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ICU rotation
- Thread starter francois
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check out this thread:
http://forums.studentdoctor.net/showthread.php?t=1003984
Some were more helpful than others (heh)
Some were more pedantic than others (heh)
Just remember to bring your fellow coffee
http://forums.studentdoctor.net/showthread.php?t=1003984
Some were more helpful than others (heh)
Some were more pedantic than others (heh)
Just remember to bring your fellow coffee
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The ICU Book by Merino. Broad approach great for your first time in the subject.
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I would say The Little ICU book by Merino is sufficient. The Big Book is a bit much in my opinion (although maybe if you are a medicine tracker it would be worth it). Be glad you are starting with ICU, it will be tough at first but once you are done you will be several steps ahead of your peers.
Survivor DO
Survivor DO
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I would say that most of us in critical care are kind of "meh" on Marino honestly.
I don't think critical care is best learned from a book and find their use rather silly in the unit. Most of of what we do is based on community practice in general, which is based mostly on first principles based on our understanding of physiology and pathophysiology. The rest of what we do is based on integration of evidence of varying degrees of strength from the medical literature as we think is appropriate and think it is true. There are very few really very strongly supported in the literature things that compels our practice - ie if we do not do them we are bad doctors.
There is a lot of noise confounding so much of what we do that you can't just use cookie cutter medicine in the unit. Any critical care doctor that can be replaced by a computer with a treatment algorithm, should be.
At the basic level critical care is barbaric and nuanced at the same time . . . Can't breathe good? Tube 'em. Barbaric, simple. But then how to ventilate and oxygenate? Nuance.
In this regard Marino is too dogmatic and not very helpful to the trainee who needs to be understanding not the dogmatism, which will become clear enough by the third day in the unit, but when you break from dogma, and to understand that, you need your nose out of a book and paying attention to a trained clinician tell you why they are doing what they are doing.
I don't think critical care is best learned from a book and find their use rather silly in the unit. Most of of what we do is based on community practice in general, which is based mostly on first principles based on our understanding of physiology and pathophysiology. The rest of what we do is based on integration of evidence of varying degrees of strength from the medical literature as we think is appropriate and think it is true. There are very few really very strongly supported in the literature things that compels our practice - ie if we do not do them we are bad doctors.
There is a lot of noise confounding so much of what we do that you can't just use cookie cutter medicine in the unit. Any critical care doctor that can be replaced by a computer with a treatment algorithm, should be.
At the basic level critical care is barbaric and nuanced at the same time . . . Can't breathe good? Tube 'em. Barbaric, simple. But then how to ventilate and oxygenate? Nuance.
In this regard Marino is too dogmatic and not very helpful to the trainee who needs to be understanding not the dogmatism, which will become clear enough by the third day in the unit, but when you break from dogma, and to understand that, you need your nose out of a book and paying attention to a trained clinician tell you why they are doing what they are doing.
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If not marino then marini. Both excellent starting texts.
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I can't
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are you sure on that? I mean yes you are the expert being a fellow and all that, but I practice a lot of evidence based stuff like the ARDS study with low ventilation volumes and the surviving sepsis campaign among other things.
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Yes I'm sure.
Here's what I said:
The bolded is the where the devil is in the detail. This is a teachable moment. Do yourself a favor and look at the level of evidence for everything in the surviving sepsis campaign.
ARDSnet data is better, but the survival advantage is actually very slim.
Almost every ass hole that rounds in the ICU likes to wax poetic about how what they are doing is the most advanced, cutting edge, right on the cusp of the evidence, when it's all largely garbage. Evidence is ONLY good as far as it goes. Learn to think for yourself.
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How about for a 4th year med student (next year), what book/resource do you recommend?
Or just learn by experience?
Or just learn by experience?
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I personally like Marino (the big one). It's easy to read. Yes, many people disagree with him. But he covers good physiology and is a fast read. It's easy to look up pertinent chapters. And even the big one is easy to stash in a backpack.
If you read pertinent stuff and are obsessive about knowing your pt, you will do fine.
If you want a high yield thing to memorize, look up the original Rivers article on early goal directed therapy in sepsis. Then your seniors can tell you all about the updates since then.
If you read pertinent stuff and are obsessive about knowing your pt, you will do fine.
If you want a high yield thing to memorize, look up the original Rivers article on early goal directed therapy in sepsis. Then your seniors can tell you all about the updates since then.
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The original therapeutic hypothermia articles in NEJM are also interesting.
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My ICU rotation was the second month of intern year. I didn't know shiet. I tried ready marino but I couldnt really wrap my head around it too well without being in the ICU first to make sense out of it properly.
If I were you: brush up on resp phys, read about interpretation of ABG's (attendings will ask you to dissect these, and ask you how to fix it) and something about mechanical ventilation (PEEP, Plateau pressure, ARDS net etc), basic stuff like that. I found the step 2 book Step up to medicine (respiratory) portion to be pretty decent at very basic things just to give you decent knowledge to build on while you're in the unit. You will learn a lot during that first month.
Other than that, show up early, know how to read them flow sheets, talk to the nurses and night team about overnight events and make sure you have followed up on EVERYTHING from the day before.
Oh and don't forget to bring your fellow coffee!
... and listen to the OG's on here for more advice.
If I were you: brush up on resp phys, read about interpretation of ABG's (attendings will ask you to dissect these, and ask you how to fix it) and something about mechanical ventilation (PEEP, Plateau pressure, ARDS net etc), basic stuff like that. I found the step 2 book Step up to medicine (respiratory) portion to be pretty decent at very basic things just to give you decent knowledge to build on while you're in the unit. You will learn a lot during that first month.
Other than that, show up early, know how to read them flow sheets, talk to the nurses and night team about overnight events and make sure you have followed up on EVERYTHING from the day before.
Oh and don't forget to bring your fellow coffee!
... and listen to the OG's on here for more advice.
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I'm in the final throws of my pulmonary and critical care fellowship at a "top-tiered" academic institution (oh how we love our "evidence"). As part of my training, I've done graduate work in biostatistics and epidemiology, which helped me tremendously to interpret studies for what they are actually worth. I absolutely agree with my colleague jdh's points.
Most of critical care medicine involves using available data about clinical scenarios and making bid decisions - often high stakes.
The evidence base for critical care is not worth bragging about. For example:
The overwhelming number of critical care trials are negative. So much so, that you could make the argument that with a collective p-value of 0.05 that several of the positive ones are by chance alone. This thinking is supported by the finding that many trials cannot be replicated (caveat: no two trials are completely the same).
Let's look at glucose control. Everyone got excited about tight glucose control and its potential to save lives. People rapidly implemented insulin drip protocols across many ICUs only to read follow up studies that spoke to the dangers of low blood sugar in critical illness (hypoglycemia is bad). Throw that on top of how commonly glucometers over-estimate (compared to glucose on a panel) by 30mg/dl or so and you have a recipe for potential harm. Tell me the right thing to do here? Prevent rapid swings in glucose and aim for 120-150. Evidence? Common sense.
What about activated protein C for septic shock? So many people go excited about this incredibly expensive drug. Threw it at people every chance they could get? Why? Because one study said it saved lives. Then, follow up study suggests harm. Removed from market. Now what? Back to salt water and pressors.
Speaking of sepsis management...The surviving sepsis campaign is a mindf*$k of guidelines based on pretty weak evidence. Take the time to read the 50 or so pages. The Rivers study was a single center study where the investigator himself managed many in the intervention arm. Despite its inherent limitations, rapidly adopted and implemented as a nationwide guideline. That point alone suggests that our evidence is pretty ****ty.
Ventilators? low-stretch mechanical ventilation. done. oh yeah, proning probably has an added benefit for severe hypoxemia but i'll be my measly salary that the magnitude of the benefit (e.g. the number of patients needed to treat to save one life) is grossly over-inflated in the study out of france in the recent NEJM. let's think before we flip everyone on their stomachs..
However, to confound results focused on short-term mortality (FACTT trial, ARDSnet) is new data suggesting that things that may save a life may create a new set of problems (post-ICU syndrome). For example, mortality benefit from a lower CVP target in FACTT trial appeared to lower mortality for ARDS. However, post-hoc analysis (quality of evidence not that great) suggests that these patients who survive go on to have higher rates of cognitive impairment compared to suvivors with a more liberalized CVP goal.
Oh god, show me the evidence that CVP is helpful? A MAP goal of 65? Rigidly adhering to these numbers harm patients on a daily basis.
Most of the evidence for critical care lies in prevention. Meaning, stop being stupid with your sedative and narcotic practices and minimize these drugs as much as possible while concomitantly assessing eligibility for extubation. It also means to hire crew of physical therapists who, on a daily basis, exercise patients with sepsis, respiratory failure, etc. Probably better than any drug. It means washing hands, elevating the head of the bed, considering proper patients for GI and DVT prophylaxis.
It also means, from my viewpoint, about being aggressive with patient-centered family communication so as not to ignore elephants in the room while you play around with fancy gadgets. A lot of the people speaking to critical care on this forum like to come off as cocky proceduralists, but I'd argue that an equally important skillset (that has some evidence to support its development) is communicating with patients and families.
So, JDH is right. We have little strong evidence to guide our treatment decisions - evidenced by the degree of heterogeneity in practice patterns across "centers of excellence"
How best to prepare, I think the Marino book stinks for the most part. If I had to pick a textbook I'd pick Hall Schmidt and Wood. But, who has time to read an entire textbook. Instead, read on ScvO2, sepsis, ARDS, COPD/Asthma on the vent, DKA, etc as they come up (or maybe on a few beforehand) in your patients. Reading about things while you have patients with those things solidified those things in your brain. I tried to offer advice as well in the link provided by JDH. The only thing I disagree with is buying your fellow coffee - unless you are truly buds - because I can't stand asskissers...
Most of critical care medicine involves using available data about clinical scenarios and making bid decisions - often high stakes.
The evidence base for critical care is not worth bragging about. For example:
The overwhelming number of critical care trials are negative. So much so, that you could make the argument that with a collective p-value of 0.05 that several of the positive ones are by chance alone. This thinking is supported by the finding that many trials cannot be replicated (caveat: no two trials are completely the same).
Let's look at glucose control. Everyone got excited about tight glucose control and its potential to save lives. People rapidly implemented insulin drip protocols across many ICUs only to read follow up studies that spoke to the dangers of low blood sugar in critical illness (hypoglycemia is bad). Throw that on top of how commonly glucometers over-estimate (compared to glucose on a panel) by 30mg/dl or so and you have a recipe for potential harm. Tell me the right thing to do here? Prevent rapid swings in glucose and aim for 120-150. Evidence? Common sense.
What about activated protein C for septic shock? So many people go excited about this incredibly expensive drug. Threw it at people every chance they could get? Why? Because one study said it saved lives. Then, follow up study suggests harm. Removed from market. Now what? Back to salt water and pressors.
Speaking of sepsis management...The surviving sepsis campaign is a mindf*$k of guidelines based on pretty weak evidence. Take the time to read the 50 or so pages. The Rivers study was a single center study where the investigator himself managed many in the intervention arm. Despite its inherent limitations, rapidly adopted and implemented as a nationwide guideline. That point alone suggests that our evidence is pretty ****ty.
Ventilators? low-stretch mechanical ventilation. done. oh yeah, proning probably has an added benefit for severe hypoxemia but i'll be my measly salary that the magnitude of the benefit (e.g. the number of patients needed to treat to save one life) is grossly over-inflated in the study out of france in the recent NEJM. let's think before we flip everyone on their stomachs..
However, to confound results focused on short-term mortality (FACTT trial, ARDSnet) is new data suggesting that things that may save a life may create a new set of problems (post-ICU syndrome). For example, mortality benefit from a lower CVP target in FACTT trial appeared to lower mortality for ARDS. However, post-hoc analysis (quality of evidence not that great) suggests that these patients who survive go on to have higher rates of cognitive impairment compared to suvivors with a more liberalized CVP goal.
Oh god, show me the evidence that CVP is helpful? A MAP goal of 65? Rigidly adhering to these numbers harm patients on a daily basis.
Most of the evidence for critical care lies in prevention. Meaning, stop being stupid with your sedative and narcotic practices and minimize these drugs as much as possible while concomitantly assessing eligibility for extubation. It also means to hire crew of physical therapists who, on a daily basis, exercise patients with sepsis, respiratory failure, etc. Probably better than any drug. It means washing hands, elevating the head of the bed, considering proper patients for GI and DVT prophylaxis.
It also means, from my viewpoint, about being aggressive with patient-centered family communication so as not to ignore elephants in the room while you play around with fancy gadgets. A lot of the people speaking to critical care on this forum like to come off as cocky proceduralists, but I'd argue that an equally important skillset (that has some evidence to support its development) is communicating with patients and families.
So, JDH is right. We have little strong evidence to guide our treatment decisions - evidenced by the degree of heterogeneity in practice patterns across "centers of excellence"
How best to prepare, I think the Marino book stinks for the most part. If I had to pick a textbook I'd pick Hall Schmidt and Wood. But, who has time to read an entire textbook. Instead, read on ScvO2, sepsis, ARDS, COPD/Asthma on the vent, DKA, etc as they come up (or maybe on a few beforehand) in your patients. Reading about things while you have patients with those things solidified those things in your brain. I tried to offer advice as well in the link provided by JDH. The only thing I disagree with is buying your fellow coffee - unless you are truly buds - because I can't stand asskissers...
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I just don't like paying for coffee. And I'm also joking. 😀
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The main text I read is Vincent. Bridges my anesthesia and medicine training perfectly.
Anypoops...
marino does an outstanding job at presenting shock, aki, arrythmias, heart failure, mech ventilation, respiratory failure, and cardiopulmonary physiology for the novice. No flippen way is someone gonna crack open one of the several daunting 2 volume monster critical care texts as an intro read to this field. Ridiculous. If any resident or med student read anything from any critical care text I'd be happy. Marino and Marini are perfect for the motivated intern, resident, and curious 4th yrs foray into CCM.
Coffee is for pu%}*es. Red bull. If I flew transatlantic bombing raids = provigil.
Anypoops...
marino does an outstanding job at presenting shock, aki, arrythmias, heart failure, mech ventilation, respiratory failure, and cardiopulmonary physiology for the novice. No flippen way is someone gonna crack open one of the several daunting 2 volume monster critical care texts as an intro read to this field. Ridiculous. If any resident or med student read anything from any critical care text I'd be happy. Marino and Marini are perfect for the motivated intern, resident, and curious 4th yrs foray into CCM.
Coffee is for pu%}*es. Red bull. If I flew transatlantic bombing raids = provigil.
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Yeah. We can't be friends anymore.
It's almost like you just admitted to being a racist.
I can't.
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Rofl!
Coffee isn't for pu😉!es. I drink red-eyes. Love em!
Coffee isn't for pu😉!es. I drink red-eyes. Love em!
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I know a medicine resident who has read large portions of civetta and Taylor's critical care as well as dellinger and parillos CC medicine texts......but I'll admit he's got a screw loose 😉
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And energy drinks destroy me. Water for thirst....high octane coffee for everything else.
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Hey more power to him! I still wouldnt recommend it to someone who is completely new to the field and wants a place to start.
Water is for pansies!
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By "A medicine resident I know" I obviously meant me lol.
I drink alot of water now. Was drinking like 4-5 sodas daily. Water/coffee is healthier. That way I don't get "the sugar".
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I know. But some sap might think you are serious!
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Good lord I'm sorry man, pretty obvious upon review! Not getting enough sleep. I was impressed with whomever you were referring to. Glad it is you.
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The icu book especially the pocket version very well written
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I just realized today at mass gen makes a "pocket ICU" going to take a look at it it's compact and pocket medicine is quite useful. Fr $40 this could be a good reference to carry
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LoL. Its my 5, 3, and 4mo old boys keepin my sorry ass up at night. 10D of residency and ONE medicine clinic left.
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I have wash manual and have made my own pocket notebook out of it. However the manual itself is heavy, hence I incorporated what I want from it into my own handwritten pocketbook. But the mass gen pocket icu is much smaller and bulky which is why I am probably gonna pick it up.
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You got nothing to lose except 40 bucks. "meh" is a popular statement on this board. Although an entertaining tepid phrase to drop it is indeed useless in terms of providing guidance to us.
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I gave you my advice. There is no good book.
Just pick one. Use it. It won't be that helpful.
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Noted. I do most of my reading on the toilet anyways.
