How are you all so competent in the SICU?

[ChordaEpiphany]

I'm an MS4 rotating through the SICU. Ours is run by surgical and anesthesia critical care attendings, and the residents are split ~40/40/20 gen surg/anesthesia/off-service residents (e.g., OB/Gyn, EM).

I understand that the gen surg residents spend at least 1 month in the SICU every year. They're also on trauma, which has a ton of overlap, and they're on surgical services which are constantly sending patients to the SICU, so they're rounding on these patients regularly. It makes sense they know what's up. However, anesthesia residents rarely round. They spend most of their time in the OR, L&D, and procedural services where rounding isn't really a thing, let alone SICU rounding with extensive plans by system, detailed floor management, etc... However, at this point I've seen at least 5-6 PGY-2 (CA-1) anesthesia residents start in the SICU and all but one have integrated on day 1 with absolutely no trouble whatsoever. The presentations are smooth and appropriately detailed, and the plans are reasonable with few changes from attendings, even for complicated patients like severe TBIs.

When I think about it, the only thing separating me from these PGY2 residents is a surgical intern year with 1-2 months in the SICU, yet I'm atrocious and they mostly seem to be highly competent. I'm 2 weeks into this and barely know when to d/c an A-line or a even a foley. I can just barely handle 2 patients, and my plans typically get significant overhaul from attendings if the patient is complex. I haven't struggled in medical school, honored all rotations, and scored high on all exams. By all objective measures, I'm good at this for my level. How do you all manage to be so competent as PGY-2s when you rarely even see this kind of medicine?

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[akinetopsia]

Anesthesia residents do an intern year that is variable, although most programs are now categorical (some do predominantly IM prelim year, some do surgery prelim year, some do TY intern year). Regardless, there are common requirements from the ABA, which include doing ICU as interns, ED as an intern, etc. Most anesthesia residents can hit the ground running in an ICU setting as a PGY-2 and above because they've already done ICU rotations and know the workflow.

 

[MirrorTodd]

Anesthesia residents do an intern year that is variable, although most programs are now categorical (some do predominantly IM prelim year, some do surgery prelim year, some do TY intern year). Regardless, there are common requirements from the ABA, which include doing ICU as interns, ED as an intern, etc. Most anesthesia residents can hit the ground running in an ICU setting as a PGY-2 and above because they've already done ICU rotations and know the workflow.

This 100%. I had no ****ing idea where even my head was let alone my pt's room numbers during my first intern rotation.

 

[Shimmy8]

Half the battle in the ICU is knowing the hospital teams, nurses, other residents, etc

The anesthesia intern year touches all corners of the acute care side of the hospital and helps us be well rounded imo.

 

[Katheudontas parateroumen]

Anesthesia residents naturally like critical care. It’s in our blood lol. But really, the environment is familiar to anesthesia residents. The acuity is actually a step down from the typical things that happen in the OR. Managing vents, drips, shock states, sedation, extremes of physiology, doing non invasive procedures are all daily occurrences

 

[Onefellswoop87]

I’ll also point out that rounding in the ICU is not inherently different than rounding anywhere else: history, 24 hour events, labs/imaging/results, exam, plan. The main problem, and likely medical comorbidities, are different whether the patient is on the medical vs surgical floor, step down, or any specific ICU but the flow of rounding is not too different. And we gather that info and make an anesthetic plan to present to our attendings nightly in residency, though the plan is for the OR (arguably short term critical care) vice long term care goals and management.
The organization of the plan in the ICU is often systems based rather than problem based, but that’s more aligned with how we think in the OR.

 

[deleted1183938]

Anesthesia residents naturally like critical care. It’s in our blood lol. But really, the environment is familiar to anesthesia residents. The acuity is actually a step down from the typical things that happen in the OR. Managing vents, drips, shock states, sedation, extremes of physiology, doing non invasive procedures are all daily occurrences

A step down? Not necessarily!!
A daily occurrence? Come on that’s a stretch. No one even in residency is doing complex, sick as hell patients daily every day. We do plenty of simple cases as CA1s as we ease in that aren’t trying to die.
While we are managing these cases in the OR frequently, it’s the night calls and the sick cardiac or transplant or Neuro months that get us sharper. And of course intern year.

Also not sure what country you are in but in the USA most anesthesiologists can’t stand the ICU. I suspect even more so in residency. Too much paperwork and rounding. If they did they would do the fellowship. Most don’t.

 

[MirrorTodd]

Anesthesia residents naturally like critical care. It’s in our blood lol. But really, the environment is familiar to anesthesia residents. The acuity is actually a step down from the typical things that happen in the OR. Managing vents, drips, shock states, sedation, extremes of physiology, doing non invasive procedures are all daily occurrences

Hardest part (not really) of the ICU was the waiting. I seriously hated putting in orders and then 3 hours later they aren't implemented. or just simply waiting for a patient to get better.

 

[NVO]

I hated the ICU. So much sitting around for nothing. Usually followed 6 patients, finishing rounds/notes by 12p, waiting around for 6 whole hours for admits/etc until sign out at 6p. Spending 45+ minutes for the whole team to sign out. Making 1 change and seeing if it does anything the next day. Deciding on bowel regimen, diet, stress ulcer ppx.. so boring

That being said, I loved the camaraderie of shooting the shiz and hanging out with the homies in the workroom. Helping teach the non-anesthesia residents how to be good at putting in ultrasound guided CVC and a-lines. I can see why medicine and surgery residents are so close while anesthesia residents see each other in passing for our 15min/30min breaks if they happen to align.

 

[deleted1183938]

I hated the ICU. So much sitting around for nothing. Usually followed 6 patients, finishing rounds/notes by 12p, waiting around for 6 whole hours for admits/etc until sign out at 6p. Spending 45+ minutes for the whole team to sign out. Making 1 change and seeing if it does anything the next day. Deciding on bowel regimen, diet, stress ulcer ppx.. so boring

That being said, I loved the camaraderie of shooting the shiz and hanging out with the homies in the workroom. Helping teach the non-anesthesia residents how to be good at putting in ultrasound guided CVC and a-lines. I can see why medicine and surgery residents are so close while anesthesia residents see each other in passing for our 15min/30min breaks if they happen to align.

This sounds super easy. Was not my experience at all.

 

[Gator7]

You learn enough intern year don’t worry about it. I hate ICU and I started on MICU intern year and got by. Just always keep dispo in mind - how to get them out of the ICU.

ICU during CA years we did q3 30hr shifts. Only 3 residents on per month so you were essentially solo after morning rounds/admits/procedures etc.

I personally kept things brief, focused on what mattered, did whatever the Attending’s asked for on rounds and crossed off dates on the calendar as it went by.

 

[NVO]

This sounds super easy. Was not my experience at all.

What made it not easy? And was it SICU? Rounds always went by fast cause it was anesthesia and surgery attendings. 4-5 days off for the month so we were working 6 days/week 12+ hr days but luckily there was night coverage so we didn't have to do that.

 

[PpfSuxTube]

I'm an MS4 rotating through the SICU. Ours is run by surgical and anesthesia critical care attendings, and the residents are split ~40/40/20 gen surg/anesthesia/off-service residents (e.g., OB/Gyn, EM).

I understand that the gen surg residents spend at least 1 month in the SICU every year. They're also on trauma, which has a ton of overlap, and they're on surgical services which are constantly sending patients to the SICU, so they're rounding on these patients regularly. It makes sense they know what's up. However, anesthesia residents rarely round. They spend most of their time in the OR, L&D, and procedural services where rounding isn't really a thing, let alone SICU rounding with extensive plans by system, detailed floor management, etc... However, at this point I've seen at least 5-6 PGY-2 (CA-1) anesthesia residents start in the SICU and all but one have integrated on day 1 with absolutely no trouble whatsoever. The presentations are smooth and appropriately detailed, and the plans are reasonable with few changes from attendings, even for complicated patients like severe TBIs.

When I think about it, the only thing separating me from these PGY2 residents is a surgical intern year with 1-2 months in the SICU, yet I'm atrocious and they mostly seem to be highly competent. I'm 2 weeks into this and barely know when to d/c an A-line or a even a foley. I can just barely handle 2 patients, and my plans typically get significant overhaul from attendings if the patient is complex. I haven't struggled in medical school, honored all rotations, and scored high on all exams. By all objective measures, I'm good at this for my level. How do you all manage to be so competent as PGY-2s when you rarely even see this kind of medicine?

There is no such thing as a highly competent surgeon in an icu... maybe some thoracic surgeons with a tonne of medical training and some anesthesia can pull it off but surgeon residents can't butter bread so don't worry about that...

They're just familiar faces so the nurses and attendings let their stupid **** slide or they pattern match what certain attending like so sound better on rounds.

I have yet to see a surgeon that take someone from emerg, resus them, diagnose and treat quickly... good surgeons cut and sew... bad surgeons pontificate on icu rounds

Icu isn't hard, especially sicu. It can be if you want to do it all yourself on every patient... but that's where consults and imaging come in. Sure I can tte or tee every patient, and I can scan for dvts, fast scan, I can put perc drains, or I can examine the urine lytes etc... but I can also just get a CT, rads to place a drain and nephro consult...

 

[We'llBeDoneIn15Minutes]

I'm an MS4 rotating through the SICU. Ours is run by surgical and anesthesia critical care attendings, and the residents are split ~40/40/20 gen surg/anesthesia/off-service residents (e.g., OB/Gyn, EM).

I understand that the gen surg residents spend at least 1 month in the SICU every year. They're also on trauma, which has a ton of overlap, and they're on surgical services which are constantly sending patients to the SICU, so they're rounding on these patients regularly. It makes sense they know what's up. However, anesthesia residents rarely round. They spend most of their time in the OR, L&D, and procedural services where rounding isn't really a thing, let alone SICU rounding with extensive plans by system, detailed floor management, etc... However, at this point I've seen at least 5-6 PGY-2 (CA-1) anesthesia residents start in the SICU and all but one have integrated on day 1 with absolutely no trouble whatsoever. The presentations are smooth and appropriately detailed, and the plans are reasonable with few changes from attendings, even for complicated patients like severe TBIs.

When I think about it, the only thing separating me from these PGY2 residents is a surgical intern year with 1-2 months in the SICU, yet I'm atrocious and they mostly seem to be highly competent. I'm 2 weeks into this and barely know when to d/c an A-line or a even a foley. I can just barely handle 2 patients, and my plans typically get significant overhaul from attendings if the patient is complex. I haven't struggled in medical school, honored all rotations, and scored high on all exams. By all objective measures, I'm good at this for my level. How do you all manage to be so competent as PGY-2s when you rarely even see this kind of medicine?

I skimmed through the answers so maybe this was stated. This is a little oversimplified, but, an SICU patient is basically a complex OR patient without the surgery going on. And who takes care of the complex patients in the OR? There's your answer.

 

[Radetzky]

I'm an MS4 rotating through the SICU. Ours is run by surgical and anesthesia critical care attendings, and the residents are split ~40/40/20 gen surg/anesthesia/off-service residents (e.g., OB/Gyn, EM).

I understand that the gen surg residents spend at least 1 month in the SICU every year. They're also on trauma, which has a ton of overlap, and they're on surgical services which are constantly sending patients to the SICU, so they're rounding on these patients regularly. It makes sense they know what's up. However, anesthesia residents rarely round. They spend most of their time in the OR, L&D, and procedural services where rounding isn't really a thing, let alone SICU rounding with extensive plans by system, detailed floor management, etc... However, at this point I've seen at least 5-6 PGY-2 (CA-1) anesthesia residents start in the SICU and all but one have integrated on day 1 with absolutely no trouble whatsoever. The presentations are smooth and appropriately detailed, and the plans are reasonable with few changes from attendings, even for complicated patients like severe TBIs.

When I think about it, the only thing separating me from these PGY2 residents is a surgical intern year with 1-2 months in the SICU, yet I'm atrocious and they mostly seem to be highly competent. I'm 2 weeks into this and barely know when to d/c an A-line or an even a foley. I can just barely handle 2 patients, and my plans typically get significant overhaul from attendings if the patient is complex. I haven't struggled in medical school, honored all rotations, and scored high on all exams. By all objective measures, I'm good at this for my level. How do you all manage to be so competent as PGY-2s when you rarely even see this kind of medicine?

I suspect you’re suffering from some recall bias here. I wouldn’t expect you to be making amazing plans as an MS4, and the same goes for a CA1, so I suspect you’re only remembering the good plans that your colleagues have presented and not the ones that have needed overhaul. Relax, take it easy on yourself, and know that everything will come with time and clinical experience.