SICU help?

[TrustMe]

I have been around this forum for about a year now and have posted very little (mainly since I was an MS4 and knew very little). But now that I have graduated and am moving on to intern year and then CA-1 (can't wait to start anesthesia) I will try to help keep up the numbers that Jet is looking for and give my opinions as I learn more.

Now time for the actual post. I got my schedule the other day for my upcoming PGY-1 year and I start in the SICU and I am kind of freakin' out. I know that as a new intern we will get a little extra supervision to start out with (I hope) but as a first month intern in the SICU how much extra help will I get so that I don't kill someone on the first day? What can I expect as a first month intern in the SICU in regards to expectations from others, responsibilities, procedures, help from upper levels, etc.?

TM

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[Noyac]

That's exactly how I started out, in the SICU. It was great. I enjoyed every minute of it. The procedures are there but the I don't remember how many procedures I really got to do. I got a lot more later on in training. Don't worry so much about getting procedures, they will come. You should always have adequate back up.

 

[swpm]

What can I expect as a first month intern in the SICU in regards to expectations from others, responsibilities, procedures, help from upper levels, etc.?

Don't panic. You should always have backup immediately available from a resident. Major decisions & treatment plans will be made during rounds, so if you're good about having ALL the data on hand, and you have a basic understanding of the patient's disease, you'll do fine. In a sense it's kind of a step backward from the "manager" to "data collector" stage.

There are few truly acute crises that can't be handled by someone who has ACLS down cold (so know it!). Also, the nurses are typically squared away and usually know what to do in order to fix an immediate problem.

SICU's a good place to start. Everything past that won't necessarily be easier, but your comfort level will be higher after you've spent a month with the sickest.

 

[militarymd]

As a former attending in the unit...here are the things that I expect from PGY-1's

1) know your patients
2) know your patients
3) know your patients
4) follow directions
5) don't be arrogant...because you don't know how little you know...no matter how many books you have read
6) write everything down.
7) and did I say, know you patient?

Things to know about your patient:

history, physical exam (and I mean serial exams...not the one on the chart from 3 days ago), labs and studies ordered (to be performed, done, results), know the culture results and when they are sent and from where, know what meds they're on and for how long, know the treatment plan for the day, for the week.


I never expected the 'terns to know anything other than the above, and the knowledge above is readily available if you decide to spend the time to look at the patients and write things down.

 

[Trisomy13]

my humble addition to Mil's list (well..all under the "know your patien" heading):

read op-reports that led to this admission. is this a new fistula, or is this a frequent-flyer player with a storied history in the hospital?

know your patient's accuchecks, what you are doing for glycemic control, and how you will improve it today.

know how to interpret an ABG, and what vent changes you can make to wean accordingly.

know indications for blood transfusion (probably lower than you think), and more importantly, the preferences for the attending on that week (you will see that anemia seems to be more of an art than a science to some).

don't snub the nurses. for several reasons - they know more than you about this SICU. not to say they should manage your patient, but listen to them if they offer a suggestion while you are frantically looking something up on your PDA. they know how to handle a lot of would-be crises, and can save you time and be a resource. they also likely know inter-attending preferences for drugs, drips, etc.

and they can torture you with useless pages, or save food for you from pharm lunches, depending on how you treat them.

show up early ;-)

 

[Mman]

in the unit (as well as floor patients later), you'll want to get a feel for which patients are sick and which aren't. By that I mean, which of them is going to be actively trying to die in the next few hours and which are just kind of chilling in a stable mode.

Pay attention to their vitals including urine output and which way they are trending. Same thing for their labs. Is that acidosis getting worse than last time? Have they been gradually getting more tachy the last few hours? Is urine output dropping off?

You'll also want to brush up on reading CXRs and EKGs before you start.

And don't forget to always ask for help if something looks wrong with the patient. Your supervising residents and attendings will want you to err on the side of calling too much instead of not calling enough, especially in July.

Procedures? I'm sure you'll probably do a few lines (arterial and central), probably pull out some tubes, and maybe put in a chest tube or two.

 

[VentdependenT]

http://forums.studentdoctor.net/showthread.php?t=199197&highlight=ICU+rotation

 

[TrustMe]

Thanks for all the tips so far. I am still a little nervous but feeling more confident. Mil, thanks for expectations from an attending. I am hoping that I learned more in my SICU month as a 4th year than I think and that it will come back quickly. I am hoping for a great month that further increases my interest in CCM.

TM

 

[Planktonmd]

Thanks for all the tips so far. I am still a little nervous but feeling more confident. Mil, thanks for expectations from an attending. I am hoping that I learned more in my SICU month as a 4th year than I think and that it will come back quickly. I am hoping for a great month that further increases my interest in CCM.

TM

Just remember: It's not rocket science, actually it's mostly simple common sense.
It's hard work when you are at the bottom of the food chain because you will do the things that no one else want to do, like writing TPN daily orders and keeping track of the endless flow of test results and labs.
Try to learn about ventilators as much as possible and develop an understanding of the different modes of ventilation and the weaning strategies.

 

[TIVA]

The great thing about critical care is that even though it looks intimidating, what with patients that are intubated, sedated, sickly, pale, anemic, and multiple problems galore, it is actually quite simple and easy. And you look like a rock-start by managing them.

You will only see three problems in the ICU:

1. Shock (and all the differentials -- hypovolemic, distrubutive, obstructive, and cardiogenic).
2. Organ failure (resp failure -- vents, kidney failure -- dialysis, heart failure -- drips, etc.)
3. Infection (pneumonias, wounds, and blood)

You already know how to treat each of these since you're a graduating medical student. But, you only know how to treat them empirically because that's what you've been taught and that's what you've read. Now, as a resident, put to practice what you've learned.

Hypovolemia? Fluids/blood/plasma/colloid.
Sepsis? Pressors and Abx.

Pretty simple, huh?

And don't get worried about not being able to see the light at the end of the tunnel. And I don't mean your tunnel, but the patient's tunnel. That comes with experience.

If the patient gets better, it's because they get better on their own. All they need is a tincture of time. Your job is just to make sure you don't hinder their progress. The ICU is basically a setting in which patients who would otherwise die, are temporarily artificially supported, until they heal on their own.

In the meantime, buy Marino's ICU book and start reading up on those topics that you encounter in the ICU.

Best of luck,