Any words of wisdom?

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Stellar Clouds

Stellar Clouds

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I am feeling a little nervous because my first rotation as an intern will be in the ICU...any advice?
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Pay attention, work hard, be honest. Hold on tight. You'll come out of your first month much more confident than your intern class piers. Don't worry about it.
 
1st thing you do is introduce yourself to the nurse. Then ask him/her if anything happened overnight.

then look at all the crap running into pt. note the drips, line sites, ventillator settings, look at pee bag (ask nurse about UoP) and poop bag, drains, wounds, feeding tube, look at scrotum, under scds, catheter insertion, diarrhea. write down drips and rates.

Watch your maintenance fluids. remember that Vanc is in 500ml bags. all the fluid from the abx and drips add up fast!
 
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I's and O's.
8h UoP important
abx day what of what: deescilate?
lines: do we still need em. how old
foley: same
how long tubed? hold sedation every am if possible. if sedation held do SBT. if restart try to lower dose.
secretions? how much? changing in nature.

if something ordered then follow up on it. face to face with consultants. learn echo views from echo tech. play with US.

read Marino : physiology, ventilator, aki, arrythmia, heart failure, sedation, oxygenation, sepsis (read surviving sepsis summary), HIT, fever, GIB, pancreatitis, ARDS, invasive monitiring. Download free EdwardsLifeSciences app and learn about dynamic monitoring. You will see tons of PNA, read about it. VAP, HAP, HCAP, CPIS score. Massive vs submassive PE, CDiff, electrolytes, acid base, osmol gap.

watch airway stuff. ask nurses about the monitors (how to hook em up, zero em, trouble shoot em). Ask RT to walk you through vent, Bipap, teach you abg draws.

ask the nurse to teach you how to put in dobhoff, foley, IVs.

Nowwwwwwww youre good!
 
VentdependenT said:
I's and O's.
8h UoP important
abx day what of what: deescilate?
lines: do we still need em. how old
foley: same
how long tubed? hold sedation every am if possible. if sedation held do SBT. if restart try to lower dose.
secretions? how much? changing in nature.

if something ordered then follow up on it. face to face with consultants. learn echo views from echo tech. play with US.

read Marino : physiology, ventilator, aki, arrythmia, heart failure, sedation, oxygenation, sepsis (read surviving sepsis summary), HIT, fever, GIB, pancreatitis, ARDS, invasive monitiring. Download free EdwardsLifeSciences app and learn about dynamic monitoring. You will see tons of PNA, read about it. VAP, HAP, HCAP, CPIS score. Massive vs submassive PE, CDiff, electrolytes, acid base, osmol gap.

watch airway stuff. ask nurses about the monitors (how to hook em up, zero em, trouble shoot em). Ask RT to walk you through vent, Bipap, teach you abg draws.

ask the nurse to teach you how to put in dobhoff, foley, IVs.

Nowwwwwwww youre good!
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This is clutch
 
Don't ask the fellow or attending stupid questions unless you've researched it yourself. I also don't spend much time teaching people who don't read something like the ICU book.
 
Dont make up numbers or events that arent true. If you didnt follow up or missed something obvious own it and move on. Dont be afraid to ask. You dont know $hit and thats fine as long as you ARENT LAZY or try to BULL$HIT your way out of a miss or error. I see people dig holes for themselves and all it does is dissolve trust. This isnt unique to ICU rotations. Its just that the consequences of a lie for fear of reprisal (oh his micro was negative or we never got cultures etc..) are often more acute than in other settings.

I dont mind being asked things. I can even tolerate a certain degree of clinical obtusiveness in 1st years but its the LAZINESS that I cant and wont stand for.

Dont bite off more than you can chew.
 
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Stellar Clouds said:
I am feeling a little nervous because my first rotation as an intern will be in the ICU...any advice?
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1. Do as many procedures as you can.
2. Pay attention when your staff has family discussions. In my experience ICU staff are very good at getting families to understand when more care won't help. This skill will translate across many different specialties.
3. Don't forget: they can always hurt you more, but they can't stop the clock from ticking.
 
If you have to fart on rounds, do it in a patient room, and then suggest that the nurse send stool for C Diff. It makes it much less likely that you will be pegged as the team farter, and C. Diff assay is not that expensive!
 
my first two months of intern year were MICU. By choice as you might have guessed. Now I had done 4 MICU/SICU rotations as an MS 4 so there was really no intimidation factor for me, that and I knew going in that it was what I wanted to do. But as wiser than me have already posted, keep a level head, remember the basics when ****s gets crazy, look stuff up first yourself before you ask your senior/fellow/attending. Be early. you should always be the first person there. don't let your senior beat you in in the morning. Be engaged.

I also agree on bringing the fellow coffee....but that's only because I just started filling out apps for next july as the wife agreed to the full 3 year fellowship with a few stipulations that I think can be handled :D:D:D And I like coffee :cool:
 
Bostonredsox said:
my first two months of intern year were MICU. By choice as you might have guessed. Now I had done 4 MICU/SICU rotations as an MS 4 so there was really no intimidation factor for me, that and I knew going in that it was what I wanted to do. But as wiser than me have already posted, keep a level head, remember the basics when ****s gets crazy, look stuff up first yourself before you ask your senior/fellow/attending. Be early. you should always be the first person there. don't let your senior beat you in in the morning. Be engaged.

I also agree on bringing the fellow coffee....but that's only because I just started filling out apps for next july as the wife agreed to the full 3 year fellowship with a few stipulations that I think can be handled :D:D:D And I like coffee :cool:
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Congrats on choosing fellowship. I think your talents would be wasted as a hospitalist. Smart move!
 
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VentdependenT said:
Congrats on choosing fellowship. I think your talents would be wasted as a hospitalist. Smart move!
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Probably not wasted. At least not at first. I'm afraid he'd eventually get pushed out. And then he's be stuck admitting demented gomers for non-specific failure to ambulate and thrive out of the ED.
 
Bostonredsox said:
I also agree on bringing the fellow coffee....but that's only because I just started filling out apps for next july as the wife agreed to the full 3 year fellowship with a few stipulations that I think can be handled :D:D:D And I like coffee :cool:
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Congratulations! I think your wife will ultimately be much happier because you'll be much happier.
 
jdh71 said:
Probably not wasted. At least not at first. I'm afraid he'd eventually get pushed out. And then he's be stuck admitting demented gomers for non-specific failure to ambulate and thrive out of the ED.
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Those are my favorite admits next to diabetic feet!
 
VentdependenT said:
Those are my favorite admits next to diabetic feet!
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CC fever, hypotension
HPI: pt nonverbal after suffering several hundred strokes, transfered here from The Greenery, pt unable to provide any meaningful information and a barely legible note frothe greenery says he had a fever of 112.3 so he was transfered here where the ER neglected (rightfully so) him for 7 hours and giving him 80mg of Lasix for decreased urine output. He has no immediate family members only a 4th cousin twice removed on his uncles side who refuses palliative care. So he is now on 7 pressors and methylene blue and 8 antibiotics and prognosis is better than the unfortunate pregnant 18 year he will be next to in the ICU.

PMH/PSH/FH/ALLERGIES/SOCIAL - please see previous 45 h&p's from last 3 months in our system
 
88 from golden gate NH with hx CHF, CVA, MI, parkinsons, lung ca, dementia, copd, bipolar, depression, nonverbal with hx MDR acinetobacter sputum, ESBL pseudomonas urine, MRSA nares, stage IV sacral decub stage III's on elbows and heels, flexion contracutre bilateral legs, and foley in for what looks like 10years presents for altered mental status and temp of 99.9. BP in ER 80/50 HR 110. 200cc NS given.

No notes from ems not much from nursing home. Nursing home "closed for weekend" per phone recording. Full code with divorced wife in mexico per ER nurse no contact number.

ER start vanc, zosyn, flagyl, imipenem, acyclovir, ampicillin.
 
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Ha. thanks for the votes of confidence. We shall see how the app cycle goes in a mere 6 weeks. trying to setup an away for july/august at whichever program I think I would be most competitive for. there's a fantastic looking 2 year IM/CC program in NC that has a not so strong looking 3y pulm/cc program. I have about 8 other 3y pulm/cc's on the list in VA, NC, FL. Only one DO program. rest MD.

Another thing I thought of for the OP...pick yourself up a decent text. Marinos third, Wash manual, etc. something to familiarize yourself with a lot of the major things we deal with in the MICU on a regular basis. Take a gander at these few links theyre worth your time...

http://courses.washington.edu/med610/secure/print/mv_primer.pdf --fantastic intro to managing a vent. I have every intern of mine read this before they start and before they ask me any question regarding the vent.

http://www.sccm.org/Documents/SSC-Guidelines.pdf --surv sepsis 2012, a must

I would also read up on invasive hemodynamic monitoring, DKA, the basics of CPB patients, COPD and respiratory failure. That's plenty of stuff to give you a leg up.

Cheers.
 
Not to besmirch our lovely DO world.....but I seriously doubt any of the DO programs are large enough to really justify a pulm-cc program except botsford and the other one around Detroit.
 
Hernandez said:
Not to besmirch our lovely DO world.....but I seriously doubt any of the DO programs are large enough to really justify a pulm-cc program except botsford and the other one around Detroit.
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agreed. like I said, only 1 of the 10 programs is DO.

This is also why the list is small. Im a DO coming from a DO IM program. Many programs are going to immediately discard my app pn that basis alone which is unfortunate, but the truth.
 
1. If you get asked for a piece of information about one of your patients on rounds and you don't know the answer - do not make it up! There are a lot of data to know in the ICU and trainees occasionally have a gut reaction to save face by making something up. You can cause harm doing that. Be honest.

2. I'm not a big fan of reading textbooks while on an ICU rotation. If you want to read before starting I would suggest Critical Care Medicine by Jesse Hall and peeps. I don't like the ICU book. It is too testimonial and simplistic. Instead, I would read extensively on all of your patient's major problems (i.e. the top two reasons why they are in the ICU). For most, that will include respiratory failure, septic shock, and various other medical problems.

3. Develop a system for pre-rounding and presenting. After a few days it will become second nature.

4. Pay attention to how patients were managed on the floors prior to ICU transfer. Watch how they are managed in the first 15 minutes of their ICU stay. Implement that management strategy when you are on the floors. The ICU prepares you how to prevent patients from decompensating on the floors, and how to appropriately respond to various medical things (flash edema, aspiration, sepsis, stroke, etc).

5. Eat. You can't function unless you take care of yourself.

6. Your obligation is to take great care of your patients. As a fellow, I always appreciate a thoughtful and dedicated resident who is invested. Those that try to kiss up to either me or the attending annoy me. If you bought me coffee or blew smoke up my ass on a routine basis I would sit down with you and remind you of why you are in the ICU.

7. Don't take it too personally when people die. The MICU is a sick place with mortality rates that approach 40% in some cases. Go easy on yourself.

8. Don't forget the big picture. A lot of people who go into critical care love procedures, vents, etc. Often times we can keep a person alive a lot longer than is necessary. You don't want to be a physician that gets infatuated by technology and procedures while at the same time not taking the time to routinely meet with families/patients to try to achieve consensus on what should be done. You want to be just as good at a family meeting as you are placing a central line. Both require commitment and practice.

9. Be a team player. Play nice. Don't be a cocky a-hole. Learn from everyone. Pharmacists, respiratory therapists, dietitians, nurses, etc. Part of why I like the ICU so much is that it is truly multidisciplinary.

10. If a patient has a fever, leukocytosis, tachypnea, and bacteremia don't list those as separate problems. Call that one thing!!
 
Bostonredsox said:
Ha. thanks for the votes of confidence. We shall see how the app cycle goes in a mere 6 weeks. trying to setup an away for july/august at whichever program I think I would be most competitive for. there's a fantastic looking 2 year IM/CC program in NC that has a not so strong looking 3y pulm/cc program. I have about 8 other 3y pulm/cc's on the list in VA, NC, FL. Only one DO program. rest MD.

Another thing I thought of for the OP...pick yourself up a decent text. Marinos third, Wash manual, etc. something to familiarize yourself with a lot of the major things we deal with in the MICU on a regular basis. Take a gander at these few links theyre worth your time...

http://courses.washington.edu/med610/secure/print/mv_primer.pdf --fantastic intro to managing a vent. I have every intern of mine read this before they start and before they ask me any question regarding the vent.

http://www.sccm.org/Documents/SSC-Guidelines.pdf --surv sepsis 2012, a must

I would also read up on invasive hemodynamic monitoring, DKA, the basics of CPB patients, COPD and respiratory failure. That's plenty of stuff to give you a leg up.

Cheers.
Click to expand...

If you're talking about Wake. Pulm is solid there.
 
Yeah I was talking wake. The have 2 year CC and 3 year pulm/CC. The latter has a full 12 months of research. I'm concerned there 3 yr program is a bit too academic pulm and not enough MICU. 2 year would be better for me there.
 
More versatile.
Better ventilator or I should say more complete ventilator knowledge
Outpt gig for more money and a second job when you tire from MICU.
Bronchs.

On that last note, as I have exceeded 250 procedures already and am looking for more higher skilled procedures to get under my belt prior to fellowship, my MICU attending has started to let me and my co-resident, also going pulm/CC, to perform all the bronchoscopies in the MICU in pts already on the vent, supervised very closely of course. It's freaking sweet. I'm sure this has been covered in other threads but I'm lazy.....good intro text for bronch basics and anatomy??
 
Pulm is a WHOLE different ballgame bro. Lots of inpt consults (many of which are bogus or heart failure treated as pna/copd in PP) Need it to join a group to split up consults and clinic. You can get crazy on the pulm stuff from sarcoid to lung/mediastinal cancer to ILD to transplant to pulm htn. good billing for pfts and cpets. far more interesting than unit but of couse unit is where we play. I find heart lung physiology interesting and try and incorporate it into teaching as much as possible (all good texts cover this, pick up West. Check out Miller/Barash/CV anesthesia texts too.) I enjoy the challenge of reading chest ct's. They very difficult to be competent at let alone be good at reading.

I started a thread asking same question bout bronchs. search for it. good input.
 
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You're just a better overall all around physician if you do the pulm too.

Besides critical care isn't that hard, pulmonary is . . .
 
Didn't want to make another thread since my question is similar, but I'll be a 4th year doing a Critical Care SubI and besides getting familiar with common ICU problems/acid base/vent stuff, anything else you guys recommend, esp maybe a text for students?
 
secants said:
Didn't want to make another thread since my question is similar, but I'll be a 4th year doing a Critical Care SubI and besides getting familiar with common ICU problems/acid base/vent stuff, anything else you guys recommend, esp maybe a text for students?
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being a 4th year is the best time to be in the ICU

I guess I always did most of my learning by jumping in and doing. You can read about stuff, but without clinical context it's hard to put it all together, that why everyone always suggest reading up on the patient's you're taking care of - pick a problem of theirs and then learn about it on each patient, each day (if you can - some days will just be too busy).
 
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