When am I supposed to call the MICU fellow when I'm on call?

[platon20]

OK guys, you remember me, the dumb medicine intern in New York who doesnt know jack about ICU stuff.

Well here I am in the middle of the month, for a status update on my rotation so far.

I've gotten into some trouble for not calling the MICU fellow in the middle of the night for the following situations:

1) Patient died in the unit. Pt with sepsis/ARDS on a vent for 2 weeks, family had decided to wait one more day then pull the tube. My fellow already knew about that and was expecting to d/c care the next morning. Well the family comes in about 3 AM after they hear about the family member not doing so well and they decided to pull the tube right then instead of waiting for morning. I got 4 MICU consults after that (fortunately none of them needed to be transferred) so I didnt have a chance to call the fellow and let him know the pt had died early. I didnt think it would be a big deal since the whole team knew this patient was going to have care withdrawn and die the next morning, but the fellow was livid, he said that he always needed to know the MOMENT somebody died, regardless of whether it was already a planned "unplugging" or not. This one was my misunderstanding. At the time I didnt think it was necessary to page them at 4 AM for a planned death that they already knew was goin to happen later that day. Lesson learned, I can live with that.

2) COPD patient transfer to the unit with hypercarbic resp failure. Pt was put on BiPAP by the general medicine team and RT had already been there and put on the initial settings: ipap 15, epap 10, fio2 60%. 1 hour before rounds (while the fellow and attending were rounding on other patients at the hospital down teh block) I get an ABG that shows CO2 increase from 51 to 61 while the pt is on BiPAP. She had a good resp rate (14 to 18) and her O2 sats were OK. She was still able to talk/protect airway/secretions, not tiring out yet, etc so I made an executive decision taht although she probably needed to be intubated, that it wasnt something that had to be done RIGHT NOW and could wait till the fellow/attending got there to see the pt. In the meantime, I noticed that her tidal volume was only in the 300s, so I figured that by increasing tidal volumes by increasing pressure support, I might be able to buy her some time by getting her to breathe off the CO2. So I changed her settings to 20/10/60%, which I noticed changed her tidal volumes from 300s up to 450s or so. I didnt want to reduce her PEEP because she had been desatting to the 60s earlier and I didnt want to lessen her oxygen support. ABG 30 mins after changing shows improved ABG with CO2 down to 53 with good O2 sats. Minutes after that ABG comes back, the fellow/attending arrive and they are pissed that I didnt call them first before changing BiPAP settings. They said my PEEP was way too high and that I should have reduced both the PEEP and increased the IPAP. I didnt think it was such a bad decision, especially since I made it knowing they woudl be there very soon to assist and that they were busy rounding on other patients. My basic idea of increasing tidal volumes by increasing pressure support was right, they just didnt agree on the ipap/epap settings.

3) I got screwed by the nurses and respiratory techs on this next one. We have a patient with ARDS who is on nitric oxide therapy. The nurse calls me at 6 AM stating that the pt was on 50% FIO2 and nitric oxide level of 20 ppm (which is considered our max dose). She said that RT decreased the nitric oxide level. I said "OK" and said that I'm not sure we should be messing with it but I would check on the patient in a little bit. Well I went by there a little later and the pt is doing fine, the nitric oxide was at 15 and pt was satting 94-96% on FIO2 50. 2 hours later on rounds (its not my patient, I was just cross covering for someone else) we notice that all of a sudden teh FIO2 is on 85% and the nitric oxide level is on 12. Apparently the pt had one desat episode to the low 80s so the nurse bumped up the FIO2. Meanwhile the RT had been CONTINUOUSLY weaning down the nitric oxide level. Worst of all, the nurse had written in the chart that I gave them a verbal order to wean the nitric, which is a total misrepresentation of what happened. The attending is absolutely livid again, threatening to fire me, that I will have to repeat my residency, etc. Of course he wont even stop yelling at me long enough to understand the nuances of what actually happened. Lesson for me: NEVER wean nitric oxide, even if they are on toxic doses. When the nurse told me that the RT had turned it down without even talking to me first, I mistakenly assumed that it must be part of an ICU weaning protocol like they use with FIO2.

4) Attending told me on rounds to transfer a very stable pt (room air, no foley, eating fine) to the stepdown unit. He SPECIFICALLY said stepdown bed, not a regular floor bed (which I thought was total overkill). If he had said a floor bed, I coulda transferred him ASAP because there were plenty available. Well we didnt have any beds available in stepdown until 3 AM at night, so he moved then. If he had moved earlier in the day, I would have transferred care over to the general medicine team, but since it was so late at night, I didnt want to call them so late, its generally considered poor form to transfer ICU patients in the middle of the night. So I moved him to stepdown but kept him on our team. Well of course the attending is pissed off again, stating that he doesnt care if its 3 AM he wants the pt transferred to medicine so he doesnt have to round on him the next day. Furthermore, he states that even if the guy had to stay in the unit for another day due to lack of beds, that we still should have transferred care anyways. Again, he berates me for not callin the MICU fellow at 3AM and asking him if its OK to transfer to the medicine service.

This is news to me, I had no idea that the general medicine team was allowed to take care of people in the ICU. Thats great news though, considering the frequency of DKA and non-critical overdose patients (like the guy who takes 10 risperdal tabs who is stone cold normal on exam with normal labs and normal EKG who just needs to be babysat for 24 hours). Usually we try to send those guys to the medicine service in stepdown beds (we have to admit them to the MICU if no stepdown beds are avail, which is a frequent problem). But if the medicine service is allowed to see people in the ICU, it means I can essentially turf all of them to the medicine service and tell them they have to round on them in the ICU.

I realize that I'm partially in the wrong here, and I can appreciate some of their frustration. My frustration is not so much about what they said, but the way they said it (stating they are going to fire me, I'm a worthless resident, I will have to repeat residency, etc).

To avoid all further bitching by the attending and fellow, this is what I'm going to do:

1) Call them for every single ABG that comes back at night, even if its stone cold normal.

2) Call them for every single patient desat at 8:30 AM just before rounds while they are driving to the hospital, even though I know they are going to be there in 30 minutes and its probably not that big of a deal.

3) Call them at night for every single change in code status, after all I wouldnt want them to yell at me for not knowing that a pt switched to DNR/DNI at 11 PM by long lost family members.

4) Call them for every single patient who drops their urine output at night (thats at least 3-4 phone calls).

5) Call them for every single pt who is requiring a higher FIO2 than where they were at morning rounds.

Yeah so I'm being a little facetious here but you get the idea. Thank god I never have to work with these *******s again after this month (the fellow is moving to a different fellowship program and the attending is retiring).

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[Tigerz_Fan]

All I can say is wow. I'm going to try to answer your questions for you:

Let me start with this: don't let a bad experience ruin you.

First of all, yes, CALL YOUR FELLOW. The fellows and ultimately, the attendings are the ones responsible for every single thing you do. I start taking call July 1st. And I'll tell you one thing: I want calls especially if I know an intern is covering the unit alone.

And your questions:

1. Yes, if a patient dies, call your fellow. Regardless of a planned trip to the beyond or not, call. In residency, we were required to call both the attending and the fellow. This was not only departmental policy, but hospital policy. Also, our fellows are responsible for knowing the "bed situation" of the unit at all times. This is critical when taking call to accept MICU transfers. We may turn down a transfer to the unit because supposedly the bed are all full, when there may be an empty bed we weren't aware of because of the lack of a phone call.

2. And the COPD patient. A call from the intern, yes that would be nice. From a senior, well depended on the senior. Managing bipap settings can be tricky sometimes, and there are things to consider that you may not be aware of. Your concept to increase the PS to increase the TV and therefore blow off the CO2 is correct. But the attending and fellow are correct that you should have reduced the PEEP as well. The reason is, and take into account I don't know the readings of the bipap or the pts wt and ht, that you could have dropped that patient's lung with such high pressures. And that was something that would not be able to wait until the attending and fellow rounded on the patient. So, hence the phone call.

3. OUr rule of thumb about nitric oxide was that NO ONE was allowed to touch it without attending orders. I am very suprised that an RT "weaned" nitric oxide without an order. In our instiution, they can't even wean FiO2 without an order to do so. The only automatic protocols are turn q2h, oral hygiene, VAP prevention, and sedation vacations. The JCAHO rules of verbal orders are that the RN must repeat them back to you to ensure accuracy. So, if a nurse wrote down that you gave a verbal order, then from the situation you described that would be a violation. That happened to me once, and I refused to cosign the order.

4. Um, well, unfortunately, in residency, I would have been yelled at for this one too. Yes, it is poor form to transfer patients out in the middle of the night. But, on the other hand, it is also poor patient care to keep the patient list so full (overworked ICU team), when pts can transfer out. It is one more patient to round on, one more to write a note on, and 30 mins of care spent on a not-so-critical patient when that 30 minutes of care could have gone to a critical patient.

And for the last (I know you were just being facetious, but you brought up good points):

1. Please dont' call for normal ABG, unless it is by an act of God and we should all celebrate!

2. Yes, call for desats because we may know a bit more tweaking of the vent than you do that may help.

3. Always call on code status changes. There may be more to the story then you are aware of. And I was always wary of the long-lost family member that wanted to change code status at 2am.

4. The UOP thing, that depends on the patient. A patient who you just started CVVHD and his UOP dropped from 30ml to 10? No, no need to call. A patient who went from normal to 25mL over the night shift, yes call.

5. Same as #2.

As I said before, since you are an intern, I would expect more calls from you than a R3 running the unit at night. The fellows are only there to help and everyone should have one thing in mind. That is taking care of the patient.

Don't worry about the threats, I doubt anything will come of it. And at the end, you will be the superstar of the MICU!

 

[mig26x]

first thing that the fellow told us in the CICU was--> if pt dies I need to know STAT no matter the time of death, no matter if pt CMO

 

[deleted59964]

not commenting on the OP's scenarios, but...

the director of our ICU tells new staff that "the time to call is when you first consider whether you should call or not"

 

[southerndoc]

When I was a resident in the MICU, we had to call for every admission, every death, and every decompensation. There was a "nocturnalist" in the ICU that we would run many things by.

If in doubt, call the fellow.

 

[Tigerz_Fan]

I wonder how the rest of the rotation is going for the OP?