Tag Archives: critical care

Critical care

Which ICU For Neurotrauma Patients: Neuro-, Trauma-, or Med/Surg?

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Different hospitals have different arrangements for taking care of critically injured patients. All Level I or II trauma centers have at least a mixed med/surg ICU, with most level I centers having a dedicated surgical unit. A few have specific trauma or neuro-critical care ICUs.

In general, severely injured trauma patients do better when taken care of by trauma teams who have sufficient experience (volume). What about patients with severe traumatic brain injury (TBI)? Does the experience and volume of patients receiving care in the ICU make a difference?

A group of 12 trauma centers with varying ICU arrangements pooled their outcome data to see if the type of ICU makes a difference. All patients admitted with GCS<14 with CT evidence of TBI were evaluated if they were admitted to an ICU.

Here are the factoids:

  • 2951 patients from the 12 centers met inclusion criteria
  • Type of ICU, age, and ISS were independent predictors of death
  • Patients admitted to a trauma ICU had the best probability of survival, and stayed high across all ISS scores
  • Those admitted to med/surg ICUs had higher probabilities of death, especially with higher ISS (> 38 or so)
  • Survival for isolated TBI patients in a neuro ICU was similar to a trauma ICU in patients with lower ISS (< 32)

AAST2016-Oral21

Bottom line: This is a fascinating study, but it is giving us just a glimpse of the complete picture. What’s the difference between a med/surg ICU vs a trauma ICU. How much head trauma does a neuro ICU have to see? What kind of nurses work in them? What types of critical care physicians? 

These questions are not answered in the abstract. And they may not be answered during the presentation at the meeting. But they are extremely important, and must be resolved in the next iteration of this study. Hopefully, there will be one!

Reference: Neuro-, trauma-, or med/surg-ICU: does it matter where polytrauma patients with TBI are admitted? Secondary analysis of the AAST-MITC decompressive craniectomy study. AAST 2016, paper #21.

General

The Return On Investment Of A Career As An Intensivist

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There is a shortage of intensivists in the US, particular in the field of surgical critical care. The are many possible reasons, from “graying” of the workforce and increased workloads to decreased reimbursement and increased legal risks. As usual, money is at the root of most problems in some form or another. So is being an intensivist actually “worth” it, and how do we figure something like that out?

A group at Chapel Hill attacked this question from a financial business/financial standpoint. They looked at the lifetime return on investment of choosing a critical care career compared to non-critical care practitioners in the same fields (surgery, medicine, pediatrics). They included income data, debt burden, opportunity costs and taxes in their analysis.

Using standard financial analysis techniques, the authors found that:

  • The financial value of the career choice of medical and pediatric intensivists was nearly identical to their non-critical care peers
  • The financial value of choosing a surgical critical care career was significantly less than that of a general surgeon
  • The lower value of a surgical critical care career was largely due to the opportunity costs of two years of lower salary during the fellowship
  • The relative value of an academic critical care career was always lower, and was most pronounced among internists

Bottom line: There are many factors that go into the choice of a career in critical care. They include job satisfaction, quality of life, and many other intangibles. But money frequently intrudes into the decision making process. It appears that choosing surgical critical care incurs some degree of financial penalty, and this may  be a factor that will exacerbate the shortage of these specialists.

Reference: The economic impact of intensivist fellowship training. Poster presentation at the EAST annual scientific session, January 2013.