Welcome to the ICU Site

The ICU rotation can be a stressful, anxiety-provoking rotation. It is also an essential rotation in your development as a family physician. This is your opportunity to see the sickest of the sick. You will find this necessary in your future career, even though you will unlikely be working in an ICU in the future. Use this time wisely!

The Chiefs maintain an Evernote Notebook to help you during your month (ICU Notebook). The notebook has tips and resources and should be reviewed by everyone before the start of the rotation. One of the notes contains a list of online learning modules for the ICU, including vent management. The notebook is full of a wealth of information and will make your month far more enjoyable if you spend the time to study and review it.

Remember, that duty hours are not to be violated. If there are any instances of duty hour violations or if there is any concern, please email a chief, Dr. Rich, Dr Spata or Dr. Bernheisel, or report a duty hours violation. Please feel free to email or call with any questions.

Procedures

Mount's ICU Survival Guide

Prior to rotation:

1. Spend 5-10 minutes reviewing ACLS algorithms and/or have your pocket card with you. Even though you will have a senior and team with you that can run the code, it will help you pay attention to the steps the senior is running down and you will have a better understanding of what is happening in the code. 

2. Read the article on the TCH Family Med website Early Goal Directed Therapy in Sepsis. It is a brief, quick read with diagrams that will help you understand the goals of treatment in sepsis (which will be 90% of your patients on ICU). 

3. View the procedure videos on the website. If you only have time for one then look at the IJ central line placement video then arterial line placement. They are around 10 minutes or less and well-worth the review.

Once you've started:

1. Read the articles on the website to review ventilator management and sepsis treatment. The Mechanical Ventillation Overview from eMedicine on the website is a great, quick review (even if you can only read the first half which is 7 pages). 

2. Ask questions!!! Most of the time (99%) the other residents don't know the reasoning or answer to the question either. If things are busy then it is easy to slip through rounds quickly without learning something new, but you only have one month so push to make the most of it. 

3. When something has been ordered or changed on your patient by the senior or attending, make sure you know why. This will help you anticipate changes you may need to make on other patients in the future as well as on call.

4. Don't be frustrated with orders being put in by the seniors. Often they will see the patients before you even know about them and put orders in so they can move to the next patient if it's busy. The important thing is to review all the orders closely so that you know what's going on with the patient (can be harder to remember if you don't actually put in the orders yourself). 

5. Pay attention to the other resident presentations. Every attending is different and the other residents know the type of presentation (length, content) that each attending prefers. 

6. Pay attention to other patients and the management of the cases. You won't always know every detail, but you'll notice patterns in management. Specifically listen to ventilator changes as this will help you when you get called on blood gases on call nights. 

7. Review interpretation of ABGs if needed. You will mainly be seeing metabolic acidosis. 

8. Make sure the senior resident gives you access to the ICU census on Epic (you need to be put on a list or have them share it with you). 

9. Your first day someone should give you a "Rally pack" which is a small pocket book that has multiple useful pages and all important phone numbers and pager numbers. Very helpful page for electrolyte replacement (good to review since we don't use as much IV replacement on inpatient).

10. Look at your chest x-rays!! This is a great time to get tons of experience reading these since there is usually a daily chest xray on every patient. Make sure to compare to the previous film. (FYI: The attendings are all pulmonologists and the CXR is usually the first thing they look at in the mornings.)

Vent tips:

-You will use PRVC on 95% of the patients so good to know this mode. SIMV is not used as much anymore although your review articles still highlight this mode. 

-If patient's SaO2 is >90 then decrease FiO2.

-To improve oxygenation you can a) increase FiO2 b) increase PEEP or c) increase I:E (inspiratory to expiratory) ratio. 

-To improve ventilation or decrease CO2 you can a) increase RR or b) increase tidal volume (shooting for 8ml/kg since increasing TV puts you at risk for barotrauma). 

-The Ventilatory Presentation (especially slides 16-19) outline these adjustments. 

-If pH under 7.0 consider bicarb although you ultimately need to correct underlying cause for acidosis.

Ways to be helpful in a code:

1. Feel for a pulse if not being done.

2. Grab an ABG kit and ask if the senior wants you to draw it (good time to get procedure).

3. Grab a computer and look up most recent labs, diagnosis, meds.

4. Chest compressions (get in line or offer to take over for someone after 1-2 minutes). 

5. If you want to intubate, get to the head of the bed! Respiratory therapy will be there usually and will help you if needed. 

6. Help with the differential! The senior is usually thinking through what needs to be done for the patient and will appreciate any input. 

7. Get supplies for procedure (especially if you want to do it). These will usually be arterial lines and/or central lines. You will not be using the ultrasound and it will usually be a femoral line (Video and Handout).

Call nights:

1. Make sure you take care of the patient first and write later. Always go see the patient when called and check last vitals (trend). Put in any orders right away then look at the patient again before writing. 

2. Cross-cover: It is good to write down notes on your census for the resident you're covering for (you will not be able to remember in the morning despite your best efforts). Even better, write a very brief note in Epic (Ex: Called to evaluate patient for X. Patient symptoms. Patient exam: General, Lungs, Heart, Pulses. One line assessment and any planned changes at that moment). The note should NOT be a copy and pasted plan with every problem and every order. You ONLY want to put in changes in orders and your plan for the problem you were called about (Example: 1. Will give 500mL IV NS bolus. 2. Check lactate. 3. Continue to monitor vitals and CVP. 4. Will discuss with attending/senior resident.). Hopefully you've considered all the patient's problems in your decision process, but you will not have time for a note with the full problem list and, more importantly, no one will read it! 

3. Your H&P write-ups are nowhere near as immaculate as they are on inpatient. Make sure you have a thorough HPI and A/P. The rest will often be unobtainable or can be addressed in more detail after putting in orders or when fine-tuning the next morning. The plan will often only address the acute issue (Sepsis or Respiratory failure), major medical issues such as DM, CHF, and prophylaxis. The attendings do not care if you use a systems-based or problem-based note usually. If you use a problem-based approach, make sure you go through all systems (good pneumonic in the Rally Pack) to make sure you don't miss something. 

4. Sign-outs from the other residents are abysmal. You will most-likely have to open up the last progress note to figure out what is going on. This makes it extremely important to PAY ATTENTION ON ROUNDS!! Things to note specifically: a) any changes today (extubation!), b) code status c) heart function (lots of calls for low BP and need to know if bolus would potentially harm or not help the patient). Most importantly: Look at every patient (especially respiratory effort) since you will get many calls about how the patient "looks different" or "looks bad" and you may sometimes think that they all look pretty sick. 

5. Speak up to do procedures! The senior will let you try if you say "I would like to try". Of course it will go faster with the senior doing it or the other intern, but if you just try a few then you will get smoother. They will just do it if you hesitate or say "I don't care". Even if you have an H&P or two to write, you can do the procedure first and write later on most nights. 

6. You need to have most of your H&Ps done by 5am to keep your sanity (unless the admission comes in at 4 or 5). Without exaggeration, you will get between 10-20 phone calls around this time when the 4am lab results hit the nurses. These will usually be electrolyte replacement (check your rally pack for IV replacement dosing), but if you have lots of writing still to do then this can break your train-of-thought every other minute leading to frustration. 

7. The nurses are your best friend! They are the best nurses in the hospital and will usually help you if you are nice. If you have questions, start with the senior. If it's important and the senior is busy or not responsive (clueless) then call the eICU for the attending. The eICU attendings are very laid back and receptive to questions. They are awake and looking in frequently so do not feel bad for calling (especially if you're concerned about the patient). You will be calling to run through a brief HPI, assessment, and plan on new admissions anyways. 

8. Go look at the patients that were admitted by the intern on call the night before. You will hear about them in the morning, but these are table rounds. These patients are usually admitted quickly with the goal of keeping them alive until the next day. Most of your calls will be about these patients. You will need to see them and also you may need to change plans or readdress the initial diagnosis if the patient's status is not improving or worsening. 

9. Keep lists of 3 things: Patients admitted(keep stickers), Procedures (keep stickers), and Questions/Topics to look up (you may not have time overnight to read on patients like inpatient months).

Logging procedures, hours, and patients:

1. Log Hours on New Innovations . 

2. Log your procedures on your Procedure Checkbook and have the supervising physician sign off. During the month, log the procedure in New Innovations and submit the slip to Judy.

3. Log patients in the procedure log in New Innovations (the name of the patient procedure is 'ICU Managment'). It is helpful to keep patient stickers on a folded up paper in your back pocket (or just put patient MRN, age, diagnosis, procedure, attending on your ipod). 

4. Enter your hours on New Innovations under the Duty Hours tab.

Sepsis Review