Life as an Active Duty Critical Care Physician

Session 192

Dr. Kevin Chung is a critical care doctor. Today, we discuss how he trains and utilizes skills for deployment, daily tasks, and myths about being a military doctor.

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[02:00] Interest in Critical Care Medicine

Kevin did his residency at Eisenhower Army Medical Center in Fort Gordon, Georgia. It’s a relatively smaller community hospital than most military treatment facilities.

When he rotated in the ICU, as an internist, or internal medicine resident, they had some really sick patients. He also happens to have a program director, who was an intensivist that head trained at the Mayo Clinic and came down there.

He was initially debating between cardiology and critical care as he likes working with his hands. He likes procedures and dealing with urgent, emergent situations.

But what really tilted him towards critical care is when 9/11 happened, and at that time, he was a second year resident. His thinking was he couldn’t really use that much of his cardiology skills when he did cardiology and we’re all going to war.

'The 9/11 event really made me think about going into a specialty where I could readily contribute and utilize my skills and be in the middle of caring for combat casualties.'Click To Tweet

Kevin explains he went into it with the mentality of gaining the skills in the states to be able to utilize in a combat sport hospital in a war zone. And when he came back, he became more confident as a intensivist having some extra skills.

Then he came back to a burn center after training. And when he got deployed, he was still taking care of combat casualties, getting wave after wave of casualties from Iraq and Afghanistan. For a three-year period, he did not have a break.

Kevin says he has no regrets getting into this at all because everything he learned during his fellowship was utilized effectively throughout his career.

[13:40] The Myths or Misconceptions Around What Critical Care Medicine Is

There’s a myth going around that critical care is all trauma, amputations, and burns, but it’s much more than that.

Kevin considers himself as a multiorgan failure therapy enthusiast as he gets excited about the opportunity to treat any type of organ failure. And so, when somebody gets really sick, whether it’s from burns, trauma after a major surgery, or they come in off the street because of bacterial pneumonia, or because of COVID. The end result when they get really sick is the same – they develop multi organ failure.

And as an intensivist, you address all those organ systems sequentially in a very systematic way. You have at your disposal multiple tools to help bridge somebody towards recovery.

'What I've learned over 20 years of critical care is that less is more.'Click To Tweet

And so, if you just provide supportive care, and do the least amount of damage you can possibly do, and just let time pass, human beings are incredibly resilient. And those that are meant to survive will survive, especially young folks.

Therefore, you just have to support them through an injury or an insult or an organ failure by putting them on the ventilator gently for a little while. If their kidneys fail, provide metabolic support with renal replacement therapy. Or if their lungs fail, you can use a mechanical ventilator and go on membrane oxygenation.

[17:07] Typical Day

As an intern resident, and even as a fellow in ICU, it can be very daunting and intimidating because you have very sick patients. You have tons of data so you’ve got to go in early to look at the charts, look at the patient and put it into a format that makes sense to present it.

And once you’ve finished all that training, now you’re on the receiving end. For instance, the rounds in the medical ICU, or even in the burn center could start at eight o’clock. Kevin would come in around seven. He would look through the chart and the major issues for each patient. A typical census that is reasonable is something around 10 to 20, which is a reasonable workload for an intensivist.

As an attending, he would be looking through charts and making sure issues from overnight have been handed off to him.

In an academic practice, you have students, interns, residents and fellows, who all gather around outside the patient’s room, along with the bedside nurse, the head nurse. In a good ICU, you’ll have the physical therapist, a respiratory therapist, a pharmacist, a social worker,.

“The more team members that are involved the better care.”Click To Tweet

As an attending, you’re running and facilitating rounds. The intern or the resident or sometimes the student will represent the patient. And optimally, the attending’s role is to facilitate discussion and make sure all the data points are covered. All the diagnoses that need to be made, are made. All the questions that need to be asked are asked.

Then within that time, you’re also teaching. You’ve got to insert some nuggets of information to help benefit the team so the entire team. Kevin admits it’s a skill set that he had to refine over time.

After rounds is when work starts happening. You’ve got to put in lines, discharge patients and transfer out of the ICU. Then throughout the day, you’re receiving new admissions to the ICU.

Kevin describes that in the ICU, they have this very regimented schedule, but it’s always interrupted because somebody is crashing. So you have to expect the unexpected and just go with the flow.

[22:45] Percentage of Urgency and Acuity in Critical Care,

Kevin says there are a lot of parallels that you can draw between emergency medicine and critical care. And that’s why a lot of emergency medicine physicians are now choosing to go into critical care. And that combination is a good marriage.

With critical care, you have the added responsibility of having to follow the patients longitudinally until they get discharged out of the ICU.

In their practice, currently, that’s when the patient leaves them and they sign out to the ward team. And they’re not responsible for the patient unless they return. And so, during the time they’re in the ICU, it could be a couple of days, or it could be months.

The longest ICU patient he has had is over a year in the burn unit. And you have that longitudinal relationship with not just the patient. In fact, it’s rarely the patient because the patient has no idea who you are.

They’re either on the ventilator being sedated, or they’re in a coma. And so, you’re dealing with their family most of the time.

'Even when you're taking care of adults, it's almost like pediatrics because you're dealing more with the family rather than the patient themselves.'Click To Tweet

Kevin says that it could be intimidating at first, but with repetition, you just get better and better at it over time because then it becomes pattern recognition. For example, most airways are the same. The sequence you go through are the same sequences. And so after a while, you go into this autopilot mode and things happen. Of course, there are anomalies, and you have to learn to deal with those anomalies.

[26:44] Shadowing at a Military Hospital

Kevin explains how shadowing could depend on the hospital, the types of patients in your hospital, and the time period.

During peacetime, you’re taking care of beneficiaries and their problems. Beneficiaries are anybody who’s retired out of the military, or active duty, and their spouses and family members. And so, you’re not going to find a lot of active duty patients in peacetime coming into your ICU. There is generally a healthy population that takes care of themselves.

'Most of the patients who come into the hospital during peacetime are going to be the retirees that have the same problems as any other civilian hospital.'Click To Tweet

During peacetime, it’s really no different than a regular community hospital or sub specialty hospital tertiary care hospital. And during wartime, it’s very different. Not only are the patients sitting there much younger, but they also have completely different injuries.

[29:40] Taking Calls

The community has moved into a 12 hours on 12 hours off shift work. For instance, if you’re assigned to an ICU in a community hospital, this isn’t a civilian setting. You’ll do 5 12-hour shifts. And so when you’re off, you’re off.

In an academic setting, they’re moving towards shift work to a certain degree. But oftentimes, you’ll take weeks at a time because you need some continuity with the residents. Everything is sort of evolving because the residents used to take months at a time. They are there the entire month.

Nowadays, even the residents are doing shifts, so they have the night service that comes on at night. And so there’s some disappointment in terms of continuity because you have multiple teams taking care of the patient.

As an attending in an academic setting, you’ll be on for a week. And at night, you’ll take calls from either the fellows or the residents who are in the hospital.

And on occasion, in a busy ICU, you’ll come in maybe once a week because there’s something that needs your urgent attention that a fellow can’t handle. In a less busy ICU, you may not come in at all the entire week. Kevin adds that there’s a lot of stuff now that you can handle over the phone or via video chat.

“Telemedicine has really accelerated over the last year and you could do a lot of things via telemedicine that you didn't think you could before.”Click To Tweet

[32:00] The Training Path

The training path depends on the specialty. If you’re a general surgeon and want to do critical care, you can do acute care, surgery or trauma, or surgical critical care. It’s just an added year after your training. For anesthesia, you do your four year residency, and then one year of critical care.

For surgery and anesthesia, the thought is you have a lot of critical care things you do during your residency that’s why only one year is necessary.

For internal medicine and emergency medicine, you need to do two years of straight critical care and then you’re an intensivist.

The vast majority of internists that do critical care, however, go into pulmonary. And so if you go into pulmonary. This is just based on how critical care came to be.

Back in the day when critical care was a very new specialty, whenever somebody got on the ventilator, it was the pulmonologist called in to take care of the patient. This evolved into the specialty of pulmonary critical care.

And so, in the United States, because of history, the main pathway to go into critical care, especially through internal medicine, is through pulmonary critical care. The program looks like two years of pulmonary heavy stuff, and then one year of critical care.

'Critical care is such an important specialty in and of itself. Now, you can do critical care through multiple pathways.'Click To Tweet

Even through internal medicine, you could be a nephrology critical care person with two years in nephrology, and then one year of critical care. You can be an ID critical care person, two years of ID and one year of critical care.

[34:33] The Reason for Multiple Pathways to Critical Care

There are starting to be pathways through cardiology, as well, so you can do cardiology and do critical care. So it’s evolving. What’s going to happen is critical care is going to become its own little special specialty, and you just do critical care. You may want to do some other subspecialty. But you got to do critical care. And the reason that there are multiple pathways to critical care is because just out of necessity.

“There are different types of patient populations that need critical care.”Click To Tweet

What Kevin is seeing now is a lot of mixed ICU’s. There are critical care departments, and you have intensivists, who are anesthesiologists, surgeons, emergency medicine doctors, internists, and pulmonologists. They’re all working in that same critical care group and covering multiple ICUs.

The neuro ICU is another one. You can become a neurologist and decide to do neuro ICU and do a two-year fellowship and become a neuro intensivist. Then work in an ICU, learn how to manage vents, and renal replacement therapy. But all your patients are either stroke, or subarachnoid hemorrhage, or some other neurological problem like the myelinating conditions.

Kevin gives his secret to overcoming burnout and that’s diversifying his activities. He does a little admin, a little research, and a little ICU. And then he does other things he enjoys and spends time with the family.

[38:42] How to Present Patients to Attendings Appropriately

Kevin says you have to be prepared with what to say. Every unit is different in terms of the culture. The way you present in a surgical ICU is going to be very different from the way you present in a medical ICU versus when you present in a trauma ICU. Therefore, you have to do your research.

Then prior to showing up on the rotation, talk to other students that have been there. Oftentimes, students are very resilient and very creative, and they help each other out. Students and residents and interns and residents are all the same in terms of when they’re presenting patients. They’re expected to present in the same fashion. And so, residency programs will have a template that you follow.

Do your research, and talk to the people that have come before you. Talk to the students that have done it and ask about what the template looks like.

'You have to tailor your preparation towards that specific unit.'Click To Tweet

[40:40] What He Wished He Knew Before Getting Into Critical Care

Kevin admits that early in his career, he did not know how to pace himself. He was so excited about being in the ICU. And he felt obligated to not leave the ICU because it was war time. And so what he would tell himself if he had an opportunity to go back in time is that the patients aren’t all going to die when he leaves so take a break.

You’ve got to be able to hand off to other people who are also going to take care of the patient. Over time, you just have to realize to trust your colleagues, and work in an environment where you’re supporting each other.

Additionally, you want to maintain your compassion, you want to be a doctor and you want to care.

'You don't want to over care. You don't want to be so invested emotionally that it drains you.'Click To Tweet

Kevin wants to remind students that you don’t have unlimited compassion so you can run out. And so, you have to pace yourself. Then when you feel yourself running out of that compassion, you have to change the scenario and change the situation. Fill your cup back up, and then come back.

[45:03] Is Critical Care Stressful?

Kevin explains that what’s stressful is being a general surgeon or plastic surgeon operating on an elective case because the expectation is perfection. And no matter how perfect you are, because of the circumstance, the patient, comorbidities or whatever, there’s going to be a bad outcome. Anytime something other than perfection happens, that’s stress.

In the ICU, the expectation is death. People come to the ICU because they’re desperate, they’re crashing, they’re physiologically deranged, and they’re going to die if you don’t do anything.

And so, you know, one of the things he tries to do when it’s really bad is he would immediately start talking with the family. He would explain how the patient is not in a good situation, but they will do their best to help their family member through this. He stresses how important it is to prepare folks for the eventuality of potential death.

“When the expectation is death, and you paint it in that way, and because humans are resilient, on average, 70% will get out of the ICU. And so, 70% of the time, you're having success.”Click To Tweet

When patients die, you take the family through that process so the dying process is as smooth and as painless as possible. So there’s even a reward as a clinician when there is that depth. And when you have this kind of perspective like Kevin does, it becomes a win-win situation and it doesn’t become stressful at all. It’s all about perspective.

[48:00] The Most and Least Liked Things

Kevin says it’s a very rewarding career. Sometimes, you can make 100 wrong decisions, and complications will occur but patients will somehow make it out of it. Sometimes, you do everything perfectly, and they still die. You basically have no control.

As an intensivist, the thing that doesn’t exist is continuity longitudinally, unless you have a patient that keeps on coming back to the ICU, which is not a good thing.

'By the very nature of what ICU is, you don't really get to know the patients.'Click To Tweet

One thing that’s missing in critical care is longitudinal follow-up and longitudinal relationships you build with patients. If you were in a general surgery practice or a family medicine practice, or pediatric practice, you watch the entire life of the kid. And there’s some joy to that that’s missing in critical care.

[50:19] Final Words of Wisdom

Finally, Kevin wishes to tell students who might be interested in critical care medicine that you don’t have to force yourself and pretend to like critical care.

'There are many different types of critical care. You can have a critical care environment where things are hopping, and people are crashing all the time. And it's just chaos.'Click To Tweet

Ultimately, if you like procedures and the challenge of having a lot of information come at you with problems that are sometimes fixable, critical care is something you should think about.

Also, understand that there are many different types of critical care and many different pathways to go into critical care. Kevin adds that critical care as a specialty is going to be in high demand. It is a very rewarding specialty at the end of the day, once you get into it.