SICU vs MICU

[aimedicine]

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So finally got my intern schedule, so i was womdering...which prepares you better for anesthesia...Surgery ICU or Medicine ICU?

Feel free to throw any pearls of wisdom, for an intern, into your answer

 

[FollowTheMoney]

SICU

 

[aimedicine]

SICU

Any particular reason?

 

[G-Man82]

Based on my residency experience and based on what I saw as a fellow, both would probably prepare you well. The advantage of the Sicu is that a lot of those patients have been to the OR already and there will be more interaction with Anesthesiology for all the bring-backs. Also you see the results of intraop care on post op course. The drawback? Dealing with surgeons and, especially as an intern, just being an order writer.

MICU on the other hand ... More bread and butter CCM. You get the patient from the ER and you basically have them from the start. You place the lines (and while we laugh at the medicine guys, they seem to let their interns do things) and start resuscitation. For surgical patients, they usually come resuscitated and lined up, though there are some exceptions.

If there's good Anesthesiology involvement in your sicu, then I'd suggest sicu because the rotation will be more tailored to you. But if it's purely surgery-run, I'd suggest a month of micu. Where I trained, the surgeons weren't very interested in the usual critical care management: vent management was from the 1990s, they still used oscillators, education was poor, no adherence to EBM, and the residents learned nothing and essentially just ordered things the nurses were missing. That being said surgeons are also high up in SCCM and can make great intensivists.

I won't hide my bias, but for learning as an intern, I'd suggest SICU if there's anesthesia involvement. MICU otherwise.

 

[FollowTheMoney]

Any particular reason?

Those are the trauma patients you are going to be taking care of and the patients you will be taking to surgery. I think those are the prototypical patients to manage well in the ICU. The MICU is great for building your medical knowledge and managing serious diseases and comorbidities. They both will help you learn how to manage vents and take care of critically ill patients. I think they both have their place, but I think the SICU is more relevant for the PSH and OR.

 

[WholeLottaGame7]

If you consider big access 14g PIVs and a MAC/Cordis (or both) and a resuscitation involves a Belmont and massive transfusion protocol, go for SICU. If you consider big access 20g IVs and a double-lumen and a resuscitation involves 250mL aliquots of NS, go for MICU.

Only partially joking. Philosophically the two units approach critically ill patients very differently, and your philosophy as an anesthesiologist will be much closer to SICU's. That said, MICU will teach you some good theoretical knowledge, and it's probably better if you do it as an intern. I don't see how the CCM anes fellows go back to MICU after an anesthesia residency; I would totally lose my mind.

 

[Twiggidy]

Agree with above and it's also these reasons I think anesthesiologist should do a surgical PGY-1. My opinion. You're going to be around surgical patients all the time so why not see it from pre and post op as well. My feeling is that for the most part MICU patients are just a touch too sick to be on the floor, like just a touch. In MICU you'll learn more about disease processes but in SICU I feel like the criticial is ACTUALLY critical because they're usually about to have or just have had surgery (i.e, they're very close to being under anesthesia care and likely still getting some form of 'anesthetic' in the SICU)

But I'm sure there's a benefit for doing medicine/MICU but I just don't see it because I'm biased.

 

[psychbender]

I did CCU, SICU, and a combined med/surg ICU as an intern. The CCU was good for reviewing ECGs and MI/heart failure management. The SICU was good for postop care of the surgical patients that you well spend the rest of your career caring for. The combined unit was great, as there was a mix of the same surgical patients, along with multiorgan failure, PNA/sepsis, and stroke. Bottom line, you can learn a lot in any ICU setting, SICU would probably be the most applicable.

 

[fakin' the funk]

Both.

Remember, you're the internist in the OR, not surgeon-second-in-command. For me, MICU is better bang for your buck (or rotation) but both are very useful.

 

[Ronin786]

At my program we're lucky enough to spend time in a CVICU. You get CCU, SICU and MICU combined.

I think you can learn a ton from either place. As has been mentioned earlier, in the MICU you'll receive a lot more theoretical knowledge, especially with regards to vent and sepsis management. SICU will give you a lot of the bread and butter stuff, so that you can get familiar with post-op weaning which is entirely different from MICU weaning.

Both are wonderful learning experiences as long as you put in the time and effort.

 

[deleted547339]

Agree with above and it's also these reasons I think anesthesiologist should do a surgical PGY-1. My opinion. You're going to be around surgical patients all the time so why not see it from pre and post op as well. My feeling is that for the most part MICU patients are just a touch too sick to be on the floor, like just a touch. In MICU you'll learn more about disease processes but in SICU I feel like the criticial is ACTUALLY critical because they're usually about to have or just have had surgery (i.e, they're very close to being under anesthesia care and likely still getting some form of 'anesthetic' in the SICU)

But I'm sure there's a benefit for doing medicine/MICU but I just don't see it because I'm biased.

In not anesthesia (I'm EM), but my experience was the exact opposite - I found my MICU patients to be much sicker. It seemed like all of the SICU patents had a few medical problems and one major issue being addressed by surgery. The MICU patients always had a laundry list of co-morbidities and we're basically half-dead. Our MICU is probably an oddity though - we have a relatively small MICU for the size of our hospital but multiple surgical sub specialty ICUs. To get into the MICU you have to be intubated or on vasopressors. The thing I enjoyed about SICU patients is that they getter better.

 

[G-Man82]

Another problem with SICU is that often you're just baby sitting patients who need to be there for nursing-specific reasons. Example: q1h post-op neurovascular checks after a fem-pop bypass. Patient is usually super stable, maybe on a little nasal cannula O2, rarely ever on pressors ... But is in the ICU. Other times they're there only because the surgeon wants them in the unit even though they have been "floor-ready" for days.

SICU is rarely ever a closed environment; it functions in the co-management model with the surgical team. Pluses and minuses there. If you want the experience of being the one and only doctor, then MICU has the advantage. No surgical problems means no dealing with the surgeons; all decisions are yours. It's refreshing at times ... And we (Anesthesiology/CCM) are very good at it.

 

[Twiggidy]

Another problem with SICU is that often you're just baby sitting patients who need to be there for nursing-specific reasons. Example: q1h post-op neurovascular checks after a fem-pop bypass. Patient is usually super stable, maybe on a little nasal cannula O2, rarely ever on pressors ... But is in the ICU. Other times they're there only because the surgeon wants them in the unit even though they have been "floor-ready" for days.

SICU is rarely ever a closed environment; it functions in the co-management model with the surgical team. Pluses and minuses there. If you want the experience of being the one and only doctor, then MICU has the advantage. No surgical problems means no dealing with the surgeons; all decisions are yours. It's refreshing at times ... And we (Anesthesiology/CCM) are very good at it.

I do agree with this but the last part I'll play devil's advocate and say that as an anesthesiologist, dealing with a surgeon is something you're going to do for the rest of your life. Even though it doesn't seem like it many times (most times), the operating room is a team area and decisions on patients are usually made in collaboration the surgeon. At least in fantasyland where I dream I work it does.

 

[nycitygas]

I learned more in my one month of MICU than the other 11 months of my fellowship combined. Also, MICU's tend to let their junior staff become much more involved in all sorts of procedures-probably bc there are so many more to go around.

 

[nycitygas]

Another problem with SICU is that often you're just baby sitting patients who need to be there for nursing-specific reasons. Example: q1h post-op neurovascular checks after a fem-pop bypass. Patient is usually super stable, maybe on a little nasal cannula O2, rarely ever on pressors ... But is in the ICU. Other times they're there only because the surgeon wants them in the unit even though they have been "floor-ready" for days.

SICU is rarely ever a closed environment; it functions in the co-management model with the surgical team. Pluses and minuses there. If you want the experience of being the one and only doctor, then MICU has the advantage. No surgical problems means no dealing with the surgeons; all decisions are yours. It's refreshing at times ... And we (Anesthesiology/CCM) are very good at it.

I agree with this 100%. I thought the SICU was often boring at times...

 

[Mad Jack]

Agree with above and it's also these reasons I think anesthesiologist should do a surgical PGY-1. My opinion. You're going to be around surgical patients all the time so why not see it from pre and post op as well. My feeling is that for the most part MICU patients are just a touch too sick to be on the floor, like just a touch. In MICU you'll learn more about disease processes but in SICU I feel like the criticial is ACTUALLY critical because they're usually about to have or just have had surgery (i.e, they're very close to being under anesthesia care and likely still getting some form of 'anesthetic' in the SICU)

But I'm sure there's a benefit for doing medicine/MICU but I just don't see it because I'm biased.

How sick the patients are in MICU vs SICU is largely facility dependent. The hospital I'm at is almost always short on all ICU beds, plus we have sizeable stepdown units for less critical patients, so both the SICU and MICU pretty much guarantee you'll have patients that are on death's doorstep. While I can only comment on things from a vent management perspective, SICU patients are very different than MICU patients- much of the time you're dealing with hemodynamically unstable patients in the SICU that have lungs that are usually optimal for surgery, while in MICU, your vented patients more often than not have pulmonary compromise or full blown ARDS. It really changes the way you ventilate and what your primary strategies are.

Generally I find SICU patients are far easier to deal with, and nightmare patients that eat up tons of my time to be far more common in the MICU. We'll see how I feel about things come internship...

 

[deleted171991]

So finally got my intern schedule, so i was womdering...which prepares you better for anesthesia...Surgery ICU or Medicine ICU?

Feel free to throw any pearls of wisdom, for an intern, into your answer

At intern level, MICU (unless SICU is run exclusively by anesthesia). Much more organized (vs knee-jerk) thinking, and sicker patients.

 

[G-Man82]

I do agree with this but the last part I'll play devil's advocate and say that as an anesthesiologist, dealing with a surgeon is something you're going to do for the rest of your life. Even though it doesn't seem like it many times (most times), the operating room is a team area and decisions on patients are usually made in collaboration the surgeon. At least in fantasyland where I dream I work it does.

Agreed and I'm fine dealing with them. However there definitely come times when there are too many cooks in the kitchen. My biggest pet peeve is when the surgeon wants to pull the "well he's my patient and I want this done my way and I won't consider alternatives" card. Prime example for me from my experience in fellowship was blood transfusions. I'm restrictive; the surgeons are not. Vent management: some of the surgeons were very old school and would gawk when I'd place granny on Vt of 370 based on her ideal body weight. In the MICU (or any true closed unit) that's a non-issue.

That's where I think it's refreshing. In the OR, as "collaborative" as we like to think we are, often we still cater to the surgeon's whim because otherwise he'll throw a temper tantrum and that makes everyone's day miserable. And we play this game willingly as long as the request won't cause harm. In the unit usually I have the freedom to make my own decisions, but occasionally that same interplay still occurs.

It's the beauty of critical care. I get to be both the anesthesiologist and intensivist. In the OR, I bring ICU with me, and during my ICU time I have the freedom to do what I want and think is indicated usually without interference.

 

[vector2]

Sorry to bump an oldish thread, but I wanted to chime in that a closed MICU rotation will likely be much more helpful to you than a typical, open SICU rotation during your intern year. SICU often has a level of complexity and requires a degree of collaboration that you just don't have the tools to effectively deal with when you're still learning the ropes. At this point in your training, I think it's more beneficial to be in a closed structure where the typical anal, academic pulm/cc attending (who, in my experience, disdains all his medicine colleagues on the floor who consult for everything) is going to force you to think about all the minutiae of your patient's comorbidities and the subsequent interventions you need to undertake to fix them. They have time to do this kind of mental masturbation during their interminable rounds because the prone ARDS patient likely isn't going anywhere anytime soon... unlike the SICU patient who might be scheduled for his 4th OR bringback that morning. More often than not, you're going to get a better foundation in EBM in the MICU because a lot of those folks constantly review the latest articles on ventilation strategies, sepsis/appropriate antibiotic use, pressors, glucose management etc. Don't get me wrong, you're definitely going to pick up some tidbits during SICU that will help you when you start doing anesthesia in earnest, but right now it's more important for you (and your future test scores) to focus on things like blood gas interpretation, cardio/pulm/renal phys, sedation pharmacology, and vent weaning strategies rather than worrying about the difference between a type I or II endoleak or whether triple H is really that effective for vasospasm.

Also, as an aside, you should be doing/volunteer for every a-line, central line, peripheral IV, intubation and LP you can get your hands on. And play with the ultrasound frequently as well, not just when dropping in an IJ. Having some decent degree of preexisting hand-eye coordination will make your life easier when you start in the OR, and also make you look like a rockstar to boot when your attending doesn't have to sit there watching you struggle when he's got another case to start in his other room.

 

[Mman]

Another problem with SICU is that often you're just baby sitting patients who need to be there for nursing-specific reasons. Example: q1h post-op neurovascular checks after a fem-pop bypass. Patient is usually super stable, maybe on a little nasal cannula O2, rarely ever on pressors ... But is in the ICU. Other times they're there only because the surgeon wants them in the unit even though they have been "floor-ready" for days.

That's the opposite of what we see. Hell even being on the vent isn't enough to get you into our SICU sometimes, they will sometimes have us ride it out in PACU for a few hours to see if they extubate because they don't have the bed space. You gotta be deathly ill to get into SICU. We will have patients in stepdown units on the vent via a trach at times.

Fem-pop patients in the ICU? Really? They are practically floor patients.

 

[vector2]

Mman, our SICU pts are also super sick and the only interns we get when we rotate on the unit are surgery. Our SICU is simply just not the structured learning environment that the MI is. The intern takes call solo but anything even slightly complex will involve a call to the cross covering surg upper level or surg fellow at home this early in the year. The education/didactics on SI are relatively informal and it's very much on the job learning. Our interns do micu and neuro icu (lots of staff/experienced midlevel backup) before venturing into the sicu as ca1s, and i think this system works well because they have a structured foundation before venturing into the chaos of having to manage sick pts who also have surg pathology.

Also i was talking about endoleaks vis a vis the the super sick endo AAAs with a ton of blood loss who we have to sleep cause our vasc surg is ******edly slow

 

[G-Man82]

That's the opposite of what we see. Hell even being on the vent isn't enough to get you into our SICU sometimes, they will sometimes have us ride it out in PACU for a few hours to see if they extubate because they don't have the bed space. You gotta be deathly ill to get into SICU. We will have patients in stepdown units on the vent via a trach at times.

Fem-pop patients in the ICU? Really? They are practically floor patients.

I wish the SICU at my residency and fellowship hospitals were like that. At both places, university settings, anyone s/p a vascular bypass surgery came to the unit for 24 hours for neurovascular checks. It was purely a nursing indication. They were hardly ever on pressors, more than NC oxygen, or really required the ICU for medical reasons. In all honesty, it was annoying. The VA is like this, too. But the again, transferring to the floors at a VA is like discharging to the streets. Same level of care.

As far as PACU goes, I think my residency hospital was like that; we could have vented patients. The question then becomes who manages them? Anesthesiology because they're post-anesthesia in PACU or are they automatically turfed to the SICU team (like at my fellowship hospital), who then had to leave sicu and come see the patients in pacu. What about if they are still in pacu on POD 1 but waiting for an ICU bed?

We could send trach patients to step down (very few beds in hospital) or floors as long as they were trach collared. If they required a vent, automatic ICU. We need more step down units in general.

I've rotated through both MICUs and SICUs (managed together or separately by Anesthesiology and Surgery) and for interns, I still stand by my opinion that the MICU is a better place for them. Interns get to do more in a MICU. As an intern, I had first crack at lines and was more involved in making some decisions under the oversight of my senior. Rounds were full teaching rounds and there were education sessions by attendings or fellows targeted at residents. In the SICU where I did residency (purely trauma run) we were glorified order-writers and everything was run by either the ICU attending or the primary surgeon. In my fellowship I experienced ICUs run by anesthesiologists and it struck me as a hybrid model, in the sense that we still taught the residents, had teaching rounds, discussed evidence, and also spoke about intraop events/management and its effect on how the patient presented to us postop. However, the residents still had to run basically everything by the fellow or attending, and occasionally the surgeon.

I may be generalizing my experience from 3 hospitals systems, but I still think an intern stands to learn the most about CCM and CCM procedures in a MICU, followed by an Anesthesiology-run SICU (less procedures as they usually come from OR rather than ER), and finally a purely surgery-run unit.

 

[Arch Guillotti]

Fem-pop patients in the ICU? Really? They are practically floor patients.

Ours almost never go to the ICU, usually tele.