Doing poorly on ICU

[Teefa]

Hello, I'm looking for some advice.

I'm a PGY2 on my third month of a three and a half month ICU rotation. I really enjoy the rotation, but have been struggling a lot in the last few weeks. Despite doing a ton of reading and working pretty hard, I'm still making stupid mistakes and missing major differential diagnoses. On call, I find that I'm disorganized and scattered, and find it really easy to be overwhelmed. No matter how hard I try to sort things out, I find out that I've missed something major (and obvious to the other residents) when I present the patient the next morning during rounds.

I've tried approaching this different ways, and things have not been improving. I had a particularly bad call where I landmarked horribly for a CVC, and today, I reported that a (much needed) CT head had not been done for a patient, when in fact it had been done and I had reviewed it when I did my consult.

I did really well during PGY1, but have been doing pretty badly over my last three rotations in PGY2. I feel like I'm still working as hard, but I'm clearly not doing something right. My last evaluation on this rotation was the poorest yet and completely unsatisfactory for someone who's been on the unit for almost three months.

I'm thinking about going to talk to the ICU education director about these concerns and see if he has any suggestions. I'm running out of approaches and am getting pretty frustrated and worried, to the point where I'm really not looking forward to going back to the ICU or being on call. I'm just wondering if you had any suggestions or advice.

Thanks.

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[dragonfly99]

First, congrats for recognizing the problem and striving to correct it.
I am floored that you have a 3.5 month ICU rotation...that's off the wall. This must be a surgical program? All our MICU months were 1 at a time, and we did the MICU as an intern, then PGY2, then PGY3.

Anyway, I think your idea about what to do is excellent. If you go to the education director then it shows you are being proactive to correct the problem. It also sounds like you need to create some sort of data collecting/monitoring strategy for yourself. The sheer number of studies/labs/imaging can be overwhelming in the ICU, but you've got to find a way to organize the information.

Nerves can be a problem when presenting, esp. if you know you haven't done a great job in the past. I don't have a better explanation of why you'd forget to present results of a head CT you had already seen.

I found that in presenting ICU patients, the most important things to present were
a) major changes in clinical status overnight
b) any new major imaging studies or other tests
c) important new labs or changes in labs (but not necessarily every BMP, etc.).

Finally, remember that sleep is key. If you are chronically tired b/c of staying up late to read, you might not shine no matter how many facts you know.

 

[captaincrunch]

I agree with Dragonfly. Taking a proactive approach can only reflect positively on you. One more thought, though. Is there any chance you might be sufferring from depression? It's extraordinarily common amongst residents and is often the cause of an unexplained dip in performance (poor sleep, lack of concentration, lack of enjoyment). Good luck.

 

[peppy]

On call, I find that I'm disorganized and scattered, and find it really easy to be overwhelmed.
...today, I reported that a (much needed) CT head had not been done for a patient, when in fact it had been done and I had reviewed it when I did my consult.

With the caveat that I'm still an MSIV, if I were in this situation, I think this disorganization is the issue I'd try to focus on first and foremost. If you can come up with a system that works for you in efficiently tracking info, you'll be much better prepared to come up with accurate differential dx and such. Maybe you can ask for advice from your fellow residents (if you have any that you're friendly with) about how they coped with organizing the info.
Hope it works out for you!

 

[Abram Hoffer]

I agree with Dragonfly. Taking a proactive approach can only reflect positively on you. One more thought, though. Is there any chance you might be sufferring from depression? It's extraordinarily common amongst residents and is often the cause of an unexplained dip in performance (poor sleep, lack of concentration, lack of enjoyment). Good luck.

An astute observation... and one that needs self- and objective exploration. Do a depression checklist, and be truthful. Talk to those who know you best. See if they see anything out of the norm. Make time to step away from medicine--exercise, maintain a good diet, supplement with vitamins, etc. Perhaps an SSRI empirically would help to level off some of the scattered thinking and disorganization. The fact that you have such an intuitive internal barometer predisposes you to anxiety/depressive symptoms.

 

[BlondeDocteur]

Rather than diagnose the OP over the internet I would say a more likely candidate to poor, declining performance in tasks of short-term memory after 3 months in an ICU would be fatigue. After 19 months of residency, the last three of which have been at least 70-80 hrs/wk, doubtless she is tired! Is it possible to find ways to get more sleep?

 

[DarthNeurology]

Hello, I'm looking for some advice.

I'm a PGY2 on my third month of a three and a half month ICU rotation. I really enjoy the rotation, but have been struggling a lot in the last few weeks. Despite doing a ton of reading and working pretty hard, I'm still making stupid mistakes and missing major differential diagnoses. On call, I find that I'm disorganized and scattered, and find it really easy to be overwhelmed. No matter how hard I try to sort things out, I find out that I've missed something major (and obvious to the other residents) when I present the patient the next morning during rounds.

I've tried approaching this different ways, and things have not been improving. I had a particularly bad call where I landmarked horribly for a CVC, and today, I reported that a (much needed) CT head had not been done for a patient, when in fact it had been done and I had reviewed it when I did my consult.

I did really well during PGY1, but have been doing pretty badly over my last three rotations in PGY2. I feel like I'm still working as hard, but I'm clearly not doing something right. My last evaluation on this rotation was the poorest yet and completely unsatisfactory for someone who's been on the unit for almost three months.

I'm thinking about going to talk to the ICU education director about these concerns and see if he has any suggestions. I'm running out of approaches and am getting pretty frustrated and worried, to the point where I'm really not looking forward to going back to the ICU or being on call. I'm just wondering if you had any suggestions or advice.

Thanks.

How many patients in the ICU? If you are only responsible for 5-7 then you likely have major time management issues. You say you are doing a lot of reading, but hopefully this is during your time off. If you have 8-12 ICU patients then you really have to be on the ball for each of them and be proactive.

This means running the list in your head every couple hours. Really. With that many patients you have to automatically re-evaluate them and make decisions with being prompted. You should have a list of ALL the patients you are covering and you should have written down Head CT Neg, and looked at it when you presented. A good idea is at 10 pm or 11 pm, after evening/afternoon rounds, pretend the attending is asking you "What are we doing for the patient in bed #3?" And ask yourself if you know the answer. Then think of what the attending would ask next, such as "Did you follow the blood cultures and consult ID?" And if not then do it. You do know what will be asked on rounds, you just have to put yourself in the attending's shoes.

I would focus on working hard and following the simple stuff like Head CTs and so on, . . . you are unlikely to improve your fund of knowledge much on such a rotation in terms of differential, you and should read maybe 1/2 hour a day, but don't let it interfer with your work. If you want during your off hours or day off/golden weekend read an ICU book then do so. But what it seems like you need to me is to do is to really know your patients well. Remember, if your patient is not getting better, they are getting worse, especially in a surgical ICU.

Most ICUs are very busy, especially surgical ICUs, and you need to be working on something all the time to stay ahead, don't just sit back and assume everything is OK, double check patients, go over labs, round on patients yourself if you have "extra time."

 

[pedidoc]

I know that when we did rounds in the PICU we all had standardized sheets where you write the days labs/radiology results/consult opinions.

I was terrified most times while presenting to two pedi CT surgeons, 1-2 ICU attendings, cardio attendings, two other residents and three med students and two NP's. It was like an audience every day. I absolutely had to write everything down or I would immediately forget what I was supposed to say.

The other thing that was a life saver for us was that the residents functioned like a team. If you're presenting it's hard to keep track of what they want you to do when you're done because you can't write it down while you're talking. We would all take turns writing down checklists of things that needed to be done on each other's patients. In addition, if any of us had downtime (very little on PICU) we would offer to help out if somebody's patient had a lot more to do.

Have you tried talking to other residents about how you feel? I am sure that they have all felt overwhelmed at some point. My PICU rotation was so terrible that if I had three months of it I would just die!! Hang in there.

 

[elwademd]

when in doubt or a panic, step back and ask :
who is this?
why did they come here?
what do they have?
what are we doing for them?

also, do you write your own notes before rounding with the attending? or do you wait until rounds, then finish your note afterwards?

it seems like the standard to is round, then write the note. which can become problematic, because you're writing your note based on someone else's thoughts and opinions, rather than your own.

personally, when i was in the icu as an intern and resident i would write my own note and leave it in the chart, and make a copy of it for rounds. my thoughts/impressions of what was going on. after rounds, i would make an addendum. i found it easier, for myself, to critically evaluate and develop a plan (or semblance of one) by writing my own notes. questions that pop up then can be read about prior to rounds, provided time permits. if not, then you can ask the question of the attending (i.e. i noticed the cvp was low, i check the i's &o's, the patient's grossly positive... he looks like he's still in shock... but i can't explain why; this post cabg pt was throwing pvc's all night, but cards doesn't have him on amiodarone...)


everyone's different, and everyone will have a different opinion about the way you should rectify the situation. as dragonfly already pointed out, the fact that you recognize the problem and want to be proactive is a good thing. there are plenty of residents who don't do that. hell, there are attendings that don't either.

best of luck, let us know how it turns out.

 

[SocialistMD]

everyone's different, and everyone will have a different opinion about the way you should rectify the situation. as dragonfly already pointed out, the fact that you recognize the problem and want to be proactive is a good thing. there are plenty of residents who don't do that. hell, there are attendings that don't either.

I agree. What initally worked for me was to look at each patient one system at a time (e.g. neuro, CV, pulm, GI/nutrition, renal/fluids/electrolytes, heme, ID, endocrine, etc). For each system, you need to know where you were, where you are, where you're going and what will get you there. The were is just the patient's history. The are is their current status (including labs, imaging, etc). Where you're going is what needs to be done to improve the patient and how you get there is your plan. Present them by systems (I think that is how most ICU attendings prefer it anyway) and it is much easier to keep your thoughts organized and to make sure you didn't miss anything. It is very time consuming at first and you feel like you are spending a majority of the time on the first two questions, but once you have it down you feel more organized and can focus on the goals and plan. The nice thing is that, except for the most extreme patients, you will really only have active issues in, at most, four systems (usually cardiac, pulmonary, renal and whatever caused the problem in the first place).

Other things to help keep yourself organized are, as mentioned above, repeatedly going over each patient. I would walk around the unit every hour (and, as I grew more comfortable with the ICU, every couple of hours), checking with the nurses, checking vitals and keep up with what is occurring with your patients.

In terms of preparing for morning rounds, make sure you biopsy the chart for any new notes from consultants that may have been left (this is particularly important if you were not on call the night previously) and include their recommendations in your presentation.
Also, I'd limit your reading (at least, right now) to disease processes currently in your patients.

 

[Abram Hoffer]

I agree. What initally worked for me was to look at each patient one system at a time (e.g. neuro, CV, pulm, GI/nutrition, renal/fluids/electrolytes, heme, ID, endocrine, etc). For each system, you need to know where you were, where you are, where you're going and what will get you there. The were is just the patient's history. The are is their current status (including labs, imaging, etc). Where you're going is what needs to be done to improve the patient and how you get there is your plan. Present them by systems (I think that is how most ICU attendings prefer it anyway) and it is much easier to keep your thoughts organized and to make sure you didn't miss anything. It is very time consuming at first and you feel like you are spending a majority of the time on the first two questions, but once you have it down you feel more organized and can focus on the goals and plan. The nice thing is that, except for the most extreme patients, you will really only have active issues in, at most, four systems (usually cardiac, pulmonary, renal and whatever caused the problem in the first place).

Other things to help keep yourself organized are, as mentioned above, repeatedly going over each patient. I would walk around the unit every hour (and, as I grew more comfortable with the ICU, every couple of hours), checking with the nurses, checking vitals and keep up with what is occurring with your patients.

In terms of preparing for morning rounds, make sure you biopsy the chart for any new notes from consultants that may have been left (this is particularly important if you were not on call the night previously) and include their recommendations in your presentation.
Also, I'd limit your reading (at least, right now) to disease processes currently in your patients.

I cut and paste this to my email for future use. Awesome recs!

Do you actually write it out system by system? Can you recommend a concise book that includes lots of pearls? Something that cuts to the chase?

 

[SocialistMD]

Do you actually write it out system by system? Can you recommend a concise book that includes lots of pearls? Something that cuts to the chase?

I do. Create some sort of mneumonic for yourself (like ADCVANDALISM for admission orders) to help you remember initially. I just go top down (Neuro, CV, Pulm, GI/nutrition, Renal/EN), then global body systems (heme, ID, endo), but do whatever works for you.

As for a book with lots of pearls, the Washington Manual of Critical Care is organized in a way that is easy to read and quick reference information you need. ICU Recall [/end shameless plugs] is also good, but not as easy to find information when you need it, as it is more of a Q&A format. Marino' ICU Book is the gold standard for pocket critical care books, but it is very dense and doesn't really "cut to the chase" for everything (still, if you are going to buy only one critical care book as a resident, make it Marino).

 

[Abram Hoffer]

I do. Create some sort of mneumonic for yourself (like ADCVANDALISM for admission orders) to help you remember initially. I just go top down (Neuro, CV, Pulm, GI/nutrition, Renal/EN), then global body systems (heme, ID, endo), but do whatever works for you.

As for a book with lots of pearls, the Washington Manual of Critical Care is organized in a way that is easy to read and quick reference information you need. ICU Recall [/end shameless plugs] is also good, but not as easy to find information when you need it, as it is more of a Q&A format. Marino' ICU Book is the gold standard for pocket critical care books, but it is very dense and doesn't really "cut to the chase" for everything (still, if you are going to buy only one critical care book as a resident, make it Marino).

Thanks so much for the info. I copied this to myself for intern year starting July. This should be a great start. The ICU scares me. 😱

 

[Winged Scapula]

I go "top down" and then global body systems just like Socialist.

As a matter of fact, I had to dictate an H&P today since the one from my office was outdated. I apparently have gotten so used to the prompts on my EMR that I initially hesitated as I tried to dictate the ROS and PE. Then I remembered..."top down"!

I was taught to do this systematically as an intern (as in "its the same F'ing thing every day for every patient"); soon it will become second nature to address each system in the H&P and then in the A&P. Tiresome but it keeps you on track with these complicated patients.

 

[gutonc]

"Top Down" by systems is a great way to get a handle on the basics, just don't ignore the forest for the trees. It's easy to get too reductionist and miss the big picture.

"Neuro - AMS
- Hypercalcemia - IVF and Zometa
- UTI - Cipro
- CT Head neg for acute bleed but bony abnormality noted"
That's all well and good but you may miss the Multiple Myeloma that's causing all of these problems and is really the major issue.

You'll find that different attendings will like to hear different things but as long as you can get the story straight and show that you've given some thought to integrating everything you see (at least at the beginning/middle of your training), you'll be fine.

To the OP's point about feeling lost at this point as an R2. I don't know what your specialty is but, at least in IM, this is probably the worst part of your residency in terms of knowledge/responsibility. You know a lot, but you also realize how little you actually know in terms of all the information that's available. You're no longer an intern, you're expected to be a leader and really drive the bus but at the same time you still feel kind of like a senior intern. At the beginning of the 2nd year, attendings (and interns, who don't know any better) will usually give you a bit of a pass, but now is the time you are expected to step up and prove you know what you're doing and can manage patients (and underlings) on your own. It doesn't help that it's dark when you come to work and when you go home, that it's cold and that you probably haven't had a good night's sleep in 2 years. You will get through it. It will get better.

 

[orientedtoself]

I'm a PGY2 on my third month of a three and a half month ICU rotation. .

i can't believe that there are places that do 3.5 month icu rotations. wtf??

 

[SocialistMD]

i can't believe that there are places that do 3.5 month icu rotations. wtf??

It is possible the residents at the OP's program set up their own schedules and the collective group set it up that way to "get it out of the way all at once," not knowing the pain they brought on themselves. Some of the residents at my program have made the same mistake in their R2 year.

 

[CambieMD]

I do. Create some sort of mneumonic for yourself (like ADCVANDALISM for admission orders) to help you remember initially. I just go top down (Neuro, CV, Pulm, GI/nutrition, Renal/EN), then global body systems (heme, ID, endo), but do whatever works for you.

As for a book with lots of pearls, the Washington Manual of Critical Care is organized in a way that is easy to read and quick reference information you need. ICU Recall [/end shameless plugs] is also good, but not as easy to find information when you need it, as it is more of a Q&A format. Marino' ICU Book is the gold standard for pocket critical care books, but it is very dense and doesn't really "cut to the chase" for everything (still, if you are going to buy only one critical care book as a resident, make it Marino).

Try the Little ICU Book which is also by Marino. It is than smaller The ICU Book.

I think that earlier posters are correct. Organizing the information better will help you. Use check list to keep track of what you did and what needs to be done.

Try to get more sleep and don't beat yourself up.

Cambie

 

[greg12345]

Marino's ICU book should be read cover to cover prior to starting in the ICU,no matter what type. It is a simple and fast read (large font!). Caveat that a lot of it is his personal opinion, but still clear and concise explanations of most of the stuff that you will encounter in the ICU. I also think you should prioritize your list so that the most important systems (or problems, which I prefer) are presented first - with long ICU presentations people start to fade at the end so you want the most important/pressing things discussed first. Yeah, glycemic control (endo) with an insulin gtt is important but don't talk about that before you talk about the septic shock that landed the pt in the unit in the first place. Just my opinion.

 

[SocialistMD]

Marino's ICU book should be read cover to cover prior to starting in the ICU,no matter what type.

It would probably lower one's anxiety level, but I don't think doing this is a must (You are going to flip some people out by saying this). Honestly, I'm not sure there is any textbook that needs to be read cover to cover in this era.

 

[CambieMD]

imI also think you should prioritize your list so that the most important systems (or problems, which I prefer) are presented first - with long ICU presentations people start to fade at the end so you want the most .That is good advice. Do not attempt to read Marino prior to starting your ICU rotation. Read about patients that you have taken care of. This will enforce your reading more than reading in isolation. This approach works in just about every setting.

Cambie

 

[Teefa]

Wow - I didn't realize that there were so many responses! Thanks for all the great ideas (and the encouragement).

Fortunately, I finished my rotation on Wednesday. I feel like I've emerged from a deep, dark hole. Ha ha. I need a break.

3.5 months is too much, especially when it's the dead of winter and includes the Christmas holidays. But that's my program's requirement. I was on with a fellow R2 who was struggling as well - on our evaluations, we are both going to suggest that the 3.5 months be spread over two years. I think we hit a plateau after 2 months...

 

[DarthNeurology]

Marino's ICU book should be read cover to cover prior to starting in the ICU,no matter what type. It is a simple and fast read (large font!). Caveat that a lot of it is his personal opinion, but still clear and concise explanations of most of the stuff that you will encounter in the ICU. I also think you should prioritize your list so that the most important systems (or problems, which I prefer) are presented first - with long ICU presentations people start to fade at the end so you want the most important/pressing things discussed first. Yeah, glycemic control (endo) with an insulin gtt is important but don't talk about that before you talk about the septic shock that landed the pt in the unit in the first place. Just my opinion.

Marino is a very interesting read, while a lot is practical, a lot is more to lay a theoretical foundation for ICU physiology and not every ICU physician agrees 100% with Marino on every topic as yes, a lot is his personal opinion. From my experience some ICU's do very formal systems review and presentations, others want just the pertinent stuff upfront first and then the attending asks about anything more they are worried about, i.e. for a septic patient it would be first off talking about their pressors, vital ranges, cultures and antibiotics and summarizing what various consult services say after this you can then go through the systems with more of a meaning i.e. describing neurological status first in relation to their sepsis, basically what was said above.