I'm starting MICU soon, and am very nervous about it. I dont know what the hell I am doing. I will have no upper level with me at nights, its a Q4 call schedule with just me and nobody in house, the MICU fellow takes home call.

So here's the laundry list of questions:

1. A typical septic shock patient requiring intubation and many lines. Am I supposed to just start doing all the lines and intubation by myself if they are unstable, or am I supposed to clear the plan with the fellow first? Might take 5 or 7 minutes for him to call me back.

2. Suppose we have a patient in our unit who starts dropping pressures overnight and needs mild pressor support at 3 AM. Should I just start very low dose levophed without waking up the fellow? Or do they want to know every single time I have to initiate/change pressors?

3. I'm not very comfortable with IJs or subclavians, femoral lines seem like they are a lot easier to me. I realize that femorals are more infection risk, but in the heat of the moment am I going to be in big trouble for doing femorals instead of the others? Is U/S helpful for femorals or is there too much tissue to see anything?

4. We have a CCU with separate housestaff. Does that mean that I wont be having to treat anybody with cardiogenic shock or acute MI? Or will I still get some of those patients? I'm trying to decide how much time I need to study up on that stuff. I will focus less on learning the ins and outs of weird arrythmias and stuff if every single one of those people will get diverted to CCU.

5. I'm assuming that the ICU nurses know how to run codes on their own. So if there's a code while I'm there, am I still expected to run it or can I just assist and let them run their own ACLS protocol until a fellow/attending shows up?

6. For GI bleed, other than transfusing them and stabilizing ABCs, do you use propanolol or octreotide or both? What other adjunctive meds are used for GI bleeds?

7. For seizures, what do you use besides ativan? Do you start other AEDs before the neuro consult in the morning, or do you just keep them on ativan overnight until the cavalry comes in the AM?

8. When escalating pressors, do you always max out the dose on the first one before starting another, or is it OK to add on another agent even though the first agent is not maxed out yet?

9. What is the purpose of rifaximin in hepatic encephalopathy?

10. When do you use SIMV vs AC ventilation? Do you always start AC first and then wean them to SIMV later?

11. When you are weaning vent settings, whats the order of the wean? Tidal volume, respiratory rate, PEEP or what?

12. I've read in several sources that its beneficial for patients with ARDS to ventilate them in prone position. If I suggest that to the staff/nurses, are they going to look at me like I'm weird, or is that strategy actually used in a hospital setting instead of just being theoretical?

1. A typical septic shock patient requiring intubation and many lines. Am I supposed to just start doing all the lines and intubation by myself if they are unstable, or am I supposed to clear the plan with the fellow first? Might take 5 or 7 minutes for him to call me back.

This is highly institution and fellow dependent, ask the fellow what he prefers. You’ll also need to know what your institution’s policy is for invasive procedures such as TLCs.


2. Suppose we have a patient in our unit who starts dropping pressures overnight and needs mild pressor support at 3 AM. Should I just start very low dose levophed without waking up the fellow? Or do they want to know every single time I have to initiate/change pressors?

This will be fellow dependent. Keep in mind that pressors should not be put through a peripheral iv if can be avoided.


3. I'm not very comfortable with IJs or subclavians, femoral lines seem like they are a lot easier to me. I realize that femorals are more infection risk, but in the heat of the moment am I going to be in big trouble for doing femorals instead of the others? Is U/S helpful for femorals or is there too much tissue to see anything?

U/S is useful for Fems. Whether or not Fems are a higher infection risk is debatable, but in an emergent situation, it is appropriate to throw in a non-sterile fem line as long as you plan to remove it within a few days. IJs are very easy with U/S after you’ve done a few.


4. We have a CCU with separate housestaff. Does that mean that I wont be having to treat anybody with cardiogenic shock or acute MI? Or will I still get some of those patients? I'm trying to decide how much time I need to study up on that stuff. I will focus less on learning the ins and outs of weird arrythmias and stuff if every single one of those people will get diverted to CCU.

This depends on your institution. Some places will still have Cardiac pts in the MICU, others don’t.


5. I'm assuming that the ICU nurses know how to run codes on their own. So if there's a code while I'm there, am I still expected to run it or can I just assist and let them run their own ACLS protocol until a fellow/attending shows up?

You should run your own codes, IMHO. Never be afraid to ask, “does anyone have any other suggestions”


6. For GI bleed, other than transfusing them and stabilizing ABCs, do you use propanolol or octreotide or both? What other adjunctive meds are used for GI bleeds?

I’m not aware of any hard and fast rules. I’m sure there might be some GI based guidelines out there, you could search ClearingHouse.gov to see what’s out there.


7. For seizures, what do you use besides ativan? Do you start other AEDs before the neuro consult in the morning, or do you just keep them on ativan overnight until the cavalry comes in the AM?

Loading doses of antiepliptics isn’t unreasonable. There are some good guidelines out there if you search. But also don’t be hesitant to push repeat doses of Ativan if they’re still seizing. And if they’re in status, let the fellow know and perhaps even get in house neuro a call if need be. You really should do all you can to break a status episode in less than 20 minutes if possible (or so the neuro docs here are adamant about)


8. When escalating pressors, do you always max out the dose on the first one before starting another, or is it OK to add on another agent even though the first agent is not maxed out yet?

There is no set rules, but I typically will add second and 3rd agents when I get to about 75% of max of the doses of pressors.


9. What is the purpose of rifaximin in hepatic encephalopathy?

Dunno


10. When do you use SIMV vs AC ventilation? Do you always start AC first and then wean them to SIMV later?

SIMV is rarely used in MICU pts, Volume control A/C is the most commonly used Vent settings in the MICU. I haven’t sent too many docs use Pressure control or APRV, but those advocates are out there.


11. When you are weaning vent settings, whats the order of the wean? Tidal volume, respiratory rate, PEEP or what?

That depends on how you’re weaning. Most of the time you’ll be using a Pressure support mode which you select the Pressure (which is commonly in the 8 range), FIO2, and perhaps add in CPAP as well. Or you can do a t-piece wean, etc, etc. Weaning modes for acute pts tend to be more minimum pressure support style modes.


12. I've read in several sources that its beneficial for patients with ARDS to ventilate them in prone position. If I suggest that to the staff/nurses, are they going to look at me like I'm weird, or is that strategy actually used in a hospital setting instead of just being theoretical?

The net benefit for proning ARDS pts hasn’t been proven well. The Low tidal volume ventilation with Peak pressures less than 35 and maintaining a low CVP pressure are really the only modalities which have been shown to have a clear benefit.

Pick up a copy of either Marini or Marino's critical care book, and don't hesitate to ask your fellow these questions in the day. and if you're in doubt, wake their butt up.

I'm starting MICU soon, and am very nervous about it. I dont know what the hell I am doing. I will have no upper level with me at nights, its a Q4 call schedule with just me and nobody in house, the MICU fellow takes home call.

I don't understand why some institutions still have interns flying solo overnight in the ICU...someone please tell me how this is good for patient care?

I think Hernandez did a good job answering most of your Q's. I will add a few extra thoughts...


2. Suppose we have a patient in our unit who starts dropping pressures overnight and needs mild pressor support at 3 AM. Should I just start very low dose levophed without waking up the fellow? Or do they want to know every single time I have to initiate/change pressors?

Assuming we are referring to distributive shock AND still unresponsive (MAP < 65, CVP < 8, ScvO2 < 70%) after running several liters of IV fluid into the patient...I would start Norepi and titrate your dose to a reasonable MAP (65). If still running low, consider adding Dopamine or Vasopressin (our institution really likes Vasopressin because there is less tachycardia and arrhythmia vs. Dopamine). This is essentially early goal directed therapy (a la Rivers). You should have at least a cursory knowledge of the Surving Sepsis guidelines.


3. I'm not very comfortable with IJs or subclavians, femoral lines seem like they are a lot easier to me. I realize that femorals are more infection risk, but in the heat of the moment am I going to be in big trouble for doing femorals instead of the others? Is U/S helpful for femorals or is there too much tissue to see anything?

See one, do one, teach one...I would be apalled if no one walked you through this prior to you needing to place an IJ or Subclavian emergently. Otherwise, I don't see how this can possibly be good for patient outcomes.

Regarding Questions 4 and 5: Have a pocket 2009 ACLS algorithim...it grossly simplifies treatment of arrhythmias. YOU WILL ENCOUNTER ARRHYTHMIAS IN THE MICU.

6. For GI bleed, other than transfusing them and stabilizing ABCs, do you use propanolol or octreotide or both? What other adjunctive meds are used for GI bleeds?

Type and cross...transfuse as necessary (consider comorbidities, i.e. CAD). Contact GI bleed team.;) Start PPI infusion. Consider IV Octreotide load and infusion (50/50) and Ciprofloxacin, both for 5 days. If the source is indeed esophageal varices, consider Propanolol (if pressure and rate permits) and shoot for SBP 80-100 mmHg.


7. For seizures, what do you use besides ativan? Do you start other AEDs before the neuro consult in the morning, or do you just keep them on ativan overnight until the cavalry comes in the AM?

Please tell me you have an overnight Ninja (Neuro on call):eek: A good triple regimen is IV Ativan prn to break the seizures, if in status, contact Ninja and consider Keppra, and Fosphenytoin.


9. What is the purpose of rifaximin in hepatic encephalopathy?

Rifaximin is a nonabsorbable Rifamycin analogue (RNA polymerase inhibitor). Presumably, nitrogenous wastes and other toxins originating from metabolism by bacteria in the gut could be eradicated by oral rifaximin administration. We do not do this at our institution and I have not reviewed the literature for RCTs...

There is, however, data suggesting long term administration can be helpful in patients with recurrent C. diff. It is also approved for the treatment of traveler's diarrhea. It is comparable in cost to Cipro. This summarizes my complete knowledge of Rifaximin:).

12. I've read in several sources that its beneficial for patients with ARDS to ventilate them in prone position. If I suggest that to the staff/nurses, are they going to look at me like I'm weird, or is that strategy actually used in a hospital setting instead of just being theoretical?

Do NOT prone position your patients. The only benefit shown is improvement in oxygenation. There is no proven mortality benefit and it "is prone to complications." (pun intended). Imagine exaplaining to your attending why the Endotracheal tubes and central lines were dislodged on all your ARDS patients:eek:.


Sorry for any typos, I am typing on a tiny Netbook keyboard....

Do NOT prone position your patients. The only benefit shown is improvement in oxygenation. There is no proven mortality benefit and it "is prone to complications." (pun intended). Imagine exaplaining to your attending why the Endotracheal tubes and central lines were dislodged on all your ARDS patients:eek:.

I've had 1 pt we proned that was in ARDS way back when I was a student. The improvement in oxygenation was very substancial, but the special bed you need and trying to get in with the IVs was a huge PIA. the pt also got horrible dependent edema even in her sclera. If you're having trouble oxygenating, well, that issue is well beyond that of a 1st month intern and most IM residents.

With more and more programs discussing the possibility of moving towards 24hr in house intensivists, I find it hard to believe that there are programs out there that have interns flying solo at night. We have residents flying solo at night, but that is totally different (most of the time).

I think you should ask your program director this list of questions so that they can see that their interns aren't prepared to take call by themselves in the MICU. I'm not trying to be harsh, but if you are asking these basic questions before your MICU rotation and will not have any supervision during your MICU rotation - it is a dangerous situation.

Are you at a large teaching hospital? How big is the MICU? Why aren't residents taking call in house? Part of me wants to call bull**** on this hole story..

With more and more programs discussing the possibility of moving towards 24hr in house intensivists, I find it hard to believe that there are programs out there that have interns flying solo at night. We have residents flying solo at night, but that is totally different (most of the time).

I think you should ask your program director this list of questions so that they can see that their interns aren't prepared to take call by themselves in the MICU. I'm not trying to be harsh, but if you are asking these basic questions before your MICU rotation and will not have any supervision during your MICU rotation - it is a dangerous situation.

Are you at a large teaching hospital? How big is the MICU? Why aren't residents taking call in house? Part of me wants to call bull**** on this hole story..

Its a medium sized teaching hospital. We have an SICU, CCU, MICU. The MICU has about 40 beds.

Our month is structured with 2 upper level residents and 2 interns on a team. On call nights, we take turns rotating call q4 days. We have a MICU fellow and upper level resident available during the day, but on call nights where the interns are on, there's no upper level at night and the MICU fellow is at home.

A 40 bed MICU - by yourself - as an intern? How is that even possible? On the general medicine floors, won't you be covering like 12 patients at a time with a senior resident around all the time? My med school's MICU was like 20 beds, with one intern and one 3rd year medicine resident on overnights, and those guys were beat in the morning.

I'm gonna make the assumption that you get an orientation guide to MICU, and that should clearly outline when the fellow or attending need to be called.

Good luck with that 40 bed MICU thing. What is the name of your hospital program?

dc

The patients are cared for by a team. One very junior member of the team happens to be on call in house q4. The correct answer to all your questions is to CALL YOUR FELLOW FOR ANY AND ALL QUESTIONS. If your fellow doesn't answer back in an appropriate amount of time, call your attending. If the situation is dire, you call both simultaneously and whomever calls back first gets your attention first.

The point is that you should never feel that you are making decisions alone without feeling comfortable. In other words, these are patients of the fellow and the attending too, and it's ALWAYS better to ask than to not ask.

There should be enough support for you to feel that you are practicing in a safe environment. If you start and you feel that this is not true, your program director is the next person to discuss the situation with, if your fellow and attending aren't responsive. However, I presume that they will be.

I agree with most of what's already been said. But here's my two cents anyway.

I'm starting MICU soon, and am very nervous about it. I dont know what the hell I am doing. I will have no upper level with me at nights, its a Q4 call schedule with just me and nobody in house, the MICU fellow takes home call.

That's totally bogus. The fellow doesn't have to be in-house (was never in-house at my hospital), but you should always have an upper level resident with you in the ICU. Your program is really hanging you out there. What do they think is going to happen in July when nobody knows anything?

1. A typical septic shock patient requiring intubation and many lines. Am I supposed to just start doing all the lines and intubation by myself if they are unstable, or am I supposed to clear the plan with the fellow first? Might take 5 or 7 minutes for him to call me back.

I'd say that if they're unstable then go ahead and throw in the IJ or femoral and tell your fellow about it later. What's he gonna do? Tell you not to put it in? Make an unstable patient wait for him to drag himself out of bed? He's gonna tell you to put it in anyway.

2. Suppose we have a patient in our unit who starts dropping pressures overnight and needs mild pressor support at 3 AM. Should I just start very low dose levophed without waking up the fellow? Or do they want to know every single time I have to initiate/change pressors?

That probably depends on your comfort level. I usually started pressors on my own without any discussion with the fellow. But I was a third year resident, not an intern. You should probably discuss some basic ground rules with your fellow prior to the rotation to get a good idea of how hands on he wants to be with you.

3. I'm not very comfortable with IJs or subclavians, femoral lines seem like they are a lot easier to me. I realize that femorals are more infection risk, but in the heat of the moment am I going to be in big trouble for doing femorals instead of the others? Is U/S helpful for femorals or is there too much tissue to see anything?

You can see femorals just fine with the US. You'll get comfortable with the IJs after one or two. Explain your situation to the ER staff, and have the ER attending or senior resident supervise your first few lines while you're admitting the patients from the ER. There should always be an ER staff in-house at all times, I'm fairly certain that's an ACGME requirement.

4. We have a CCU with separate housestaff. Does that mean that I wont be having to treat anybody with cardiogenic shock or acute MI? Or will I still get some of those patients? I'm trying to decide how much time I need to study up on that stuff. I will focus less on learning the ins and outs of weird arrythmias and stuff if every single one of those people will get diverted to CCU.

It's probably institution dependent, but I'd assume that the CCU will take care of cardiogenic shock and AMIs. But you'll be sure to see plenty of arrhythmias despite that.

5. I'm assuming that the ICU nurses know how to run codes on their own. So if there's a code while I'm there, am I still expected to run it or can I just assist and let them run their own ACLS protocol until a fellow/attending shows up?

I guess there are hospitals out there where nurses run codes on their own. I haven't been in any of them.

Expect to run your own codes, even as an intern. Do the MICU residents not run all the codes in the hospital? Codes really aren't that hard once you've done a few of them. Keep your code cards on you and follow the directions. Don't be ashamed or embarrassed to look at them during the code if you're unsure of yourself.

6. For GI bleed, other than transfusing them and stabilizing ABCs, do you use propanolol or octreotide or both? What other adjunctive meds are used for GI bleeds?

I wouldn't use propanalol until they've been stepped down. Using propanalol implies that the pressures are relatively stable. If they're stable why do they need to be in the ICU? Turf turf turf! (you'll soon appreciate that as much as I do ;) )

Octreotide is for variceal bleeds. You can always call the GI fellow on call for any GI bleeds that end up in the ICU. More than likely they'll need to be scoped and by telling them early you can get them on the endoscopy schedule quicker. Earlier scope means earlier stepdown. Keep your census low!

7. For seizures, what do you use besides ativan? Do you start other AEDs before the neuro consult in the morning, or do you just keep them on ativan overnight until the cavalry comes in the AM?

Just keep upping your ativan until you snow them. If you get uncomfortable with the doses you have to use wake up the neuro resident.

8. When escalating pressors, do you always max out the dose on the first one before starting another, or is it OK to add on another agent even though the first agent is not maxed out yet?

You can do whatever you want, there's no hard and fast rule. (look into the pH if your pressors aren't working) But multiple pressors is usually bad news. It's a good idea for you to call your fellow (if you haven't already) once you reach multiple pressors, since the patient is now more likely to crash, and you'll want them on board to share in the awesomeness that is M&M :laugh:

9. What is the purpose of rifaximin in hepatic encephalopathy?

I have no idea.

10. When do you use SIMV vs AC ventilation? Do you always start AC first and then wean them to SIMV later?

Never say never, but don't use SIMV - ever. Let the surgeons have fun with that crap. Your MICU attending will ridicule you if you use it.

11. When you are weaning vent settings, whats the order of the wean? Tidal volume, respiratory rate, PEEP or what?

Use the ARDSnet protocol.

12. I've read in several sources that its beneficial for patients with ARDS to ventilate them in prone position. If I suggest that to the staff/nurses, are they going to look at me like I'm weird, or is that strategy actually used in a hospital setting instead of just being theoretical?

I think they'd just look at you like you're weird.
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I still can't believe you'll be flying solo in the ICU as an intern. That's bad azz. GOOD LUCK!

-The Trifling Jester

I am skeptical.

I am betting either you are misunderstanding the level of back-up you have, starting a bogus thread (come on - even an 8-bed ICU left to an intern solo?...and, as someone mentioned, what about July? I can not believe there is an ICU anywhere in this country being run solo by what is essentially a med student (aka, medical intern in July). No way.), or need to demand supervision.

I am for pushing the limits - but what you are describing (and given the level of experience you have based on your questions) is a disaster. Patients will die (they must have died unnecessarily already). I may get hell for this, but if I were in your situation, the first sign that a central line will be needed or an intubation may be required with any patient I would call the fellow and demand he comes in immediately (or surgery/EM/anesthesia, whoever is in-house). If he doesn't show up and you have time, I would call the attending, the ICU director, then the program director, and so on...

If you don't have time, call the ED/code (please don't tell me you are also the code team).

Under no circumstances should a medical resident who is asking questions like you have above be trying to intubate anyone without serious back-up...and I would argue that it is ethically wrong to be doing any central line (except maybe a femoral line in an urgent/emergent situation) without instruction. It seems you are unfamiliar with ultrasound (ie not sure what the femoral vessels look like with an ultrasound). Are you seriously considering a blind IJ as your first line in a crashing patient without any instruction? subclavian? in an intuabted patient? The complications are scary, my friend - and many can't be handled by the majority of medicine interns. The " the purpose of rifaximin in hepatic encephalopathy" (whatever the answer is - and I certainly don't know without looking it up) should be the least of your concerns.

...but of course, I still think you must have back-up or this is a BOGUS POST:laugh:

Good luck, HH

I am skeptical.

I am betting either you are misunderstanding the level of back-up you have, starting a bogus thread (come on - even an 8-bed ICU left to an intern solo?...and, as someone mentioned, what about July? I can not believe there is an ICU anywhere in this country being run solo by what is essentially a med student (aka, medical intern in July). No way.), or need to demand supervision.

At the hospital nearest where I live (146 beds; 10 ICU), the only two doctors in house at night are the ED attending and the on-call intern. When the intern runs in to trouble, they're supposed to call down the the ED first, rather than call their attending. I **** you not. This has been a major contributing factor to at least one ED attending quitting. Very occasionally, there is also an FM PGY-2 overnight. Maybe next year, there'll be more residents running around, as some interns continue into the new residency programs.

At the hospital nearest where I live (146 beds; 10 ICU), the only two doctors in house at night are the ED attending and the on-call intern. When the intern runs in to trouble, they're supposed to call down the the ED first, rather than call their attending. I **** you not. This has been a major contributing factor to at least one ED attending quitting. Very occasionally, there is also an FM PGY-2 overnight. Maybe next year, there'll be more residents running around, as some interns continue into the new residency programs.

:scared::scared:
Who does the intubations? Central lines?
Does the EM attending run up there all night?
And does the EM attending answer management questions? If the July intern has a spetic pt. levo who goes into Afib RVR does the EM attending get a call? Must the ED attending have help manage that? I would expect a piece of the CCM attending's paycheck...of course, that also hurts the care of the ED patients.

...but I guess I stand corrected - such a thing exists. :scared:
That is horrible patient care.
I still think I will stick with my original assesment of the first post:
bullsh!t or misunderstanding. Although a bad situation, a 10-bed ICU in a small hospital with an EM attending downstairs to help is nothing like an intern only running a 40(!)-bed ICU solo.

I remember from the interview trail that the MICU at UTSW is intern-only overnight...

Crazy this still exists, but bad azz nonetheless.:thumbup:

There are 40 beds in the MICU, but I dont think I have to cover all of them. A few of them are covered by other teams (overflow from SICU maybe?)

I think the most I will have to manage would be half that number, maybe 25 max.

:scared::scared:
Who does the intubations? Central lines?
Does the EM attending run up there all night?
And does the EM attending answer management questions? If the July intern has a spetic pt. levo who goes into Afib RVR does the EM attending get a call? Must the ED attending have help manage that? I would expect a piece of the CCM attending's paycheck...of course, that also hurts the care of the ED patients.

...but I guess I stand corrected - such a thing exists. :scared:
That is horrible patient care.
I still think I will stick with my original assesment of the first post:
bullsh!t or misunderstanding. Although a bad situation, a 10-bed ICU in a small hospital with an EM attending downstairs to help is nothing like an intern only running a 40(!)-bed ICU solo.

Yeah...not a good situation overall. At night, from what I've seen, the ED attending supervises the intern doing those invasive procedures (or, if the intern is not on the "trusted" list, just does it him/herself). The fact that the liability rested on the ED attending is the reason why at least one left. She got fed up with being responsible for the management of patients she did not even know, and situations for which she was not properly trained (and not being paid for this extra liability). I can think of a few situations in which the care of ED patients did suffer, because the doc was off the floor, dealing with an issue in the ICU. Finally, there is no CCM attending. Other than the Pulm attending (consultant only), I don't think there is anyone trained specifically in CCM in the entire hospital. The ICU patients are handled by hospitalists and consultants in a very open model. These are but a few of the reasons why I hate that hospital--outside of the ED.

The hospital where I'm from currently has no in house coverage (for anything) over night. Most medicine/ICU/surgeons are all out by 6 and the Radiologist is gone at 11. The ER is double coverage 24/7 and after 6pm they respond to codes throughout the entire hospital. This is a 230 bed (total, med/surg/ICU) hospital with around 50,000 ER visits/yr. So its not crazy busy but it still gets hectic for them at times.

atkinsje -

Does that hospital you refer to sponsor residency training? I'm under the impression that smaller, non-teaching hospitals might fly without much in the way of in-house physicians. I'm curious as to how the mortality rates differ at places without docs around the clock.

It's off the topic, but stuff like this does make "regionalization" of certain healthcare services at least worth discussion.

You are correct bigdan, the hospital is not a teaching facility. I am closely associated with it through my work as a medic, and I shadow several medcine docs and a few surgeons. Its through the shadowing that I learned that the ER docs essentially cover all the admitted patients over night. The ER docs here write admission orders as well, and patients that they admit (even to the ICU) likely won't see the actual admitting doc until the morning. The one exception is some emergent surgical procedures (emergent cardiac cath for STEMI, appy, etc, etc..). As far as mortallity rates, I haven't the slightest.

There is a lot of data out there in health services research that is trying to decipher the Leapfrog recommendations that suggest that there is a benefit to being care for by an intensivist. Jeremy Kahn at UPENN does a lot of this research as does Gordon Rubenfeld (previously at UWash) and T.J Iwashyna at U Mich. I'm super interested in this area of research b/c I think it will be critical in guiding where critical care should go.

Personally, I think it is almost negligent to have no in house physician coverage for critically ill patients. There are a couple single center studies that show an improvement in mortality and morbidity for people admitted at night to ICUs staffed by 24hr intensivists. What this poster is describing is an ICU where an intern is responsible for being the first responder for septic shock, arrhythmias, desaturations on ventilators, etc. I understand that there is presently a shortage of board certified critical care doctors, but to not put a more senior resident (at minimum) in the ICU at night is negligent given the current data available.

Some people in my training program think that having a fellow in house or an attending in house will take away their ability to manage the ICU on their own. This may be partially true, but when you put yourself in a patient's shoes - the right thing to do in terms of organizing staffing becomes clear.

ER doctors are not critical care doctors. There is a difference. To have ER doctors cover ICUs at night is subpar compared to most university/teaching/academic hospitals. I would argue that a senior resident in IM is better than an ER attending for taking care of patients in a MICU.

#1 Personally, I think it is almost negligent to have no in house physician coverage for critically ill patients.

#2 Some people in my training program think that having a fellow in house or an attending in house will take away their ability to manage the ICU on their own. This may be partially true,


#3 but when you put yourself in a patient's shoes - the right thing to do in terms of organizing staffing becomes clear.

#4 ER doctors are not critical care doctors. There is a difference. To have ER doctors cover ICUs at night is subpar compared to most university/teaching/academic hospitals. I would argue that a senior resident in IM is better than an ER attending for taking care of patients in a MICU.

#1 I completely agree!
#2 As someone pointed out on a thread in the EM forum, there is always a balance in academic settings between education and patient care...but it is not either-or...with some forethought, both can be accomplished at near maximal levels. During my prelim IM year, the on-call medicine intern "covered" the entire MICU or attempted to when it wasn't crazy. However, there was always a senior IM resident on too, with the responsibility to monitor the intern's coverage, step only when needed or asked to help, kinda playing a "junior-attending" role. If the intern was good and it wasn't too crazy, the senior could sleep most of the night except during admissions. This left the intern to push his/her limits and one could really get the confidence and experience needed...competent interns were allowed to basically run it all and these same interns actively tried to not wake up the senior or ask for help.
On top of all of that, there was 24-hour attending (CCM) coverage. This covered patient care, as the attending evaluated every addmission and ensured proper CCM was in place and was also there for when things went to hell - beyond the level of the house staff (rare, but it happens...if you looked hard, you could often find the attending monitoring things from a distance trying not to make his/her presence known). I would argue this was necessary for patient care (there are MANY CCM procedures even the most experienced and competent IM senior should not be doing alone - intubation (esp. crash intubation) comes to mind quickly) AND EDUCATION. Some of the best critical-care education I got was when I was on-call overnight and admissions came in. The attending would eval the patient independently and allow the house staff to get everything settled, but then review the case making diagnosis and treatment suggestions and often pointing out things the IM senior missed (stuff that CC-trained docs are better at than non-CCM docs in the ICU setting). Good for patient care and education, I say!
#3 Hell yes! If that is your mother, brother, etc trying to die in the ICU, do you really feel comforatble with a resident alone (nevermind an intern!!) being the last line of defense 50% of the time (the 12 hours overnight). Get me and my family to a real ICU with intensivists.
#4 Depending how recently the EM attending finished residency and what type of EM residency the attending came from, there are probably are cases were an IM senior might be better...but in the emergent setting, especially when a procedure is needed (chest tube, intubation, vascular access for HD, etc.), someone with more skill than nearly all IM seniors needs to be there - an EM attending, an intensivist, an anesthesiologist (in most cases), etc. In situations that are not emergent, an IM senior could be better than an EM attending...certainly better than an EM attending who is trying to run an ED and is asked about non-emergent management decisions on unfamiliar patients six floors up.
Cheers! Hamhock

There is a lot of data out there in health services research that is trying to decipher the Leapfrog recommendations that suggest that there is a benefit to being care for by an intensivist. Jeremy Kahn at UPENN does a lot of this research as does Gordon Rubenfeld (previously at UWash) and T.J Iwashyna at U Mich. I'm super interested in this area of research b/c I think it will be critical in guiding where critical care should go.

Have there been any data which shows a benefit? The only study I recall showed a slightly worse outcomes with intensivists vs non-intensivists coverage of a MICU.

I completely agree with you on all points, but I personally think that a large push to do this without some empiric data is worse than the UK going bare-below the elbows with the public opinion data they put out.

Hernandez

The majority of studies in this area suggest that intensivists have a positive impact on mortality. This led to the current Leapfrog recommendations on regionalization. To date, there are no multi-center studies that look at ICU staffing and mortality. As surrogates, studies have shown that high intensity staffing is associated with a higher likelihood of evidence-based practices and Kahn did a very cool study looking at the hospitals with a high frequency of mechanically ventilated patients and their mortality compared to hospitals with a low frequency. Cool stuff. There have been some single center studies that have shown that mortality is higher for ICU patients admitted during the evening and on the weekends. There's also a single center study that showed that the institution of a 24hr intensivist was associated with no difference in mortality when looking at time of admission.

At ATS this year, all this was very much a hot topic. Health Services Research and Critical Care is a really cool combination.

This book is great: Evaluating Critical Care using Health Services Research to Improve Quality. It is by William Sibbald and Julion Bion. Can get it cheap off amazon.

I do agree though. There is yet to be a great multi-center study that looks at ICU staffing and its affect on mortality and morbidity. That is what fellowship is for!!

Here's some cool papers...

Team model: Advocating for the optimal method of care delivery
in the intensive care unit Charles G. Durbin Jr, MD, FCCM

Intensivist physician staffing and the process of care in
academic medical centres. Jeremy M Kahn, Helga Brake, Kenneth P Steinberg

Volume, outcome, and the organization of intensive care
Jeremy M Kahn

Weekend and weeknight admissions have the same outcome of
weekday admissions to an intensive care unit with onsite
intensivist coverage* Yaseen Arabi, MD, FCCP; Abdullah Alshimemeri, MD, FRCP(C); Saadi Taher, MD, FRCP

Effects of organizational change in medical intensive care unit of a teaching hospital: A comparison of "open" and "closed" formats. JAMA. Shannon Carson et al

Out-of-hours consultant cover and case mix adjusted mortality in intensive care. Lancet. Blunt et al

Physician staffing patterns and clinical outcomes in critically ill patients: A systematic review. JAMA. Pronovost et al

I'm an intern who started on ICU last week-- and was originally scheduled for alone overnight call in a 24 bed MICU.

I've done several months of ICU as a med student and subI. I've read Marino. And I married a critical care surgeon. Basically, as prepared as you can probably get as a med student.

Still, I brought up my (and other's) concerns.

The program quickly reorganized its schedule. No more alone overnights for interns. (Actually, no more overnights for interns at all. Sorry, R2s.)

You need to do the same. There is no way to be prepared enough to provide the standard of care in an ICU overnight as a new intern. Just forward your list of questions to your program director, and he should quickly see the problem...

(And don't do femorals outside of emergencies-- too much thrombosis. Most places lean heavily towards IJs at this point.)