in Adult Multiprofessional Critical Care. 7th ed. Mount Prospect: SCCM; 2011.

Important skills to practice while in residency to prepare for fellowship

  • Central and arterial line placement, intubation, tube thoracostomy, thoracentesis, paracentesis, emergency airway, thoracotomy
  • Ultrasound - FAST, transthoracic and transesophageal echocardiography, lung, vascular access, deep vein thrombosis assessment
  • Bronchoscopy, fiberoptic intubation
  • Conscious sedation
  • Wound management - complex dressings and vacuum-assisted closure devices

Tips on how to succeed as a fellow
Work hard, but eat and sleep when you can. Continue to read and stay up to date on current literature and guidelines. Learn from your colleagues (particularly those who trained through different specialties). Get to know your patients and their families; participate in as many family meetings as you can. Identify mentors and role models. Respect and learn from the nurses, respiratory therapists, and ancillary staff. Teach someone something new every day. Don’t be afraid to get your hands dirty, and don’t be afraid to ask for help. Try something new (procedure, management style, etc.) every week. Keep in touch with your loved ones. 

CONCLUSION

Additional resources

Journals

  • New England Journal of Medicine
  • JAMA
  • The Lancet
  • Chest
  • Critical Care Medicine
  • Critical Care
  • Intensive Care Medicine
  • Journal of Trauma and Acute Care Surgery
  • JAMA Surgery
  • Journal of the American College of Surgeons
  • Resuscitation

Podcasts

Blogs

Articles

  • Napolitano LM, Rajajee V, Gunnerson KJ, Maile MD, Quasney M, Hyzy RC. Physician Training in Critical Care in the United States: Update 2018. J Trauma Acute Care Surg. 2018 Feb 17.
  • Tisherman SA, Alam HB, Chiu WC, Emlet LL, Grossman MD, Luchette FA, Marcolini EG, Mayglothling JA. Surgical critical care training for emergency physicians: Curriculum recommendations. J Amer Coll Surg. 2013;217:954-959.

National organizations

  • Critical Care Sections of ACEP, SAEM, and EMRA
  • Society of Critical Care Medicine
  • American Association for the Surgery of Trauma
  • Eastern Association for the Surgery of Trauma
  • Western Trauma Association
  • Shock Society
  • American Heart Association

Conferences

  • ACEP, SAEM, and EMRA critical care section meetings
  • SCCM EM section meeting
  • AAST
  • EAST
  • WTA
  • AHA Resuscitation Science Symposium
  • Social Media and Critical Care Conference (SMACC)

How to find a mentor
Ways to network and find a mentor include: EMRA Critical Care Virtual Mentorship, critical care section meetings, social media, and alumni network.