how to be a terrific M4 in ICU rotations

[ULTRA nerves]

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It has been about two weeks since my ICU rotation started and I am confused as to what my role is as a M4. The senior considers me that I am considered a sub-I because I'm a M4 but I am pretty much doing the work of M3 (i.e. getting H&P and presenting pt in the morning rounds.) I don't get to submit orders and not expected to sign out on the pts that I follow. The senior tells me I am doing a good job but I myself isn't convinced of that. I feel that I can do more and should do more (i.e. hands on procedures such as getting ABGs, central line placements, signing out on pts, submitting orders, calling the nursing homes). Since not much is expected of me, I am not motivated to take the extra steps neither. At same time, do not wish to overstep my boundaries and try to be too aggressive while the interns and seniors are busy with pts with critical conditions.

How can I carry myself in the ICU to get most out of my rotation and do a good job? I know that this is a vague question but any tips would be appreciated!

Thank you!

 

[FutureInternist]

Did you try talking to the resident and asking for more responsibility?
Is there a hospital policy where students cannot write orders?

 

[ULTRA nerves]

I haven't specifically asked for more responsibility but have asked for feedbacks to improve on my performance. One feedback I got was a generic one: that I should read more. Your question actually gives me an idea of volunteering to submit orders next time. Normally when a M4 or M3 submits an order, a resident still needs to cosign it electronically.

Unfortunately, I haven't asked for more responsibility. A part of the reason is I am afraid that perhaps the residents do not have the confidence in me to give me more responsibility. I am not the best when it comes to presenting a pt but my H&Ps are very thorough. I am quiet in nature, but eager to learn and willing to work hard.

It is my first time in the ICU and I work with no other medical students so it is difficult for me get a good grasp of what I should strive for. If someone can provide me with a good picture of M4's responsibilities/work that can be done, I think that will be very helpful for me.

 

[FutureInternist]

I used to have an order sheet for each of my patients with what I thought needed to be ordered. Then during presentation you can hand that to your senior or attending, they can look it over, add/subtract & put it in the patient's chart. Do this enough times & they may decide you know what you are doing & be OK with you writing the orders.
Just be sure to draw a line thorough any half used order sheets that are already in the chart before you put your sheet in.

You can't lose if you ask for more responsibility. Best case - you get it & shine, worst case - they say no & you can stop wondering/obsessing over it

Good Luck.

 

[Orange Man]

It has been about two weeks since my ICU rotation started and I am confused as to what my role is as a M4. The senior considers me that I am considered a sub-I because I'm a M4 but I am pretty much doing the work of M3 (i.e. getting H&P and presenting pt in the morning rounds.) I don't get to submit orders and not expected to sign out on the pts that I follow. The senior tells me I am doing a good job but I myself isn't convinced of that. I feel that I can do more and should do more (i.e. hands on procedures such as getting ABGs, central line placements, signing out on pts, submitting orders, calling the nursing homes). Since not much is expected of me, I am not motivated to take the extra steps neither. At same time, do not wish to overstep my boundaries and try to be too aggressive while the interns and seniors are busy with pts with critical conditions.

How can I carry myself in the ICU to get most out of my rotation and do a good job? I know that this is a vague question but any tips would be appreciated!

Thank you!

It's a tough place to be a medical student. I felt so bad of the medical students on our service (I'm an intern who just finished an ICU rotation) when they ask for more responsibility. Simple fact is that you can't get any because you can't sign orders, you can't work independently, and residents need to get certified in lines etc for board certification, so they get them all before you. Things move so quickly, that the med student simply cannot play an integral role. Sorry. It's just a tough place to be a med student.

One thing you can do is try to help out with getting things done for patients--especially the patient or two you are following (get outside records, call the lab etc.) and write a concise note so that it helps your team. Also, I try to get MSIII's and MSIV's involved in ABGs, blood draws, place NG and OG tubes, and EKGs if they want to. It is important to do these things well. Word of advice: if an intern or resident asks if you want to do this to help out, the answer is yes. You will gain great practical experience, you will serve the patient, and you will help the team. Try and be quick though when you do things. The team will love you if you help out. Also, try to read and learn about ventilators. You will have no time to read as an intern.....

 

[ULTRA nerves]

You are very right, Orange Man with things moving fast in the ICU. One minute the patient was breathing on his own and the next minute, the pt is on norepi drip and on ventilation.

Another pt on my team was admitted in the am and she was pronounced by 1pm. It is amazing how critical some pts are and I have to say, residents do so much for the patients in the ICU. If I may vent, however, it is somewhat frustrating as M4 because I am the last one to know (by the nature of things) and even if I try to understand by being attentive, it is difficult for me to follow at times. The ICU book by Marino is the lifesaver and probably one solid assistant guiding me through the rotation.

FutureInternist, I will definitely try your suggestion on the order sheet.

Your comments are very helpful. Thanks.

 

[Orange Man]

If I may vent, however, it is somewhat frustrating as M4 because I am the last one to know

No way around this. The first priority of the unit it to appraise the intern and resident since they and not the student pronounce, write the death note, and discharge summary. You don't get to know not because you are not important, but simply because the patient takes priority over your education. Period.

When I had to pronounce a patient last week, I took the two MSIIIs with me to at least give them what might be their only exposure to doing this unfortunate task properly. As a med student, I too felt that it was annoying to be overlooked (residents would write their own orders in the computer and totally ignore the fact that I was so on top of it that they just needed to electronically approve mine; nurses would ask the resident questions about patients I was primary caregiver for when everyone in the room including the nurse knew it my 'my patient'). It's hard to be a med student.

In the end, in MS4, I took the advice of interns and dropped the attitude about not having enough responsibility; it will com in droves as an intern when you no longer have time to think. Use MS4 as a time to solidify your general knowledge and to get practical experience placing i.v's, doing ABGs etc.....as well as to relax. This will lead to less frustration. Your time will come and it will hit you as hard as it has hit me.

 

[FutureSurg]

You should ask the resident if you can do more procedures if, and when, the opportunity arises. They usually don't mind passing them if they don't need to do them or have the interest. I'm in the same boat, except I don't really ask/want to do more

 

[mrpankration]

I'm also an MS4, just finished a month long rotation in the MICU. I agree that the ICU can be a tough place to be as a med student as things can move very fast and the stress level of the residents/fellows is usually a little higher.
I took call q4. I admitted 1-2 pts. on call days, would do the H & P, including the A & P, which I would run by the resident and then make any changes if needed. I would write the admission orders and then have the resident look them over and sign them. The next morning I would present the pt. first to the fellow and then to the attending. Each day I would write progress notes on my pts. as well as daily orders and then just have the resident sign them. I would also present my old pts. each morning during fellow rounds and update my pts. on our team's list daily.
My biggest advice to the OP is that if you know what needs to be done for your pts. just do it and then run it by your resident. I'm sure most residents will appreciate the fact that they have to do less work. Also, know everything about your pts. i.e. meds, drips, vent settings, code status, labs, imaging, family situation etc. If someone asks a question about your pt. answer it, even if they are not asking you. Pretty soon your residents/fellows/attendings will know you are on top of it and will ask you about your pt. and give you the responsibility you want. Of course being solid on vent settings, drips, and just general ICU mgmt. will get you a long way as well. An article that was very helpful for me was "Surviving Sepsis Campaign 2008" You can download the PDF off the net for free. Hope this helps a little!