Critical Care Elective

[Doctor Bob]

One of the more difficult elective/selective rotations in 3rd/4th year can be the medical ICU. Machines and medications that aren't seen outside of the ICU, patients dying on a not-so-infrequent basis, difficult family situations, etc. If your school doesn't require an ICU rotation, I would still strongly encourage that you do an elective in critical care during your 4th year.

I'm the clerkship director for the medical student CCM rotation at my hospital, and the fellowship director for the CCM fellowship... so... I'm probably biased, but I think it's a great rotation, whether you do it with us or at an institution near you. Some students shy away from CCM because it can be an overwhelming rotation but by the time you finish it, you'll feel a lot more comfortable with complex medical patients.

(start of shameless plug)
At my institution we have over 160 ICU beds at my hospital so we have capacity for a lot of rotators each block. Our GME office worked hard during COVID to keep the hospital open as much as possible for in-person rotations so students could continue to get hands on experience with patients so it's a very friendly hospital for visiting students.

You can find us in VSAS; AdventHealth Orlando Critical Care. VSAS # 7857-2
(end of shameless plug)

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[FrechToastFries]

Do you have any recommendations or resources for how a student can prepare for a critical care elective, or what you recommend for your students?

 

[Chads2]

Do you have any recommendations or resources for how a student can prepare for a critical care elective, or what you recommend for your students?

1. Learn how to read an ABG. This goes beyond simply looking at the pH. Identify the primary acid/base dysfunction and if the compensations are appropriate. Also hypercapneic and hypoxic respiratory failure. I have yet to meet anyone who can calculate an A-a gradient in their head but at least be able to quickly get the PaO2/FiO2 ratio.

2. Learn basic ventilation. Pressure vs Volume control strategies. And learn which vent settings affect hypercapneia and which ones affect hypoxia.

3. Sepsis and recognizing shock. Only two things help with sepsis - Antibiotics and fluids. Don’t be afraid to give a septic patient fluids even in heart failure. You can always diurese or dialyze them while they’re on the vent.

4. Brush up on ACLS.

 

[FrechToastFries]

1. Learn how to read an ABG. This goes beyond simply looking at the pH. Identify the primary acid/base dysfunction and if the compensations are appropriate. Also hypercapneic and hypoxic respiratory failure. I have yet to meet anyone who can calculate an A-a gradient in their head but at least be able to quickly get the PaO2/FiO2 ratio.

2. Learn basic ventilation. Pressure vs Volume control strategies. And learn which vent settings affect hypercapneia and which ones affect hypoxia.

3. Sepsis and recognizing shock. Only two things help with sepsis - Antibiotics and fluids. Don’t be afraid to give a septic patient fluids even in heart failure. You can always diurese or dialyze them while they’re on the vent.

4. Brush up on ACLS.

Thank you! Is there any book or study resource you recommend for brushing up on these topics?

 

[WheezyBaby]

The ICU book by Marino is a good med student entry level book to ICU imo

 

[Radetzky]

1. Learn how to read an ABG. This goes beyond simply looking at the pH. Identify the primary acid/base dysfunction and if the compensations are appropriate. Also hypercapneic and hypoxic respiratory failure. I have yet to meet anyone who can calculate an A-a gradient in their head but at least be able to quickly get the PaO2/FiO2 ratio.

2. Learn basic ventilation. Pressure vs Volume control strategies. And learn which vent settings affect hypercapneia and which ones affect hypoxia.

3. Sepsis and recognizing shock. Only two things help with sepsis - Antibiotics and fluids. Don’t be afraid to give a septic patient fluids even in heart failure. You can always diurese or dialyze them while they’re on the vent.

4. Brush up on ACLS.

The two things that help sepsis are antibiotics and drainage of pus.

The key thing to learn in critical care is that despite all the fancy machines, patients still have medical problems. People tend to get distracted by the ventilators and drips and forget that usually none of this actually makes the patient better- it just buys time for the treatment (or nature) to work. Focus on understanding the medicine and the patient first, by having a good general medical knowledge; understanding the machines will come if you’re interested and ask questions and go away and look up the stuff that confuses you.

 

[BigRedBeta]

4. Brush up on ACLS.

Codes aren't the hard part - just pull out your code card and follow the algorithm and H's/T's
The hard part is managing the patients that are nearing that cliff of an arrest, and slowing/preventing that progression. Time would be better spent on having a rough idea of various vasopressors IMHO

 

[Siggy]

Codes aren't the hard part - just pull out your code card and follow the algorithm and H's/T's
The hard part is managing the patients that are nearing that cliff of an arrest, and slowing/preventing that progression. Time would be better spent on having a rough idea of various vasopressors IMHO

Codes:
Start watch counting forward.

Even number minutes: pulse check.
number divisible by 3 : Epi push
Constantly spiking or small squiggly line: Shock.
Big constant spikes going into little constant spike going into big constant spikes: shock and push mag.

If asked which vasopressor to start first, answer norepinephrine. You'll be right 99% of the time.
If asked which vasopressor to start second, answer vasopressin. You'll be right 99% of the time.

If asked about steroids:
Shock: hydrocortisone.
Respiratory: Solumedrol (although prednisone works well for COPDers who can swallow)
Neuro/COVID: Dexamethasone.

 

[NontradICUdoc]

Understand physiology. Then work on answering “why?”

Why are they in shock, why are they acidemic, why are they in respiratory failure…..

 

[CanIMakeIt]

One of the more difficult elective/selective rotations in 3rd/4th year can be the medical ICU. Machines and medications that aren't seen outside of the ICU, patients dying on a not-so-infrequent basis, difficult family situations, etc. If your school doesn't require an ICU rotation, I would still strongly encourage that you do an elective in critical care during your 4th year.

I'm the clerkship director for the medical student CCM rotation at my hospital, and the fellowship director for the CCM fellowship... so... I'm probably biased, but I think it's a great rotation, whether you do it with us or at an institution near you. Some students shy away from CCM because it can be an overwhelming rotation but by the time you finish it, you'll feel a lot more comfortable with complex medical patients.

(start of shameless plug)
At my institution we have over 160 ICU beds at my hospital so we have capacity for a lot of rotators each block. Our GME office worked hard during COVID to keep the hospital open as much as possible for in-person rotations so students could continue to get hands on experience with patients so it's a very friendly hospital for visiting students.

You can find us in VSAS; AdventHealth Orlando Critical Care. VSAS # 7857-2
(end of shameless plug)

Couldn't agree more!
I did all possible electives including heme/onc, CC, renal etc in med school itself and helped a ton during internship

WashU critical care book is pretty good as well - comprehensive (once you are done with Marino)