ICU Prep

[NastyNick45]

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[drfunktacular]

My $.02 is that the best way to prepare as an intern in the ICU is just to work on being a good intern. ICU patients are COMPLICATED so you need to be organized and efficient in terms of figuring out WTH happened overnight, collecting data (vitals, labs, Xrays, meds) and figuring out how to put it all together into a cohesive picture and communicating that to the rest of the team on rounds. This is hard to do at first, and it's more dependent on skills than knowledge. So, working hard on wards and other rotations to develop these skills is really the best way to prepare for ICU.

Other key skills to have in the ICU are interpreting CXRs & EKGs, managing complicated electrolyte disturbances (eg repleting PO4 and Ca in light of hypo/hyperkalemia, hypo/hypernatremia, etc), managing IV fluids, making sure your patient is getting nutrition, deciding what antibiotics and for how long, being vigilant for pressure sores, etc etc etc.

Basically, you need to be good at internal medicine. All the fancy stuff about glucocorticoids, fancy vent modes, etc are more often than not going to be at the discretion/whim of your attending/fellow and they will teach you about it. If you don't have a solid base of IM skills built up over your intership, no one will think you're a superstar for quoting the latest study to them.

 

[jdh71]

You learn ICU medicine from doing ICU medicine . . .

You can't "book" your way into being or feeling competent. Sorry.

 

[WorkaholicsAnon]

You learn ICU medicine from doing ICU medicine . . .

You can't "book" your way into being or feeling competent. Sorry.

Agreed, but nothing wrong with doing a little reading to be at least a little more prepared. I dont think the OP is necessarily expecting to "be competent" just from the reading.

However, the reading isn't going to make a whole lot of sense or mean much, until you actually are dealing with issues in the ICU and have a practical application for that info. I think this is true for most of internal medicine, actually. at least was for me.

 

[drfunktacular]

Agreed, but nothing wrong with doing a little reading to be at least a little more prepared. I dont think the OP is necessarily expecting to "be competent" just from the reading.

However, the reading isn't going to make a whole lot of sense or mean much, until you actually are dealing with issues in the ICU and have a practical application for that info. I think this is true for most of internal medicine, actually. at least was for me.

This is so true. I will read a ton about a disease, but then if I see a patient with it, even the very next day, it's like I didn't read it at all and I have to go back and review everything in context for it to make any sense. The best way to learn medicine really is to go home and read about the patients/diseases/procedures you saw THAT DAY.

 

[Bonza Debogian]

2 things that may be helpful before starting are to look through the surviving sepsis protocols - looks really long but you can get the gist quickly, and to review acid/base stuff. Both come up a lot. But overall there's a steep learning curve that you can't really totally prepare for before you get there.

 

[chitown82]

Hey Fellow Forumers,

MSIV going into IM here, trying to get some advice on how best to prepare for ICU months. I know there's been some posts on this before, but none that I found were recent and some weren't that helpful (though I'm definitely no forum search wizard). What do you guys think of Marino's book? Especially now in light of a lot of new trials (eg. with streroids, glucose control, etc.). I've heard it's now a little outdated. How about the Washington Manual? Others? I was hoping to find something that will give me a good foundation in as compact a form as possible.

Also, if it helps for recommendations, I don't plan on doing a pulm/cc fellowship, but I really enjoy it and would like to do well on my rotations.

I read a fair amount from The ICU Book prior to starting internship - it made me look pretty good as far as knowledge base is concerned. Having said this, you will learn from "doing" pretty quickly so don't sweat it if you don't read much before starting internship.

 

[gutonc]

2 things that may be helpful before starting are to look through the surviving sepsis protocols - looks really long but you can get the gist quickly, and to review acid/base stuff. Both come up a lot. But overall there's a steep learning curve that you can't really totally prepare for before you get there.

+1 on both Acid/Base and Surviving Sepsis as high-yield pre-ICU studying.

Don't get all hung up on learning vent settings, pressors and empiric antibiotic choices since it will all be different based on who your attending is. That's the stuff to learn at the bedside anyway.

I started internship in the ICU. Didn't know squat. Learned a crapton...nearly all of it at the bedside.

 

[NastyNick45]

z

 

[km11]

vanco zosyn fluids LPV. That should buy you more than enough time to check uptodate =p

 

[jdh71]

I wanted to thank everyone for posting, this is actually very helpful; I appreciate it. 👍 Also, to clarify, I've never thought that there is a substitute for "doing". My intention was never to read some random book and transmute on the spot into a pulm/cc fellow. I agree medicine is best learned at the bedside. And it seems like the general consensus is that most people just show up and absorb it? Makes some sense, but the optimist in me still feels like there must be at least some good resources out there to demystify some of the high yield topics.

That said, maybe my learning style is a little different than some. I'll remember most of what I read, even if I don't see a patient with xyz disease/condition. And I'm embarrassed to admit that I'm lacking much of what might be considered very basic ICU fundamentals. For example, I know diddly squat about the different types of oxygenation and masks, very little about ventilation in general, totally unfamiliar with CVVH other than it's continuous, TPN is a big question mark in my mental file, etc. etc. Even mucous plugging was foreign to me until I stated studying for CK. Obviously I'm not going to be the one deciding on how to change the vent settings. Clearly I'm not going to be running the CVVH. Don't get me wrong, I know as an intern I'm not going to be doing a lot of this. I can learn about these things later, but I'm very curious about them and wanted a way to bring it all together so I can at least be in a good place to "learn by doing" when I get there. My learning on the wards is sooooooo much more efficient if I have some sort of foundation to work off of when the attending goes off on some topic. I feel like I have absolutely no foundation to build on when it comes to most ICU topics. Not sure if this makes any sense or if anyone else out there learns like this. I'm not necessarily trying to be a superstar, I just want to understand what's going on so I'm not just an order monkey trying to survive in an unfamiliar world. Maybe to some degree that's inevitable though.

Unless there are other recommendations, I guess I'll just start reviewing CXR, EKGs, surviving sepsis protocols and acid/base+electrolyte stuff, then flip through Marino's book. That should keep me very busy anyway.

Here's some key stuff:

The Surviving Sepsis Campaign is good - covers pressors and fluids in the kind of detail you will need (Norepi is now your "go to" pressor)

Check out the latest ASPEN guidelines on nutrition in the critically ill (TFs >>> TPN [avoid TPN unless absolutely necessary])

Know Early Goal Directed Therapy (Emanuel Rivers, NEJM, 2001) - importance of measured SvO2, and what to do with it

Understand low-pressure ventilation and why it's used

Know how to interpret electrolytes, especially the importance of Mg and Phos - know how to replace said electrolytes

That should be enough to allow you to show up the first day and know a little bit about what's going on and the rationale for why things are going on and will help direct you in starting to make management decisions on your own.

 

[km11]

Here's some key stuff:

The Surviving Sepsis Campaign is good - covers pressors and fluids in the kind of detail you will need (Norepi is now your "go to" pressor)

Check out the latest ASPEN guidelines on nutrition in the critically ill (TFs >>> TPN [avoid TPN unless absolutely necessary])

Know Early Goal Directed Therapy (Emanuel Rivers, NEJM, 2001) - importance of measured SvO2, and what to do with it

Understand low-pressure ventilation and why it's used

Know how to interpret electrolytes, especially the importance of Mg and Phos - know how to replace said electrolytes

That should be enough to allow you to show up the first day and know a little bit about what's going on and the rationale for why things are going on and will help direct you in starting to make management decisions on your own.

Isnt it lung protective ventilation?

 

[jdh71]

Isnt it lung protective ventilation?

yes, protected by lower pressures, produced by lower tidal volumes

 

[km11]

yes, protected by lower pressures, produced by lower tidal volumes

I thought it was mostly the big change in volumes. So higher peep, lower volume is better

 

[lord_jeebus]

change in volumes

(that is the definition of "tidal volumes")

 

[km11]

(that is the definition of "tidal volumes")

No I get that. I was asking because i thought what makes LPV good was the reduced tidal volume and any supposed decrease in pressure since you might not have that much less pressure if you have PEEP

 

[jdh71]

I thought it was mostly the big change in volumes. So higher peep, lower volume is better

What happens to pressures in the system when you lower tidal volumes? What is it that causes damage with larger volumes?

 

[jdh71]

No I get that. I was asking because i thought what makes LPV good was the reduced tidal volume and any supposed decrease in pressure since you might not have that much less pressure if you have PEEP

PEEP generally doesn't add that much pressure. If you're trying to keep peak pressures less than 35 and plateaus less than 30, and PEEP is only making up 5 cmH20, the rest of the pressure in the system is coming from where do you think?

 

[km11]

PEEP generally doesn't add that much pressure. If you're trying to keep peak pressures less than 35 and plateaus less than 30, and PEEP is only making up 5 cmH20, the rest of the pressure in the system is coming from where do you think?

ouu gotcha. thanks

 

[PlutoBoy]

That said, maybe my learning style is a little different than some. I'll remember most of what I read, even if I don't see a patient with xyz disease/condition.

My learning style is also "different". When I was a MS, my dad and my older brother (who are also clinicians) used to tell me all the time "books don´t smell, don´t move, don´t yell" and that I couldn´t really understand or diagnose a condition until I see it.

Most clinicians will tell you this or something similar but I strongly disagree. If that is the case, then why have books?

I don´t want to sound pretentious but if you REALLY know your books, have common sense and know how to associate things, then I don´t know what´s so hard about working up a patient with dyspnea or chest pain, for example. You just do what the books/articles are telling you to do!

Of course, the ICU is much more complicated than the 60 yo smoker with PMH of COPD complaining of SOB, but reading and knowing your stuff well will go a long way.

So yes, I´d recommend reviewing The ICU Book or any other material that you might find important. Some things you don´t learn at the bedside.

 

[jdh71]

ouu gotcha. thanks

No problem.

 

[bigj626]

I am going into IM and i want to get some good ICU experience. The problem is that all the MICU is full of students already and I can do a SICU month instead. Do you feel doing an SICU month is suffice enough to get me that experience?
Or should I just do an ID month?

 

[jdh71]

I am going into IM and i want to get some good ICU experience. The problem is that all the MICU is full of students already and I can do a SICU month instead. Do you feel doing an SICU month is suffice enough to get me that experience?
Or should I just do an ID month?

Do the SICU. It will be good to see critical care from their perspective, plus it mostly crosses over.

 

[LukeWhite]

When I was doing ICU as a medical student I discovered the Elsevier clinics, which are a great way to get a grasp of the state of the art without losing yourself in too much detail or (like you point out) relying on old texts that are probably outdated. MDConsult has all the Elsevier journals online and it's worth searching for some of the obvious main topics.

To make it a little simpler, you might browse through the ATS Reading List. It's curated, organized by topic, and has plenty of free texts. The downside is that unlike the clinics, most of these articles aren't intended to give you a broad basic overview, which is definitely the way to start.

Acid Base is the keystone of ICU teaching, perhaps out of proportion to its importance, because it has tricks and can be taught anywhere in manageable chunks. The best acid-base article I've read is this one (also available through Elsevier sources). It's around 50 pages but extremely readable and if you digest it you will never be stumped on rounds.

I will risk controversy and recommend Marino's ICU Book (not the little one). It is opinionated and based largely on pathophysiologic reasoning rather than exclusively evidence-based medicine. I find this refreshing, and even if it teaches you something your attending tells you is wrong (and they will), it's useful to read as a guide to how to think about critical care.

Also, know when your patient's last bowel movement was. Always, more thoroughly than your own.

Have fun!