How to ICU

Nearly 4 weeks into ICU and I am still uncertain as to what is going on. On a regular basis. It’s been a strange rotation. Partly because I have missed an inordinate amount of time on this rotation combined with having patients that are extremely complicated. Luckily, much of the ICU is managed by a team of  really good RNs, Respiratory therapy, social work, and solid pharmacists. And of course your Pulmonologists/Critical care doctor. It really takes a team to manage one patient.

Overall, I have enjoyed the freedom provided on this rotation as I am able to pre-round independently, write my own notes, and present my patients to the team. Being able to do your own thing is really nice. But fear not! – a Resident is always around in case I have lingering Q’s. Something that I found to be immensely useful is chatting with the nurses before ICU rounds. These nurses know their medicine and are some of your best allies when training and beyond.

Before I started ICU, I didn’t really know what to expect and relied on the google machine to help me out. I stumbled upon these resources and reviewed them throughout the rotation:

I guess that’s not too many. I also relied on good ol’ fashioned uptodate and Medscape app.

The majority of your time will be spent reviewing drips and vent settings. Having a good understanding of pharmacological sedatives and vasopressors will serve you well. Additionally, knowing how vent settings work is helpful; at the bare minimum you should know how to interpret them. Jenny did a great job detailing this in her ICU video, so give that a listen for more info.

Everyone that warns you that ICU will be depressing was right. I had a patient die each day. Not fun stuff. Plus your patients are either intubated on a ventilator or altered or sedated so you can’t interview them. You end up relying on their vitals, PE, labs, and imaging to communicate with you their progression. Some of the more interesting cases included:

  • Meth user with valvular vegetations and septic emboli to the pleura causing pneumothorax requiring multiple chest tubes.
  • Former meth user found down in his trailer found to be in DKA and septic shock with a necrotic right foot that underwent emergent guillotine below knee amputation (BKA).
  • Diffuse scleroderma in a young adult resulting in advanced interstitial lung disease complicated by pneumomediastinum.
  • Lung metastases secondary to advanced ovarian cancer, undetected until admission.

Image result for ICU medical school memes

Of course, we also had a lot of the bread & butter cases like COPD exacerbation, isolated DKA, toxic vs metabolic encephalopathy, acute respiratory failure, and septic shock. I also was able to get in a couple of procedures: intubation and placing chest tubes. Nothing too crazy. Oh, and in case you’re wondering, I only missed time because of residency interviews – those wait lists are no joke – if you pop off of one, you find out last minute!

By the way… anyone notice the fog after January 20th? I think the Dementors were let loose from Azkaban.

Nari

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