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Where else can I improve?
- Thread starter fatefeather
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It sounds like you're doing fine. I think that after writing your note (that someone may or may not read), preparing for the shelf is a okay idea. Just be sure to be available for anything that comes up. Just being around during third and fourth year gave me some awesome opportunities to do procedures or to scrub in on cool cases that I otherwise would not have had if I bounced out to study for shelf. Be available, be affable, and be able in that order of importance.
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ICU is a tough place to start. Every other patient will seem easy by comparison. Carrying just a couple patients is fine and not far off what fresh interns would carry in an icu. Critical patients just have too much going on.
You can absolutely do physical exams on critical patients. I guarantee nearly all your patients have heart murmurs as well as abnormal lung sounds. This is tough as a first rotation, but something valuable in an icu is figuring out what their critical care needs are and what markers you’re following to see if your plan is working. For some patients, the pulmonary exam is a big part of what you follow to see if your dieresis or dialysis is working well, along with Xray and lab values and whatnot. You surely have some folks with ascites in your MICU so practice your abdominal exam and learn what that fluid feels like. Grab an ultrasound and see what it looks like too and have someone show you other ways to use bedside ultrasound in critical care. Great skills that will transfer.
In an icu, learn how vents work and what the settings mean and how they can go wrong. It amazes me how many residents don’t understand the fundamentals of vents, so find someone who gets it and have them teach you. You should be able to look at the settings and have an idea of the pathology being addressed. I can’t even begin to tell you how often this knowledge has saved my bacon.
Learn how an insulin drip works. Actually watch the nurse adjust it and figure out (or ask) how it can go wrong. Ditto for other powerful meds on a nurse adjusted protocol. Start learning the black boxes of the hospital, things where a doc places an order and magically something happens. Figure out what actually happens. Inevitably these things will eventually break down and you will have to figure out why.
Along with vents, learn about criteria for intubation and extubation and how those decisions are made. Read an analyze every blood gas you see. Figure out how you would adjust the vent based on that and the overall clinical picture.
Big picture, start to gain a sense of what critical care is and does and use the opportunity to learn about some tools and interventions you won’t see on floor or outpatient rotations. Hopefully you’ll get some good didactic as well, but there are some good critical care podcasts and websites as well. There really aren’t too many things that land someone in an icu, so even in a short while you should be able to start getting some idea of this and what management options are available to you.
And yes definitely ask to get your hands on procedures. They can be super tough sticks but if you’ve got a dude incubated and heavily sedated who needs another IV, that’s a great one to practice on. Ask your residents about doing some procedures as well, or at least getting your hands on it. If they’re doing an ultrasound guided line placement, if they won’t take you through doing it, maybe they can at least let you use the probe and find the vessel and mark out where you would put it. At your level there’s so much to be learned just in handling equipment and set up, so make yourself available and you’ll start learning some skills.
You can absolutely do physical exams on critical patients. I guarantee nearly all your patients have heart murmurs as well as abnormal lung sounds. This is tough as a first rotation, but something valuable in an icu is figuring out what their critical care needs are and what markers you’re following to see if your plan is working. For some patients, the pulmonary exam is a big part of what you follow to see if your dieresis or dialysis is working well, along with Xray and lab values and whatnot. You surely have some folks with ascites in your MICU so practice your abdominal exam and learn what that fluid feels like. Grab an ultrasound and see what it looks like too and have someone show you other ways to use bedside ultrasound in critical care. Great skills that will transfer.
In an icu, learn how vents work and what the settings mean and how they can go wrong. It amazes me how many residents don’t understand the fundamentals of vents, so find someone who gets it and have them teach you. You should be able to look at the settings and have an idea of the pathology being addressed. I can’t even begin to tell you how often this knowledge has saved my bacon.
Learn how an insulin drip works. Actually watch the nurse adjust it and figure out (or ask) how it can go wrong. Ditto for other powerful meds on a nurse adjusted protocol. Start learning the black boxes of the hospital, things where a doc places an order and magically something happens. Figure out what actually happens. Inevitably these things will eventually break down and you will have to figure out why.
Along with vents, learn about criteria for intubation and extubation and how those decisions are made. Read an analyze every blood gas you see. Figure out how you would adjust the vent based on that and the overall clinical picture.
Big picture, start to gain a sense of what critical care is and does and use the opportunity to learn about some tools and interventions you won’t see on floor or outpatient rotations. Hopefully you’ll get some good didactic as well, but there are some good critical care podcasts and websites as well. There really aren’t too many things that land someone in an icu, so even in a short while you should be able to start getting some idea of this and what management options are available to you.
And yes definitely ask to get your hands on procedures. They can be super tough sticks but if you’ve got a dude incubated and heavily sedated who needs another IV, that’s a great one to practice on. Ask your residents about doing some procedures as well, or at least getting your hands on it. If they’re doing an ultrasound guided line placement, if they won’t take you through doing it, maybe they can at least let you use the probe and find the vessel and mark out where you would put it. At your level there’s so much to be learned just in handling equipment and set up, so make yourself available and you’ll start learning some skills.
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As an ICU attending (albeit the PICU - but there's not that much different between critically ill patients at any age), I'm a bit flabbergasted that you can say "there's only so much I can read about my patients".
Now, granted, you're green beyond green, and there's an element of knowing what non-critically ill patients look like that makes the ICU stand out. So I'll give you that youre in a challenging situation in trying to determine what's important and what isn't. So here are some thoughts about how you can improve.
1) Your mindset from now until the end of intern year should be that every patient has something to teach you. That's moreso true now, then it will be 3 years, but there's so much growth to happen in front of you, that it shouldn't be hard to find something that you didn't know before or didn't do as efficiently as possible.
2) Working on your clinical skills that are widely applicable to ANY clerkship or specialty is so incredibly high yield for you at this stage of the game. That means efficiency in gathering data, conducting a physical exam, writing notes, creating differentials, creating treatment plans, and so on. Pay attention to how your senior residents take a history and how you take one. Odds are yours takes an hour, theirs takes 15 minutes and contains a lot more useful information than yours.
3) Studying for the shelf exam or Step 1 will always be there. But you need to take advantage of things that are unique to the ICU - that means Ventilators, Blood Gas interpretation, how the various pressors work, why CPR is effective (or not), and the physiology of sepsis those are bread and butter ICU topics. Unlike 90% of the rest of medicine, the ICU is where all those physics formulas and concepts you learned in CV and pulmonary physiology actually come out to clinical importance - if you can understand those again in clinical context you'll begin to see why people make the decisions they do. In effect, you are studying for step one if your putting your effort in to the right things. Additionally, watch how your residents and attendings give bad news - it's obviously common in the ICU, and something that nearly every physician has to do in their careers. The more you watch other people, the more you can begin to create your own style for when it's ultimately your responsibility.
4) It's hard when all your patients are critically ill, but begin using this experience to develop that "sick vs not sick" radar. That's a critical skill for new interns as you need to know when to bring in more resources. Talk with your seniors about which patients are they worried about vs not and then ask why that's the case, and then ask what sort of things they'd be looking at for patients on the floor prior to transfer (the subtle cases, not the ones that post-arrest that everyone knows needs the Unit).
5) At least start seeing procedures for your "see one, do one, teach one" moments. If nothing else, have someone teach you how to bag valve mask patients. It's not so crucial you know how to intubate, but if you can bag someone adequately, you'll save a lot of people.
Now, granted, you're green beyond green, and there's an element of knowing what non-critically ill patients look like that makes the ICU stand out. So I'll give you that youre in a challenging situation in trying to determine what's important and what isn't. So here are some thoughts about how you can improve.
1) Your mindset from now until the end of intern year should be that every patient has something to teach you. That's moreso true now, then it will be 3 years, but there's so much growth to happen in front of you, that it shouldn't be hard to find something that you didn't know before or didn't do as efficiently as possible.
2) Working on your clinical skills that are widely applicable to ANY clerkship or specialty is so incredibly high yield for you at this stage of the game. That means efficiency in gathering data, conducting a physical exam, writing notes, creating differentials, creating treatment plans, and so on. Pay attention to how your senior residents take a history and how you take one. Odds are yours takes an hour, theirs takes 15 minutes and contains a lot more useful information than yours.
3) Studying for the shelf exam or Step 1 will always be there. But you need to take advantage of things that are unique to the ICU - that means Ventilators, Blood Gas interpretation, how the various pressors work, why CPR is effective (or not), and the physiology of sepsis those are bread and butter ICU topics. Unlike 90% of the rest of medicine, the ICU is where all those physics formulas and concepts you learned in CV and pulmonary physiology actually come out to clinical importance - if you can understand those again in clinical context you'll begin to see why people make the decisions they do. In effect, you are studying for step one if your putting your effort in to the right things. Additionally, watch how your residents and attendings give bad news - it's obviously common in the ICU, and something that nearly every physician has to do in their careers. The more you watch other people, the more you can begin to create your own style for when it's ultimately your responsibility.
4) It's hard when all your patients are critically ill, but begin using this experience to develop that "sick vs not sick" radar. That's a critical skill for new interns as you need to know when to bring in more resources. Talk with your seniors about which patients are they worried about vs not and then ask why that's the case, and then ask what sort of things they'd be looking at for patients on the floor prior to transfer (the subtle cases, not the ones that post-arrest that everyone knows needs the Unit).
5) At least start seeing procedures for your "see one, do one, teach one" moments. If nothing else, have someone teach you how to bag valve mask patients. It's not so crucial you know how to intubate, but if you can bag someone adequately, you'll save a lot of people.
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