History of Critical Care

Emergency Medicine Critical Care Medicine (EM-CCM) was first conceived in the 1970s and 1980s by Peter Safar and Ake Grenvik at the University of Pittsburgh as one aspect of the continuum of critical care medicine (CCM) spanning from the pre-hospital environment to the intensive care unit (ICU). In the 1990s, trauma surgeon Thomas Scalea of Shock Trauma in Baltimore, Maryland, was the next to open doors to emergency physicians in trauma resuscitation and critical care. Interest in EM-CCM has risen dramatically in the past several years, as pathways to board certification for emergency physicians opened up and the number of fellowship training options expanded. More history on this foundation can be found here.

The State of EM-CCM Today

As the population of the United States ages, the incidence of critical illness will increase further, leading to greater demand for critical care services. Recent evidence on critical care indicates an increase in the number of critically ill patients in the emergency department (ED) and ICU. As many as one in five Americans will receive ICU services before death, and critical care services account for approximately 0.56% of the gross domestic product of the United States.

Patient care provided in the ED and the ICU often lies on a continuum, with overlap of many critical care principles across both departments. Perhaps unsurprisingly, the number of EM residents entering critical care fellowships has been increasing. As this path to intensive care medicine grows in popularity, more fellowship and career opportunities are arising for EM physicians.

Why Choose Critical Care?

For many, the draw to critical care is based on the desire to continue participating in the continuum of acute care medicine. Others are drawn by the cognitive and psychological challenges of managing patients at very high risk of death or by the procedural intensity inherent in the management of critically ill patients. The ICU allows for more detail-oriented and longitudinal care of critically ill patients, which many EM physicians are attracted to, while offering similar opportunities for multidisciplinary care as those seen in the ED. A critical care fellowship can afford the EM physician a variety of potential practice patterns, including split time between the ED and ICU, an academic position with a niche in critical care or resuscitation, or full-time practice in either setting alone.

What is the Advantage of Entering Critical Care from an ED Background?

EM residents tend to have more proficiency in resuscitation and procedures commonly performed in the ICU than their colleagues from other disciplines. Emergency physicians are experts in initial stabilization of critical illness and operating in clinically uncertain and dynamic situations. This experience allows for greater confidence and technical prowess during the initial hours in the ICU when the patient will likely require these advanced skills and procedures and can form a strong foundation for critical care training.

What Does Critical Care Training Look Like?

The path to critical care through EM is still relatively new. Historically, critical care training was only offered to trainees in internal medicine, anesthesiology, and surgery. Even without a fellowship, some EM providers still managed ICUs with the proficiency of fellowship-trained intensivists. The first ICU setting to establish a formal critical care training path for EM physicians was Neurocritical Care, and Surgical Critical Care followed suit shortly after. EM residents are now able to apply to medical- and anesthesia-based critical care programs as well. The path to each is similar, though application timelines differ across the various tracks (see the Senior Resident page for more information).

The path from the ED to the ICU became more standardized when the Accreditation Council for Graduate Medical Education (ACGME) approved critical care as an official subspecialty for EM physicians in 2011. Trainees complete a three- or four-year residency, gaining exposure to various ICU settings during this time. In the final years of training, residents are eligible to apply for critical care fellowship, which generally lasts an additional two years, after which graduates are eligible to sit for critical care boards.

Is There a "Set Path" to Critical Care for ED Physicians?

There is no set path to critical care, and the right path for each individual is often guided by their ultimate career goals. For example, an EM resident who wishes to work in the Neuro-ICU would be best served by a neurocritical care fellowship, while a resident interested in care of surgical critically ill patients may choose a surgical or anesthesia program. This is discussed in more detail in the Senior Resident section. An alternate approach to choice of program is to choose based on desired breadth of exposure. A resident who is insure which ICU setting they would prefer to work in long-term, or one who would like to gain the most diverse critical care education possible, may choose a less specialized path such as an internal medicine (IM) program.

In general, critical care fellowships are two-year programs following EM residency. This time can be shortened in certain situations. For example, some EM/IM programs have a critical care track that allows trainees to receive their critical care training in 12 months following residency. This pathway includes a five-year EM/IM residency followed by a one-year critical care fellowship, as opposed to the typical three-four year EM residency followed by a two-year critical care fellowship. While one year longer than the typical EM pathway, the dual EM/IM residency can be beneficial to those pursuing critical care by providing exposure to both acute and chronic care management.

What if My Residency Doesn't Have a Structured Critical Care Pathway?

Use your elective time to help hone your skills in critical care, regardless of whether your residency has a dedicated track for it. You can use elective time in the operating room to hone airway management skills, perform ultrasounds to increase your point-of-care skills, etc. In addition, there are several online resources that can connect you with mentors within the EM-CCM community to help guide your path. You do not need to be at an academic center to place yourself in a good position for a critical care track. Expressing interest early and actively seeking critical care-associated learning opportunities will help set you up for success.

Differences Between Community-Based vs. Academic Residencies

Training at a community hospital has both advantages and disadvantages. With fewer resources and trainees, these programs can provide increased exposure to procedures and critical cases. For example, in some centers the ICU is managed by an upper level resident rather than having a critical care fellow or attending in-house for 24 hours daily. These centers generally do not have access to all of the subspecialty coverage available in academic centers. This presents a unique opportunity for residents to gain more experience in a variety of skills and topics that would otherwise be performed by a subspecialist. However, there may be fewer patients with particularly complex or rare medical conditions, as they more commonly present to or are transferred to academic tertiary and quaternary care centers. One common example is transplant medicine. Most community centers do not perform transplants or care for post-transplantation patients; therefore, exposure to these patients is limited in such settings. Residents training at an academic center will conversely often see more complex and uncommon pathologies routinely, and have the opportunity to learn from a wide variety of subspecialists. In certain cases, involvement of subspecialists in patient care may limit autonomy, however. Both types of training institutions offer unique perspectives on critical care practice.