Rade B. Vukmir, MD, JD, FCCP, FACEP, FACHE, is an emergency and critical care physician and one of the first trained and certified EM intensivists in this country. He is national medical director of critical care medicine and chief clinical officer of patient safety organization for Schumacher Clinical Partners. He also serves as adjunct professor of emergency medicine at Temple University in Philadelphia. He has been practicing intensive care medicine since the 1989 and was the founder of the ACEP Critical Care Medicine (CCM) Section. Dr. Vukmir recently sat down with Joseph E. Tonna, MD, secretary of the ACEP CCM Section and editor of its newsletter, The Unit, to discuss about the history of EM/CCM and the ACEP CCM section and how his career path led him to the interface of EM and CCM. Here are some excerpts from the conversation.
JT: Tell me about the history of the ACEP CCM Section and of the feeling among its first members. Who were they?
RV: It will help to offer a historical perspective, as these issues are related. When you look at emergency medicine and critical care, the founders always thought that the interface of emergency medicine and critical care was a logical one. It was Peter Safar and, subsequently, Ake Grenvik that truly appreciated the multidisciplinary nature of critical care, with the natural fit of emergency medicine as they developed their critical care vision. If you think about emergency medicine and critical care, the concept of surgical critical care in general and the emergency medicine-critical care interface were both born, in some ways, in Pittsburgh.
Peter Safar came to the University of Pittsburgh in the 1960s, became the chairman of the department of anesthesiology, where he established the first CCM training program. When he came, in the 60s, one of the things that he did was establish essentially the first EMT/paramedic training program in the country, and created the first van style ambulance with cardiac monitoring capability that was a minority staffed and run program, and it used “advanced resuscitation techniques” at the time. This was instead of getting thrown into the back of the hearse-style ambulance, which is what they did up into the mid 1960s. The first medical director for Pittsburgh’s Freedom House Ambulance Service was Nancy Caroline, the first EM/CCM fellow in 1974. So, when you look at the emergency medicine contribution to critical care training, Peter always felt that emergency medicine with critical care was a natural interface.
One of his first fellows, Ake Grenvik, went on to be the first chairman/division director for the critical care program at Pittsburgh, and is appreciated by generations of critical care providers to this day. The University of Pittsburgh is the program that, as you recognize, trained a substantial portion of critical care intensivists that practice around the world today
The people who were originally interested in ACEP EM/CCM or involved in the Society of Critical Care Medicine EM Section section in the 80s were people who had trained in that Pitt program and had a foot in each arena. Those are names like Norman Abramson, Rob Levine, David Crippen, Mark Angelos, and Emanuel Rivers. These were the fellows that predated me. Each of them went out and tried to advance the prominence of emergency medicine in critical care through groundbreaking research, while CCM clinical practice at that time required internal medicine training as well as EM.
In 1991, after a resuscitation research fellowship with Dr. Safar, I accepted a position as the first EM trained full-time intensivist in an academic university based critical care fellowship program, providing trauma, transplant, and neurovascular care. During this period in the 1990s, with the advice and counsel of Dr. Grenvik, I worked with the ABEM executive director at the time, Benson Munger, to once again attempt to resurrect the EM certification pathway. We reactivated the ACEP EM/CCM section petition as well in an attempt to increase awareness of all critical care issues. However, we need to remember there were people before me who fought for the recertification the previous decade, as well trying to establish the section.
In general, the drive wasn’t successful for either goal for various reasons, including lack of the EM board certification pathway as the subtext. The majority of the issue was certification-driven during this time period. It was almost a self-fulfilling prophecy, where lack of a certification process naturally decreased the interest in CCM among EM practitioners. It was at this point that I got involved.
JT: Was the issue with certification related to a professional lack of legitimacy or to something else?
RV: People did critical care because they were passionate about the discipline. Of the people mentioned who came before me, it was very difficult to sustain a critical care practice exclusively based on their EM training alone. At that time, the available career pathways included an EM clinical practice performing critical care research or combining internal medicine with EM training to allow CCM board certification to allow a clinical critical care practice in the training institutions.
My pathway was decided relatively early on, as I wanted to do primarily critical care. July of my internship year there was recognition that for my own personal desire, I wanted to care for a more critically ill population for a more sustained time. That was literally decided that first month of internship, when one morning I met Ake Grenvik. It was 4 a.m. While still up on call, I noticed an attending rounding in the cardiovascular ICU. I thought if the attending was up in the middle of the night rounding, that was dedication.
We talked in the X-ray viewing room, and he said, “We would love to have you. Emergency medicine folks do great in critical care. Unfortunately, we can’t offer you board certification, but we would love to have you train anyway.”
JT: You imply that advocacy was a significant portion of the initial impetus to form the section.
RV: Yes. The original intent of the section was an attempt to convene a group of interested individuals with diverse aims in critical care medicine. We began in 1994 and originally it did not succeed, as there were never enough members to achieve the 100 required members. However, ACEP was very supportive of the mission. We went on for three or four years with Gloria Thompson as the section liaison. Regardless, we had meetings every year, and finally achieved the magic number and the CCM section was born.
JT: What is our role as EM intensivists? We are people who understand the need to be fast and yet also we understand the need to be complete.
RV: As an EM/CCM physician, you often live in two different worlds. You understand the problems of two different disciplines balancing both inpatient and outpatient. We should serve as the interface, or bridge to deliver the best quality care that can be given at your institution. In some places, that means helping the ED to augment their critical care capability to improve the quality of care there. As an alternative, you may improve an ICU process to assist the ED throughout, though there is an efficiency limit, often involving nursing resources as well. Then there is the transition to the ICU, where there are often better nursing resources and better conditions for patient and families. You should help be the final arbiter of that transition, because you are the person that is most well positioned to facilitate the patient care goals. You are the person that helps to ease that transition and reassure people on both sides that you are doing the best thing for the patient in both environments.
I’ve gone up to the floors before and helped people who were outside of their comfort zone. We have answered outside requests for assistance. As an intensivist, the answer is always “yes” because that’s what people need to hear. We will assist them in delivering the