The expansive practice of emergency medicine cannot be fully taught or learned in 3 or 4 years. Lifelong learning, self-assessment,1 and ongoing skill acquisition and retention are necessary. How do we teach and acknowledge this during residency training and how do we support our isolated, rural colleagues? Importantly, there is a growing shortage of rural emergency physicians and many of our trainees may work in these environments.2 As educators, we must study potential solutions and bridge these gaps for our trainees entering independent practice and for our colleagues far removed from formal training. Recent cases, and many like them, illustrate this point. A rural emergency physician expertly places a small-bore chest tube for an atraumatic pneumothorax, the pneumothorax resolved, they requested transfer to a larger center for ongoing management. The tertiary care center is at full capacity. A phone consultation with a specialist recommends removal of the chest tube in the emergency department (ED) and discharge home if a follow up chest x-ray shows sustained resolution. The emergency physician has never removed a chest tube before and the patient is transferred to a larger regional ED for uncomplicated removal. In a second case, a patient is transferred from an hour away, during a snowstorm, for a peritonsillar abscess. The procedure is within an emergency physician's scope of practice. The referring physician had never performed this procedure in their decades of practice. The patient is transferred to the tertiary care center where it is drained by the attending emergency physician and emergency medicine resident. On a winter night, an emergency physician intubates a patient with a head injury in their critical-access emergency department. They request lifesaving medications and the respiratory therapist to set the ventilator. It is nighttime; there is no respiratory therapist or pharmacist. The physician must assist in mixing the medications and setting up the ventilator. The skills required for an emergency physician are ever expanding, particularly as access to tertiary care becomes more difficult. Lifelong learning and practice development to best serve our patients is a necessity in our specialty. Solutions may include regional conferences, collaborative case reviews, real-time peer-based decision support with telemedicine, maintenance of board certification, asynchronous, self-directed learning through free open-access medical education (FOAM), podcasts, textbooks or journal articles, and academic–rural partnerships that create shared faculty positions between rural and tertiary sites and rural rotations for trainees. Each of these has its limitations and time represents a major barrier.3-5 The American Board of Emergency Medicine requires continuous learning for maintenance of certification; this is beneficial but is not tailored to the physician's practice environment.6, 7 Our own work in the rural state of Vermont and upstate New York has led us to offer high-acuity, low occurrence (HALO) courses at the regional academic center twice a year for both residents and practicing emergency physicians within our region and create a rural-specific simulation lab at one of our critical-access sites. Additionally, we established a tele-emergency medicine program to offer a virtual resource from the tertiary care center in times of high-acuity, high-complexity care, or volume surge. The skill of delivering and accepting tele-emergency medicine assistance must also be learned and taught. Our education must continue to adapt to meet the needs of our unique and evolving practice environments. We must also acknowledge that many scenarios cannot be predicted. Instilling the motivation for lifelong learning, self-assessment1 and exposure to resource limited settings during training may help prepare trainees for these challenges. Although these issues are not unique to emergency medicine, we are a specialty that prides itself on adaptability. We must confront this challenge with creative solutions. Skyler Lentz, Ashley Weisman, Jordan Ship, and Matthew S. Siket conceived the idea for this manuscript and contributed substantially to the content, design, writing and editing of the commentary. The authors declare no conflicts of interest.
SummaryIn areas with limited access to critical care services, the intensivist's reach can be expanded by removing the silo of the ICU and providing care wherever the patient is located. The University of Vermont Health Network includes a tertiary care center, two community hospitals, and three critical access hospitals, and often experiences limited ICU bed availability. The community hospitals have ICU services; however, only the tertiary site has consistent staffing for many subspeciality services. For example, the University of Vermont Medical Center is the only Vermont hospital to offer inpatient dialysis services or continuous electroencephalogram. The tertiary center ICU beds can be occupied by patients with brief ICU needs, but who remain in the ICU due to constraints in system throughput. The critical care transition (CCT) service was created in October 2022 to provide critical care consults for patients outside of the ICU. CCT serves the tertiary care ED and hospital wards, and provides peer-to-peer support for emergency physicians at the rural network EDs via telehealth. Dual-boarded emergency medicine/critical care medicine (EM/CCM) physicians provide the consults and offer procedural assistance within the tertiary care site. By increasing this access to critical care consults — independent of patient location — the long-term goals are to reduce short (<24-hour) ICU admissions, reduce the rates of transfer declines to the ICU due to capacity, decrease the time to evaluation by the intensivist for critically ill patients, and improve patient-centered measures of quality, such as inter-facility transfers and mortality. Short-term measures of success included demonstration of value and sustainability through either cost avoidance or revenue generation, favorable staff satisfaction evaluated via surveys, and successful deployment of telehealth to support rural network providers. The authors present the pilot phase of this care delivery model in a rural setting. Work is ongoing to expand and improve the ways in which critical care can be effectively delivered where and when needed. The initial 9 months of coverage, through August 2023, suggest improved access to ICU care, mitigation of avoidable high-cost services, and positive feedback from staff in the management of complex patients. The service, which started with just two EM/CCM physicians (limited, sporadic shifts, 60% full-time equivalent [FTE]) was approved in April 2023 for full-time staffing of one shift per day (2.3 FTEs) with a goal to continue data collection for evaluation of long-term objectives, continued rapid cycle improvement testing to increase patient volumes, and expanded use of telehealth opportunities throughout the network. This model of a peri-ICU consult service, focused on critical care anywhere, utilized the same physicians to concurrently support patients and providers outside of an ICU in multiple health care settings. The health system has demonstrated the feasibility of implementing a creative solution to complex health care delivery challenges.
Background: The impact of critical illness on the right ventricle (RV) can be profound and RV dysfunction is associated with mortality. Intensivists are becoming more facile with bedside echocardiography, however, pedagogy has largely focused on left ventricular function. Here we review measurements of right heart function by way of echocardiographic modalities and list clinical scenarios where the RV dysfunction is a salient feature. Main: RV dysfunction is heterogeneously defined across many domains and its diagnosis is not always clinically apparent. The RV is affected by conditions commonly seen in the ICU such as acute respiratory distress syndrome, pulmonary embolism, RV ischemia, and pulmonary hypertension. Basic ultrasonographic modalities such as 2D imaging, M-mode, tissue Doppler, pulsed-wave Doppler, and continuous Doppler provide clinicians with metrics to assess RV function and response to therapy. Conclusion: The right ventricle is impacted by various critical illnesses with substantial mortality and mortality. Focused bedside echocardiographic exams with attention to the right heart may provide intensivists insight into RV function and provide guidance for patient management.
