RaginMD

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Internal medicine resident here and I just have a question for anyone else who may rotate through ICU in their programs.
Is it normal for an upper level with only 1 month of ICU experience as an intern to work an ICU alone (20 beds) with no fellows or in house staff.

Our interns don't work overnight in the ICU so we do q4 24 ICU call as an upper level and you work alone at night. I'm scared of this because 1) I barely have experience in managing ICU patients 2) We cap and 20 and are often almost full and 3) how the hell am I suppose to take care of 20 critically ill people alone at night!!!

Is there any other programs doing this? How do other people handle this? I feel like it's very unsafe and can't possibly be legal.
 

BoardingDoc

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Internal medicine resident here and I just have a question for anyone else who may rotate through ICU in their programs.
Is it normal for an upper level with only 1 month of ICU experience as an intern to work an ICU alone (20 beds) with no fellows or in house staff.

Our interns don't work overnight in the ICU so we do q4 24 ICU call as an upper level and you work alone at night. I'm scared of this because 1) I barely have experience in managing ICU patients 2) We cap and 20 and are often almost full and 3) how the hell am I suppose to take care of 20 critically ill people alone at night!!!

Is there any other programs doing this? How do other people handle this? I feel like it's very unsafe and can't possibly be legal.
I'm EM, not IM which changes the calculus a bit, but as a 2nd year we did a month in the ICU that was q3 30hr hr shifts where we'd be solo coverage for the overnight portion of it (with an attending available by phone if needed).

So yeah, it happens.
 
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I'm EM, not IM which changes the calculus a bit, but as a 2nd year we did a month in the ICU that was q3 30hr hr shifts where we'd be solo coverage for the overnight portion of it (with an attending available by phone if needed).

So yeah, it happens.
This was my experience as well in EM. Fortunately, our schedule was a bit less brutal than yours--I want to say it was q4 "24 hour" shifts.
 
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jurassicpark

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Yes, it happens. Seniors can be alone in the ICU without in-house support from staff or fellows. Never heard of interns not working at night though? While interns are like lost little babies, does free up time for the senior.

It's okay to be scared and nervous. You should be otherwise I'd think you're cocky. And do NOT be afraid to call your attending.
 
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This is not safe IMO... Our cap is also 20 but most of the time we have between 8-12 patients. It's one intern and one resident.
 

MedicineZ0Z

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The argument might be that neither should
Maybe. But the doctor in training stays and the midlevel can go out first. If we're talking patient safety, lets first target the main problem then move onto secondary issues (residents covering ICUs alone).
 
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20 by yourself does seem a bit much.
I don't miss these days one bit. "28 hour call" quickly turned into 32 hours... etc.
 

WinslowPringle

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Not IM but general surgery and as 2nd years with no ICU experience we did q2 24hr ICU shifts in about a 20bed ICU as “the upper level” with backup available by phone call. It happens.
 
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MedicineZ0Z

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Family med - We do this as interns but in the 2nd half of the year. Fellow available but often not very readily available so we will run codes etc and some of us will do some procedures solo too (lines we often place alone).
 

Kaustikos

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Internal medicine resident here and I just have a question for anyone else who may rotate through ICU in their programs.
Is it normal for an upper level with only 1 month of ICU experience as an intern to work an ICU alone (20 beds) with no fellows or in house staff.

Our interns don't work overnight in the ICU so we do q4 24 ICU call as an upper level and you work alone at night. I'm scared of this because 1) I barely have experience in managing ICU patients 2) We cap and 20 and are often almost full and 3) how the hell am I suppose to take care of 20 critically ill people alone at night!!!

Is there any other programs doing this? How do other people handle this? I feel like it's very unsafe and can't possibly be legal.
Hospital I'm at is "capped" 16 beds but having 20 patients can/does happen. And there's only 1 senior. ICU is not always full, though. And not all patients in the ICU are necessarily acutely dying or require constant intervention. Several DKA's that are closing the gap vs COPD patients that are intubated and just need monitoring.
It sucked in March/April. We went from 16 to 40-50 patients/beds.
But 20 patients is not unsafe nor abnormal.
 
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Lexdiamondz

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EM

As PGY2s and 3s we were the overnight seniors in the MICU and CCU. No in house fellow or attending however both were reachable by phone and we were "capped" at 16 but very frequently would have up to 20. Not everyone was crashing all the time so really mostly it's only 3-4 active players with a dozen or so "stable-sick" people but sometimes **** hit the fan. It's scary but doable - this is how you learn to triage sick vs not sick and how to be a leader during a crisis as an attending.

You don't grow by staying in your comfort zone - you need to feel stressed a bit in order to become better. That being said, don't be afraid to call in the cavalry when you need to since that's what they are there for
 

Kaustikos

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EM

As PGY2s and 3s we were the overnight seniors in the MICU and CCU. No in house fellow or attending however both were reachable by phone and we were "capped" at 16 but very frequently would have up to 20. Not everyone was crashing all the time so really mostly it's only 3-4 active players with a dozen or so "stable-sick" people but sometimes **** hit the fan. It's scary but doable - this is how you learn to triage sick vs not sick and how to be a leader during a crisis as an attending.

You don't grow by staying in your comfort zone - you need to feel stressed a bit in order to become better. That being said, don't be afraid to call in the cavalry when you need to since that's what they are there for
Emphasis on the bold portion. This is so true.
 
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Yes but when you’re learning how to triage sick vs not sick you’re going to mistakenly think not sick when the patient is sick with bad outcomes, needless to say I don’t think anyone would want their family member in an ICU being managed solely by a resident without any prior ICU experience..but it seems to be working so I guess it’s possible
 

Lexdiamondz

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Yes but when you’re learning how to triage sick vs not sick you’re going to mistakenly think not sick when the patient is sick with bad outcomes, needless to say I don’t think anyone would want their family member in an ICU being managed solely by a resident without any prior ICU experience..but it seems to be working so I guess it’s possible
As mentioned previously, most ICUs in this country don't have in-house intensivist coverage 24/7 and often it's a midlevel (sometimes a new grad) who is managing the unit overnight. If you find yourself in an ICU in most cities with <100k people, chances are at night your sole caretaker will be a midlevel with less experience than a PGY-2. It is normal to get more autonomy as you progress - that's the point of training.

Your job as nighttime coverage is to stabilise sick patients and put out fires and while you're physically alone, your supervising fellow and attending are both on the phone and can come in if you need them too, plus there's always anesthesia and the ED if you're really in a bind and need help quick.
 

Kaustikos

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Yes but when you’re learning how to triage sick vs not sick you’re going to mistakenly think not sick when the patient is sick with bad outcomes, needless to say I don’t think anyone would want their family member in an ICU being managed solely by a resident without any prior ICU experience..but it seems to be working so I guess it’s possible
I get your hesitation and concern. Are you a PGY1 going to PGY2 or PGY2 going PGY3? My advice is different based on that.
If you're an incoming PGY2, you just need to breath and relax. You've had a month in the ICU as a PGY1 and you'll learn quickly what your job is on nights/being in the ICU. Like Lexdiamondz said, your job is stabilizing the patient or putting out fires. You're not there to do anything fancy or change management unless you have to. Most times, you don't need to. Plus, the attending should be available by phone if need be. Not only that, I've found the nursing staff in the ICU tend to have a good grasp of how to help.
Learning to triage/know who's sick is part of the training. We could have our hands held throughout our entire training, but that would make me a worse doctor. I learned better by doing. 4 months in the ICU as a second year went a long way but I wouldn't trade that training for anything else. It's okay to be nervous, but just realize you'll get through it.
Not to mention - the day team's job is to tell you who the sick patients are and what they want. You'll get endorsements about the patients and they'll let you know who to keep an eye out on. That doesn't guarantee someone won't take a turn; but that's uncommon. The day is usually good about letting you know what's happening and what they want.

I'm biased a bit given that I love the unit. However, just take a deep breath. You'll be fine.
 

CCM-MD

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As mentioned previously, most ICUs in this country don't have in-house intensivist coverage 24/7 and often it's a midlevel (sometimes a new grad) who is managing the unit overnight. If you find yourself in an ICU in most cities with <100k people, chances are at night your sole caretaker will be a midlevel with less experience than a PGY-2. It is normal to get more autonomy as you progress - that's the point of training.

Your job as nighttime coverage is to stabilise sick patients and put out fires and while you're physically alone, your supervising fellow and attending are both on the phone and can come in if you need them too, plus there's always anesthesia and the ED if you're really in a bind and need help quick.
Most common is a nocturnist hospitalist at night manning the ICU rather than a lone midlevel.
 

NITRAS

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As A PGY2, my third week of the year, I did night float. I covered ICU and supervised the baby interns. If I needed to tube someone, I called the ED staff to assist. If I needed a CVC,. . . It largely waited to am. All of the admissions, the attending got a call (well. . . .4 of the 5 attendings). Bad stuff happened, the attending got a call.

I only did 2 24 hour calls a month (they suck) with q 4 call. I had 2 months of ICU during my intern year.

Did the duty hours change? I wasn’t sure ABIM was ok with hours like this.
 
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I get your hesitation and concern. Are you a PGY1 going to PGY2 or PGY2 going PGY3? My advice is different based on that.
If you're an incoming PGY2, you just need to breath and relax. You've had a month in the ICU as a PGY1 and you'll learn quickly what your job is on nights/being in the ICU. Like Lexdiamondz said, your job is stabilizing the patient or putting out fires. You're not there to do anything fancy or change management unless you have to. Most times, you don't need to. Plus, the attending should be available by phone if need be. Not only that, I've found the nursing staff in the ICU tend to have a good grasp of how to help.
Learning to triage/know who's sick is part of the training. We could have our hands held throughout our entire training, but that would make me a worse doctor. I learned better by doing. 4 months in the ICU as a second year went a long way but I wouldn't trade that training for anything else. It's okay to be nervous, but just realize you'll get through it.
Not to mention - the day team's job is to tell you who the sick patients are and what they want. You'll get endorsements about the patients and they'll let you know who to keep an eye out on. That doesn't guarantee someone won't take a turn; but that's uncommon. The day is usually good about letting you know what's happening and what they want.

I'm biased a bit given that I love the unit. However, just take a deep breath. You'll be fine.
You have 4 ICU rotations during PGY2 year! That is hard core.
 

WheezyBaby

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Until recently we had seniors on q4 long call covering a technical cap of slightly over 30 (though in practice typically less) with a per day admit cap around 10 and fellows taking home call back up. Fellows were generally very receptive to coming in, but I think it was still subpar for patient care, though was a great opportunity for growth as a resident. Theres now some overnight assistance with cross cover which I think was overall a smart move
 

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As A PGY2, my third week of the year, I did night float. I covered ICU and supervised the baby interns. If I needed to tube someone, I called the ED staff to assist. If I needed a CVC,. . . It largely waited to am. All of the admissions, the attending got a call (well. . . .4 of the 5 attendings). Bad stuff happened, the attending got a call.

I only did 2 24 hour calls a month (they suck) with q 4 call. I had 2 months of ICU during my intern year.

Did the duty hours change? I wasn’t sure ABIM was ok with hours like this.
There's always Anesthesia, Surgery and ED if need be for what you're talking about. The CVC I got down okay, but those emergent intubations were a nightmare without skilled supervision/help. I'm glad Anesthesia was there to help or intervene.

And the 4 months of unit were luck/circumstantial - one colleague was pregnant and maternity and then...well...COVID.
 

WheezyBaby

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There's always Anesthesia, Surgery and ED if need be for what you're talking about. The CVC I got down okay, but those emergent intubations were a nightmare without skilled supervision/help. I'm glad Anesthesia was there to help or intervene.

And the 4 months of unit were luck/circumstantial - one colleague was pregnant and maternity and then...well...COVID.
Yes, I should clarify, even before things changed we had anesthesia in house for emergent airways
 
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Kaustikos

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Yes, I should clarify, even before things changed we had anesthesia in house for emergent airways
That's what I thought. Didn't mean anything by it. Just curious what staff physicians other people had available at other hospitals.
 
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WheezyBaby

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That's what I thought. Didn't mean anything by it. Just curious what staff physicians other people had available at other hospitals.
Oh no you're fine just wanted to clarify for the thread. I think it's unacceptable to have a medicine resident solo covering without established airway back up, or to be intubating unsupervised for that matter regardless of back up unless dire situation and no back up available and can't get by with an LMA as a temporizing measure. But anesthesia for emergent airways was our only established in house back up. Home call ccm fellow was responsible for everything else
 

akwho

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SICU intern at my hospital covers primary call on 40-60 SICU patients. Exhausting and scary at first. Benefits are you have excellent nursing staff with 1:1 or 1:2 ratios, and RT staff with you who help guide you with simple decisions throughout the night.

Trick is to get good sign out, keep an eye on the sick ones. Bump things up quickly to the in house SICU fellow, in house ACS trauma attending. Also have some junior trauma residents (R5, R3) in house you can call if the SICU fellow or ACS attending is busy and they were usually glad to help. You can learn as much on a month on that rotation as you'd learn in 5 months of outpatient medicine and overall was a great experience.
 
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SICU intern at my hospital covers primary call on 40-60 SICU patients. Exhausting and scary at first. Benefits are you have excellent nursing staff with 1:1 or 1:2 ratios, and RT staff with you who help guide you with simple decisions throughout the night.

Trick is to get good sign out, keep an eye on the sick ones. Bump things up quickly to the in house SICU fellow, in house ACS trauma attending. Also have some junior trauma residents (R5, R3) in house you can call if the SICU fellow or ACS attending is busy and they were usually glad to help. You can learn as much on a month on that rotation as you'd learn in 5 months of outpatient medicine and overall was a great experience.
that’s much different lol you have like 5 in house people to help you..
 
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