July sub-i question

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Hey all, I am signed up for my sub internship in the ICU in July. At first I thought this was a great idea, now I kind of regret the timing-wish I had more general medicine experience before trying to impress potential letter writers. All in all I am looking forward to the challenge of it though.

Along those lines, I was looking for advice on what to read up on prior to starting. I bought "The ICU Book" off ebay for pretty cheap, but its like 1000 pages so I was hoping maybe there would be some key chapters to look at.

Or other resources you all have liked. Obviously I read about my patients and UpToDate is good, but looking for other practical advice.

Thanks

Originally Posted by ericL

Hey all, I am signed up for my sub internship in the ICU in July. At first I thought this was a great idea, now I kind of regret the timing-wish I had more general medicine experience before trying to impress potential letter writers. All in all I am looking forward to the challenge of it though.

Along those lines, I was looking for advice on what to read up on prior to starting. I bought "The ICU Book" off ebay for pretty cheap, but its like 1000 pages so I was hoping maybe there would be some key chapters to look at.

Or other resources you all have liked. Obviously I read about my patients and UpToDate is good, but looking for other practical advice.

Thanks

My suggestion is to be awesome

Ok. Since I've got like three minutes and I'm feeling kinder than usual.

Just show up, be present, show interest.

You could spend months in general IM prior to the MICU but it wouldn't matter. The MICU is a tricky thing, and "reading up" on the ICU is even trickier, especially with an old book like Marino's. Hell, even the surviving sepsis guidelines are mostly garbage (depending on who you ask of course!!).

Pick up a patient or two and try to know everything you possibly can about that one or two patients. And try to start thinking about next step in management which means how to get medicines stopped, tubes and lines out, and the patient from the ICU to the ward. Make those next step in management suggestions in your daily plan - back them up in a rational manner if asked about them. Be ok with being wrong, your attempt to actually THINK should be/will be noted - don't argue.

Leave late.

Ask to put in lines. Ask to use the ultrsound. They may not let you, but you should ask.

Ask the fellow to tell you about the vents. He may not, but then he's a douche.

In Marino's book read about vents, pressors, and fluids. Almost every MICU patient will have you needed to make intelligent comments about those three things.

Norepi is your go-to pressor. Don't debate pressors. If someone asks you which one you want to start you say, "levophed" (norepi).

Vanco/Zosyn. These will be your empiric antibiotics. Your shop may like to add an additonal drug for "double coverage" of pseudomonas . . . depending how pedantic the clinical professors you are working with are, adding the extra abx may be "bad form". When they ask you what you want to start you say, "Vanco/Zosyn". If they want another drug they will say, if they ask you for another, guess . . . intelligently (levaquin or similar) . . . you will quickly learn your shop's favorite abx.

Fluids. You will say, "Normal saline". If they ask you how much say, "liter bolus". Don't be a pus$y with fluids, and don't use half normal anything.

CVP is GARBAGE, but they will probably perseverate about it, and if they do shake your head meaningfully and act interested. Don't pay attention to it unless you know your attending does.

Know when to start dialysis/CRRT.

That should be good start for the first day on the unit. You'll pick up the rest.

Originally Posted by jdh71

Ok. Since I've got like three minutes and I'm feeling kinder than usual.

Just show up, be present, show interest.

You could spend months in general IM prior to the MICU but it wouldn't matter. The MICU is a tricky thing, and "reading up" on the ICU is even trickier, especially with an old book like Marino's. Hell, even the surviving sepsis guidelines are mostly garbage (depending on who you ask of course!!).

Pick up a patient or two and try to know everything you possibly can about that one or two patients. And try to start thinking about next step in management which means how to get medicines stopped, tubes and lines out, and the patient from the ICU to the ward. Make those next step in management suggestions in your daily plan - back them up in a rational manner if asked about them. Be ok with being wrong, your attempt to actually THINK should be/will be noted - don't argue.

Leave late.

Ask to put in lines. Ask to use the ultrsound. They may not let you, but you should ask.

Ask the fellow to tell you about the vents. He may not, but then he's a douche.

In Marino's book read about vents, pressors, and fluids. Almost every MICU patient will have you needed to make intelligent comments about those three things.

Norepi is your go-to pressor. Don't debate pressors. If someone asks you which one you want to start you say, "levophed" (norepi).

Vanco/Zosyn. These will be your empiric antibiotics. Your shop may like to add an additonal drug for "double coverage" of pseudomonas . . . depending how pedantic the clinical professors you are working with are, adding the extra abx may be "bad form". When they ask you what you want to start you say, "Vanco/Zosyn". If they want another drug they will say, if they ask you for another, guess . . . intelligently (levaquin or similar) . . . you will quickly learn your shop's favorite abx.

Fluids. You will say, "Normal saline". If they ask you how much say, "liter bolus". Don't be a pus$y with fluids, and don't use half normal anything.

CVP is GARBAGE, but they will probably perseverate about it, and if they do shake your head meaningfully and act interested. Don't pay attention to it unless you know your attending does.

Know when to start dialysis/CRRT.

That should be good start for the first day on the unit. You'll pick up the rest.

All great recommendations.

To offer another piece of advice: If the fellow doesn't want to show you the vents, ask the RTs. In my experience they've always been super helpful and have wanted to teach me things, whether it be on the vents, drawing a blood gas, etc.

Originally Posted by jdh71

My suggestion is to be awesome

I crip walked outta my mom's womb so bein awesome ain't no thang.

Originally Posted by jdh71

Ok. Since I've got like three minutes and I'm feeling kinder than usual.

Just show up, be present, show interest.

You could spend months in general IM prior to the MICU but it wouldn't matter. The MICU is a tricky thing, and "reading up" on the ICU is even trickier, especially with an old book like Marino's. Hell, even the surviving sepsis guidelines are mostly garbage (depending on who you ask of course!!).

Pick up a patient or two and try to know everything you possibly can about that one or two patients. And try to start thinking about next step in management which means how to get medicines stopped, tubes and lines out, and the patient from the ICU to the ward. Make those next step in management suggestions in your daily plan - back them up in a rational manner if asked about them. Be ok with being wrong, your attempt to actually THINK should be/will be noted - don't argue.

Leave late.

Ask to put in lines. Ask to use the ultrsound. They may not let you, but you should ask.

Ask the fellow to tell you about the vents. He may not, but then he's a douche.

In Marino's book read about vents, pressors, and fluids. Almost every MICU patient will have you needed to make intelligent comments about those three things.

Norepi is your go-to pressor. Don't debate pressors. If someone asks you which one you want to start you say, "levophed" (norepi).

Vanco/Zosyn. These will be your empiric antibiotics. Your shop may like to add an additonal drug for "double coverage" of pseudomonas . . . depending how pedantic the clinical professors you are working with are, adding the extra abx may be "bad form". When they ask you what you want to start you say, "Vanco/Zosyn". If they want another drug they will say, if they ask you for another, guess . . . intelligently (levaquin or similar) . . . you will quickly learn your shop's favorite abx.

Fluids. You will say, "Normal saline". If they ask you how much say, "liter bolus". Don't be a pus$y with fluids, and don't use half normal anything.

CVP is GARBAGE, but they will probably perseverate about it, and if they do shake your head meaningfully and act interested. Don't pay attention to it unless you know your attending does.

Know when to start dialysis/CRRT.

That should be good start for the first day on the unit. You'll pick up the rest.

Nice! Thank you much! That's exactly the tangible advice I was looking for. Especially abx and pressors and such.

It's much appreciated!

Originally Posted by ericL

Nice! Thank you much! That's exactly the tangible advice I was looking for. Especially abx and pressors and such.

It's much appreciated!

This advice will probably get you about halfway through a CCM fellowship. The other half will be learning the "why" and the "what next."

Originally Posted by jdh71

Ok. Since I've got like three minutes and I'm feeling kinder than usual.

Just show up, be present, show interest.

You could spend months in general IM prior to the MICU but it wouldn't matter. The MICU is a tricky thing, and "reading up" on the ICU is even trickier, especially with an old book like Marino's. Hell, even the surviving sepsis guidelines are mostly garbage (depending on who you ask of course!!).

Pick up a patient or two and try to know everything you possibly can about that one or two patients. And try to start thinking about next step in management which means how to get medicines stopped, tubes and lines out, and the patient from the ICU to the ward. Make those next step in management suggestions in your daily plan - back them up in a rational manner if asked about them. Be ok with being wrong, your attempt to actually THINK should be/will be noted - don't argue.

Leave late.

Ask to put in lines. Ask to use the ultrsound. They may not let you, but you should ask.

Ask the fellow to tell you about the vents. He may not, but then he's a douche.

In Marino's book read about vents, pressors, and fluids. Almost every MICU patient will have you needed to make intelligent comments about those three things.

Norepi is your go-to pressor. Don't debate pressors. If someone asks you which one you want to start you say, "levophed" (norepi).

Vanco/Zosyn. These will be your empiric antibiotics. Your shop may like to add an additonal drug for "double coverage" of pseudomonas . . . depending how pedantic the clinical professors you are working with are, adding the extra abx may be "bad form". When they ask you what you want to start you say, "Vanco/Zosyn". If they want another drug they will say, if they ask you for another, guess . . . intelligently (levaquin or similar) . . . you will quickly learn your shop's favorite abx.

Fluids. You will say, "Normal saline". If they ask you how much say, "liter bolus". Don't be a pus$y with fluids, and don't use half normal anything.

CVP is GARBAGE, but they will probably perseverate about it, and if they do shake your head meaningfully and act interested. Don't pay attention to it unless you know your attending does.

Know when to start dialysis/CRRT.

That should be good start for the first day on the unit. You'll pick up the rest.

Very interesting, also from someone interested in CCM. Care to expand on the Surviving Sepsis guideline controversy?

Originally Posted by sineapse

Very interesting, also from someone interested in CCM. Care to expand on the Surviving Sepsis guideline controversy?

Most of it has to do with the heavy reliance of Early Goal Direct Therapy (EGDT) as used by the surviving sepsis campaign coupled with the fact that there is really not that much great EBM with regards to critical care medicine, especially septic patients, for any number of reasons, that you're left with a set of guidelines that are mostly expert opinion on top of EGDT which as it has been dissected the last 10 years is showing that not only can it not be reproduced, but all of the end points, especially CVP, are basically not helpful.

At the end of the day, you have to treat the patient and not numbers. Septic patients are too complicated to use any single static variable(s) to decide weather or not you are doing the right thing. It's all part of the whole - pieces in the puzzle of a critically ill patient.