ICU Rotation

I'm going to be working in the ICU in a couple months as well. Also, could people comment on differences between MICU, SICU, CCU, etc.?

Grab THE ICU BOOK by Marino. Thats got everything you need in it my friend. For a quick guide to vent settings and respiratory failure/acid base grab one of your uppers Pocket Medicine books and copy those relevant sections out of it. Should be around 10-15 pages in total. You'll look quite studly and sound quite astute.

Get your hands on the Tarascon Critical Care/Internal Medicine pocket book (14 bucks) and use it for drugs, lytes, nutrition, all sorts o' clinical goodies.

If you can get through big chunks of The ICU Book you'll be way ahead of your peers for next year.

Random stuff to know:
Alter O2 by through PEEP, I:E ratios (longer inflation time at a lower flow may decrease airway pressures and allow better oxygenation), adding FIo2, use directional suction to get all the goobers out. Want Fio2 less than 50% w/in 24 hours to avoid O2 toxicity

Alter CO2 though dead space, tidal volume, rate. Your patient should breath slightly over the vent to prevent complete respiratory muscle atrophy.

BIPAP is your friend.


SICU = MICU patients that have surgery
CCU = MICU patients that have cath's/CABG/Valve sx
MICU is a fine place to start.

Other bits of advice: At the minimum know/do this stuff on your patients
FIRST:Ask the overnight nurse if anything big happened in pm/night shift.
Vent settings : Mode/rate/tidal volume/FI02/PEEP. Peaks and Plateaus.
Is sedation being titrated down or turned off for holidays and neuro checks?
Is pain controlled?
ABG/CXR/BMP/CBC q AM
Insulin requirements? Drip running at what rate with what goal (70-110)?
Lines where, why, how long, clean?
I's n O's, fluids, drips, what rates. Urine output > .5cc/kg/hr at a minimum.
Can we/should we (hold for weaning trials/sx/lines/procedures) start Tube Feeds? Folks gotsta eat.
Consults up to date and following? Rehab, speach n' swallow, that cardiologist show up yet?
What the heck are we doing next for this guy?
Code status?
Make sure someone flipped the pt over once to check for fulminating decub's.

Watch weaning trials, airway stuff, lines, codes, ethical encounters between physician and family. ICU is a unique experience as a fourth year. Relax (yup I said relax) and enjoy it!

My last rotation was ICU, and I loved it. Ventdependent pretty much covered the things you need to know for everyday rounds. ICU is different than other rotations because you look at the patients in a system-based fashion. Notes are written differently and patients are presented on rounds differently.
e.g.
Pulmonary - vent settings, O2 sats on current vent settings, is patient breathing above the vent or at the vent? how many days on vent? good airway pressures? (i.e. peak/plateau) is pt on any abx for aspiration pneumonia?
CV - hypotensive/tachycardic or normotensive/NSR. Any cardiac meds? central access (which sites and when was the line inserted?)
ID - is pt febrile? What has been temperature trend? On which antibiotics and for how many days? have blood cultures grown out any organisms?
GI - tolerating tube feeds? on any gastritis prophylaxis? (all ICU patients are)
Heme - H&H/WBC count? DVT prophylaxis? (again, all ICU patients are on DVT prophylaxis of some sort)
Renal - BUN/Cr trends? urine output/hr? I/O's?
Neuro - pts are usually sedated. are they on a short-acting med (propofol) or long-acting med (ativan) - at least these are the ones used in the hospital I was in.

ICU is a great rotation to do because by the end of the rotation you will actually understand the vent and be more familiar with drugs like pressors and paralytic agents. And depending on your residents, you may get to do central lines - I did about 5 or 6 on my rotation. You'll have a great time doing ICU!

Some great advice already has been given so I won't go into specific details, but more philosophy especially in that you mentioned you are using your ICU as an audition for a potential residency spot. Get friendly with your resident/intern. They will be an invaluable resource. This holds especially true if you are exposed to a variety of attendings who may prefer their own presentation style vs. that of attending X--knowing this in advance helps you look good in front of all the attendings. Granted, pretty much all ICU presentations procede by organ system; however, some attendings want a "what's the specific plan? and save the details for later" review, while others want systems...but high points only, while yet others want every single detail you could ever possibly know to be included in the presentation. Like any other rotation of interest, let your resident know that you are interested in the program. If you work hard and show interest, and better yet find ways to cut down on some of their stress they are likely to speak very well of you to the attendings and the program director. A lot of attendings in the ICU have specific areas of interest in which they love to focus their pimping---if you are fortunate enough to acquire this knowledge before hand it behooves you greatly. Overnight call can be a great opportunity to do lines and procedures that might otherwise during the day go to residents or interns who need to get signed off. All in all, I loved my MICU month; it was my favorite rotation of both years--I recommend doing an ICU month highly as a 4th year.

If you get a chance, also pick up the
"mini" Tarascon Internal Medicine & Critical Care Pocketbook, Third Edition.
check it out a the bookstore or amazon.com. it's only $10-$14 and
a great resource, packed with hi-yield ICU and IM info and fits in one's breast pocket nicely.

MGH blue pocket medicine has some great info. but the Tarascon's is awesome and perhaps more focussed for the ICU environment.

I agree that the Tarascon book is great. The only thing I didn't like was that it didn't explain vents well - I mean, what each setting means (AC vs SIMV vs CPAP, etc.) I learned vents the best by reading the section in The ICU Book, an article on emedicine, and being really annoying and asking my attending and residents a ton of questions

DOtobe said:

I agree that the Tarascon book is great. The only thing I didn't like was that it didn't explain vents well - I mean, what each setting means (AC vs SIMV vs CPAP, etc.) I learned vents the best by reading the section in The ICU Book, an article on emedicine, and being really annoying and asking my attending and residents a ton of questions

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funny. that's the same way i got to understand vents.
also, thank goodness for fellows who can teach....

DOtobe said:

I agree that the Tarascon book is great. The only thing I didn't like was that it didn't explain vents well - I mean, what each setting means (AC vs SIMV vs CPAP, etc.) I learned vents the best by reading the section in The ICU Book, an article on emedicine, and being really annoying and asking my attending and residents a ton of questions

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You cannot change your username as far as I know.

Chisel said:

Just wondering if any current outgoing 4th years or current Residents could give advice on what to expect on an ICU rotation.

I will be doing a rotation in an ICU next month which happens to be the second rotation of my 4th year and it will be at the hospital that I expect to apply (and be accepted) for residency.

Any advice on what to study, make sure I know? Any good books specifically for an ICU rotation? Things I may encounter regularly in the ICU that I may not have in 3rd year rotations?

I know nothing about ventilators and their uses....any advice on what to read to learn more about vents?

Thanks in advance,

Chisel
MS IV

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Didn't Simelaro lecture to you about Vents and give every student the Blood Gas and Ventilator Manual during Renal/Pulm? Just Curious. This could be something new.

njbmd said:

Hi there,
Go the the Society for Critical Care Medicine site and you can download an ICU manual for medical students that gives a pretty good introduction to the ICU. It is in PDF form. ICU Recall is as much as you need and is easy reading. The Marino book is pretty dense and very boring. If you can get your hands on House Officers Guide to the ICU by Elefritedes, it is the best book written and easy to get through. You can read it in a couple of days and know everything from ventilators to chest tubes to hemodynamic monitoring.

Good luck and enjoy
njbmd

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Elefteriades has 2 books with the title House Officers Guide to the ICU, and one is for management of the Heart and Lungs (278 pages), while the other is management of the cardiothoracic surgery patient (207 pages). Which one are you talking about?

thanks a ton to everyone who has posted here thus far. I, too, am starting in the ICU tomorrow for a month long rotation, and am a bit nervous but looking forward to it.

Have the best time! This is a great rotation. You will learn SO MUCH. And the more interested you are, the more interest and attention and teaching you will get.

Critical care can be so rewarding - you don't realize what a deal it is until you've been up all night literally fighting for someone's life. And they pull through. That is just the best.

awesome thread, you guys!!!! thanks so much for hte advice!

njbmd said:

Hi there,
Go the the Society for Critical Care Medicine site and you can download an ICU manual for medical students that gives a pretty good introduction to the ICU. It is in PDF form. ICU Recall is as much as you need and is easy reading. The Marino book is pretty dense and very boring. If you can get your hands on House Officers Guide to the ICU by Elefritedes, it is the best book written and easy to get through. You can read it in a couple of days and know everything from ventilators to chest tubes to hemodynamic monitoring.

Good luck and enjoy
njbmd

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anyone have link to this pdf? i'll be doing micu sub-i in 3 wks. if any updated resources, please post. thanks.

Yogi Bear said:

anyone have link to this pdf? i'll be doing micu sub-i in 3 wks. if any updated resources, please post. thanks.

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I'm starting my MICU sub-I in three weeks too ... very excited but scared as well. Here is the link: http://www.sccm.org/publications/documents/MedicalStudentsGuide.pdf

Pocket Medicine also has some great stuff on vents, abg's, and the ever present ARDS.

Know about ards and its requirements for vent settings.

starten with the diagnostic criteria:
Acute onset

Bilateral infiltrates

Pulmonary artery wedge pressure less than 19 mm Hg (or no clinical signs of congestive heart failure)

PaO2/FIO2 ratio less than 200 (ARDS) or less than 300 (acute lung injury [ALI]): ALI is a milder clinical expression of the injury of ARDS that may or may not progress to ARDS.

Just finished a month in the SICU, had a great time, intubated 4 or 5 patients, many SC and IJ central lines, A lines, and shiley dialysis caths, multiple rewires, dobhoff tubes etc. By far the best month of medical school i have spent. i used the Mariono's ICU Book and multiple online resources, i also found the ICU Intern Pocket Survival Guide and Tarascons to be great resources. Have FUN!

Skialta