what to do.. ICU first?

[bantyran]

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hmm, ok.. well, i found out that i may get rocked (i think) and be the first to get ICU posting the first month i start my IM residency. i'm a US fmg but actually starting in a intense posting on day one is scaring the hell out of me. i was thinkin maybe doing floors for the first few months would be good and easy for me. but now im afraid itll be such a big deal and impossible. even now, im kinda fresh and its been a bit since med school ended. anyway i can prepare? or will the other residents know ill be scared and wont know **** walking in. hah. im just wondering. cause then i was thinking maybe i'd read "the icu book" like 2 weeks before .. anyone got any advice?

 

[edfig99]

hmm, ok.. well, i found out that i may get rocked (i think) and be the first to get ICU posting the first month i start my IM residency. i'm a US fmg but actually starting in a intense posting on day one is scaring the hell out of me. i was thinkin maybe doing floors for the first few months would be good and easy for me. but now im afraid itll be such a big deal and impossible. even now, im kinda fresh and its been a bit since med school ended. anyway i can prepare? or will the other residents know ill be scared and wont know **** walking in. hah. im just wondering. cause then i was thinking maybe i'd read "the icu book" like 2 weeks before .. anyone got any advice?

just breathe, you'll be fine. pay attention during bls and acls (learn your code algorithms). your residents will walk you through everything else and you'll learn by doin'. it never hurts to read ahead, but don't lose sleep over it. the plus side to starting with unit is you'll know what sick really is, and you'll learn to multitask. intern year is big on organization. someone has to start in the unit, and congrats it's you 🙂

 

[orientedtoself]

may as well get your unit month out of the way early, while you're still rested.

some advice:
1. in a code, remember, the patient is already dead. anything you do will only help them. and have your code cards in your pocket.
2. ask for backup when you need it. if you are concerned about a patient and it looks like they're going south, call your senior resident.
3. always review the results of every study you order yourself. if you order an ekg or a cxr, it's your job to follow up on it
4. don't piss off the icu nurses
5. early goal directed therapy for sepsis. do it.

 

[edfig99]

may as well get your unit month out of the way early, while you're still rested.

some advice:
1. in a code, remember, the patient is already dead. anything you do will only help them. and have your code cards in your pocket.
2. ask for backup when you need it. if you are concerned about a patient and it looks like they're going south, call your senior resident.
3. always review the results of every study you order yourself. if you order an ekg or a cxr, it's your job to follow up on it
4. don't piss off the icu nurses
5. early goal directed therapy for sepsis. do it.

#4 👍 actually should be higher on the list. the nurses determine your level of miserability and panic on call. always be nice to the nurses.

 

[bantyran]

good advice. so far you guys are tellin me it may be tough but it will be best for me to learn the worst of it from the start. i think im gonna take it with stride and while im totally rested the month before ill deal with it. oh, any good books i can read or atleast start before i walk in? any essentials that i should read up on for sure?? vent settings?

thanks. you guys are a big help.

 

[Swaydaa]

As per above the ICU nurses are awesome and you never want to get on their bad side. They will most likely teach you more than your attendings.

I will also tell you, one of the best books I've read is Marino's ICU book. If you "throughly skim through" the book and read as much as you can that would be awesome!

You will be 10X more confident on floor call after doing an ICU month early.

 

[deleted89854]

ICU is actually one of the least "scary" months you can rotate through. There is usually never a situation where an intern is alone in the ICU. You should always have access to a resident or fellow while on call. Read your book and pay attention to the protocols for antibiotic therapy, vent weaning, etc. I started out in the SICU and found it very helpful for the rest of my rotations.

 

[Bobblehead]

The never get on the ICU nurses' bad side comment cannot be underemphasized, particularly to housestaff at the beginning of their training. Much later in your training you can start picking your battles, but even then they should always be at times when you think any other course of action would cause direct harm to the patient. Usually by that point in your career, having a rational explanation for your decisions makes everyone go along with your plan even if they don't agree.

 

[ekydrd]

I also have to agree on the be nice to the nurses statement. As an intern in the ICU I learned that many times they know what to do in most situations. If you aren't sure just ask "what is normally done in this situation?" And remember YOU ARE NEVER ALONE! There is always someone senior to you somewhere in the hospital. It may be your upper level, or another upper level covering, but there is also the ER attending (if your hospital has an ER) who might be able to help too. In a code... ABCD and yell for help.

 

[swpm]

hmm, ok.. well, i found out that i may get rocked (i think) and be the first to get ICU posting the first month i start my IM residency. i'm a US fmg but actually starting in a intense posting on day one is scaring the hell out of me. i was thinkin maybe doing floors for the first few months would be good and easy for me. but now im afraid itll be such a big deal and impossible. even now, im kinda fresh and its been a bit since med school ended. anyway i can prepare? or will the other residents know ill be scared and wont know **** walking in. hah. im just wondering. cause then i was thinking maybe i'd read "the icu book" like 2 weeks before .. anyone got any advice?

In July I'll be a CA-3 (PGY-4) anesthesiology resident, and working in our SICU, so I'm looking forward to having a group of brand new interns. 🙂 I also did two months as a CA-1, but those were in February and May, so I had the benefit of more experienced interns. Even so, the expectations of the interns were modest. Attendings didn't expect a lot of independent management, even from residents. (No ICU fellows at my institution, so we were directed by attendings.)

The internet is full of horrible stories of malignant programs that throw you to the wolves, but the common reality is that interns (especially new ones) are guided very closely. Nobody - from the nurse to RT to resident to attending to fellow if you've got one - wants a bad outcome, so every one of them will assume you know nothing, and can barely (barely) be trusted to follow explicit directions. Your job will be primarily one of information gathering and scut (scut being the tedium of writing up H&Ps, entering admission orders, babysitting new admits in CT, calling the nephrology fellow early in the morning with a consult, chasing him down that afternoon to nag him into writing up the consult, etc).

So long as you are able to gather all the data before rounds each morning, know everything about your patients (everything), and can present that information in a reasonably coherent way, you'll do fine. Everyone knows you're new. No one expects you to be able to recite River's study on day one.

You'll get pimped on rounds, and unless you're a star already, it'll probably suck. If you have jerks for residents or attendings, they may make you feel like you're unusually clueless as they lie about how they knew and did so much more when they were interns. But you won't be thrown into a void where you can really hurt someone.

So sure, you'll probably get worked half to death, and people will yell at you, and maybe some bitter superior will try to torture you, but the leash will be short enough such that you won't be able to hurt a patient unless you deliberately, grossly overstep your bounds.

If you feel compelled to get a jump on things, look over the new edition of Marino's ICU book before you start, and glance at a few articles ...
- surviving sepsis & River's early goal directed therapy
- The ARDSnet trial
- Tobin's mechanical ventilation review article
- daily wakeups (Kress?)
- Dalen's PA catheter article (not so great, but everyone talks about it)
- Van der Berghe's insulin therapy in the ICU
- Hebert's transfusion article
- I'm sure others can suggest more

And for the love of god know how to read a blood gas. 🙂

I don't know why "be nice to the nurses" is always emphasized in these threads. You should be polite and respectful to everybody, if for no other reason than everybody from the janitor up can hurt you. If you're an jerk by nature, no amount of faux respect is going to fool them.

Nurses aren't out to get you ... but don't let them (or especially RTs) talk you into anything without talking to your senior.

By August you'll be way ahead of your classmates, especially the ones who started out with a month of outpatient no-call peds clinic (as I did).

 

[jacksparrow82]

I wouldn't get too bent out of shape over ICU. I did a sub-I ICU rotation in January and I loved it. I learned more that month than any other IM month I've had. They treated me just like the interns and really it wasn't that bad. Compared to floors you'll be expected to carry fewer patients because they are sicker. Also, they realize that you're just an intern and they will help you out a lot and really keep an eye on you. Just try to do everything your attending likes and be respectful to your seniors and you'll do great.
I highly recommend "The ICU Book" by Marino. I used it on my rotation and I was a star on rounds many times throughout the month and I really attribute it all to that book. It will help you understand everything you need to know to do great as an intern.
Good Luck!!

 

[DarthNeurology]

I have done medical student rotations in ICU and SICCU. Students and resident do get *reamed* and chewed out on these rotations, I think it is institution dependent, so don't get fooled into thinking that everybody will take it easy on you because your an intern, that works for about the first half of the first day. Student/Residents/Attendings don't "socialize" a lot in ICU/SICCU because these are very sick patients that could go down the tubes very quickly, i.e. this isn't that laid back outpatient clinic where eat lunc with the attending for 45-minutes and leave at 4 pm. . . Because of the high stress and fear of patients dying it is important for residents to really take ownership of the patients, I sort of started out by pretending/envisioning that the patient was an aunt or grandmother i.e. a close relative and tried to learn everything about their care, i.e. blood cultures, antibiiotics, etc . . . if you had a relative in the ICU you would want to know why they were going for an abodminal CT or what the ID doctor said about their WBC of 30 . . . surprisingly a lot the residents PGY-2s couldn't answer these questions, i.e. "ID is on the case, no I don't know why antibiotics were changed . . ." this just looks bad, i.e. that you don't care. It is easy for the patient in ICU Bed #3 to become just the 67 y/o with ARDS on ventilator, especially if they are sedated and you never interact with them. I really got involved with my patients and I came to *hate* residents who loved to talk about experiences on other rotations or give a poor 50minute presentation on some topic that only really knew a little bit about while letting the patient in SICU Bed #7 who is dyspneic go without an ABG for 3 hours even though I pointed this out and the attending reams the resident later, it is this type of resident that you want to take to the side and yell at them and tell them to "Get their !@$@ing act together and start monitoring the patients and know what is going on!" (Though I couldn't do this as student obviously🙄). You really have to be proactive and follow up stuff religiously as the attending doesn't care if you ran 14 codes in 6 hours if you haven't checked the CT results or don't know about the culture results for 8 hours on a critical patient this is inexcusable.

 

[RTrain]

I really got involved with my patients and I came to *hate* residents who loved to talk about experiences on other rotations or give a poor 50minute presentation on some topic that only really knew a little bit about while letting the patient in SICU Bed #7 who is dyspneic go without an ABG for 3 hours even though I pointed this out and the attending reams the resident later, it is this type of resident that you want to take to the side and yell at them and tell them to "Get their !@$@ing act together and start monitoring the patients and know what is going on!"

You really are unbelievably critical of residents for a 4th year student. It's pretty hard to swallow. That resident was most likely required to give that presentation, as are they required to manage six times the number of patients that you are. That's great that you were so much smarter and more on the ball than the overworked, under-respected, and just generally physically and mentally stretched-to-the-breaking-point resident, but you shouldn't brag about it so much.

To the OP, chiefs (or whoever is in charge of scheduling) generally make a point to schedule especially strong upper-levels in the ICU during the first couple of months, so the people who will be backing you up will be good residents and good teachers, by and large, so just work hard, get in early, and read; you'll do fine. 👍

 

[DarthNeurology]

as are they required to manage six times the number of patients that you are. That's great that you were so much smarter and more on the ball than the overworked, under-respected, and just generally physically and mentally stretched-to-the-breaking-point resident, but you shouldn't brag about it so much.👍

My responsibilities included:

1. Working longer hours than the residents (yes, we had to stay behind when our resident left for the day and were conscripted into coming in early before the next shift started to work on the list. Resident's hours: 6:00 am to 6:00 pm always, at the extreme my hours were: 4:45 am to 7:30 pm.

2. I always see ALL the patients that my resident's see (i.e. the team's patients), this usually requires coming in around 5 am on other electives to pre-round on ALL the patients. Yes I've been told I don't need to, but I am a dark lord of sith😀

3. Oh yes, oh yes, the junior residents do know they work less than me, especially when commented about it in front of the attending how they should be the hardest worker on the unit. Respect is earned through hardwork, it cultivates a presence of "being on the ball" such that few would openly harass me, if ever.

4. In terms of being physically and mentally stretched to the breaking point, your body will get tired but you can jog your mind to stay on task. That was my message in my post basically is to stay on task and ICU/SICCU requires a lot of attention.