ICU was my 1stblock as an intern!? As someone who had been OUT of the hospital setting for almost 3 years…
You can say I was.. oh I don’t know…
I may have done an ICU/CCU elective when I was in my 4thyear.. which I definitely recommend just so you get an idea of what it is like before you’re there yourself…
BUT it was a long time ago…. And I was
? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ?NERVOUS.
So, naturally… as all of you reading this… I Googled how to prepare.
But, now that I have finished my 1st month of residency in ICU. I can now give you guys a few tips for survival and succeed!
- Introduce yourself IMMEDIATELY to all the nurses:??
Let them know you’re the new intern. Tell them your name. Shake their hand. Let them know that you KNOW you’re in their territory and that you will need their help. They have the experience to be able to guide you. Do not think yourself above them just because you’re “the doctor”. ? ? ? ? ? ? ? ? ? ? ? ?? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ?
? ? ? ? ? ? ? ? ? ? ? ? ? ? We are all tadpoles still.
- Check Potassium, Magnesium, and Phosphorous on ALL your patients. Every day!
- By far the thing you will do most in ICU is replacing these electrolytes. ICU patients have a lot of electrolyte imbalances. They are likely intubated, NPO, or getting TPN or Tube Feeds. So make sure you know their levels and replace them if needed.? If you replace one, RECHECK IT in a few hours.
- HINT: You can give them PO if they have a feeding tube. PO is better absorbed so it replaces levels better. But IV is also acceptable.
- FYI: When given a choice… choose potassium chloride. You’re welcome.
- PS: Different doctors and different facilities prefer different ways of replacing.. learn their ways.??
- Make sure you have labs ordered in the AM.
- Check that every patient has labs ordered for the following morning. Often times you are trending things, especially in the ICU. I always made sure I had a CBC, CMP/BMP.? If the patient has pancreatitis or is very ill… I would get the CMP because it includes the LFTs. The BMP does not!?Patients in the ICU can quickly deteriorate and go into multi-organ failure. You won’t catch liver failure unless you’ve got those LFTs.
- Find out who the nurses are for your patients and ask them how your patient did overnight.??
- Ask about overnight events! To know your patient you need to know how they’re doing and how their night went. So ask about it. The nurses record everything! If the patient tried to pull out their tube, if they went into DTs and had to get Ativan, how much Ativan. If they were put on pressors, or taken off pressors… If their BPs and HRs have been stable. ASK! And KNOW! It will be your job to fill in the attending.
- Introduce yourself to the patient and their family as a resident on the team taking care of their family members.
- Be prepared to answer questions, and IT”S OKAY TO SAY YOU DON’T KNOW but will find out.??
- Create your checklist every morning
- Make sure you create a checklist every morning of all the things you need to do for each patient to make sure you don’t forget. Create symbols that mean TO DO and others to mean PENDING. Honestly… I’d check out OnlineMedEd.Com and use code OME18. They have an awesome way to help you use symbols to your advantage so you don’t have to use so many words for things. Helps with time management.
- AM labs
- Replace electrolytes and recheck
- Consult GI, or Cards or Neuro or whoever else
- CXR or other Imaging
- Progress Note! Progress Note! Progress Note!
- Discharge summary
- History and Physical
- This will help you keep track of things you’ve done and things you have yet to do. ORGANIZATION is the key to TIME MANAGEMENT.
- Get there early!
- You won’t know how many patients you will have. So get there early, that way you will have enough time to review everyone’s chart, see the patients, and prepare your plan of care by the time you have to round with your attending.I started out getting there at 7am.. once I knew how long it took me to get through my to do list and see the patients and prep the note and create a plan… I was able to get there later and still be ready for rounds with time to spare.
- Read about your patient’s conditions and common treatments to help you make a plan
– Getting there early was a great way to give yourself time to read up on a patient’s lab results, or physical exam finding that you weren’t sure what to do with. UpToDate was my go-to. I would read up on it, and find usual treatment options for it and even a diagnosis for it. I would add all of it to my assessment and plan. The AP of the SOAP…. Yep.. SOAP notes. If you don’t remember what it is or how to write one… check out OnlineMedEd.Com. Use code OME18. Get acquainted lol.??
- Look at everything at the patient’s bedside.
- Read everything that is hanging bedside. It will be fluids, tube feeds, medications, titrations, antibiotics etc etc. Know what your patient is on, how much, how often and for how long. Document it all. Confirm that they should still be on those things and if they shouldn’t because the previous note said to stop it… ask the nurses about it. Chances are maybe it wasn’t discharged in the system, or they were told verbally to give it. DOCUMENT everything.
- Ask for help when you need it!
- You won’t always know what to do, especially if your attending isn’t next to you and neither is your upper level. So ask the nurses what is usually done in those situations. Ask other docs around you for their input. Read about it in update. Aks for help!
- Few things to go over before you even set foot in the ICU
- Acid Bases – pH, PCO2, PO2, HCO3 and FiO2 all those metabolic and respiratory acidosis and alkalosis.
- Fluid management: Normal saline (9%) vs Half NS (45%), D5W, Dextrose, Lactated Ringers etc etc. Learn a bit about each. Also…..review a little about which conditions require boluses (like acute pancreatitis or rhabdo or severe sepsis with septic shock) and maintenance fluids after.
- Vent modes. A lot of patients are on them. Know what affects PO2, and what affects PCO2. Etc.
- You don’t need to study unless you want to… just skimming through these things will make things a little easier.
I LOVED my ICU block. My attendings were phenomenal, and so was my upper level. I am eternally grateful to my ICU nurses.? I think it’s definitely an advantage to start in the ICU as your first block. So if you’ve already had it and feel like sharing other tips you wish you had known… feel free to share them with me! Write to me on IG or here. If you have not had it yet.. I hope these few tips help you.? Overall though, you’re never truly ready till you start! So take the plunge and have fun being a doctor!
PS: Don’t forget to:
- Attend Didactics, Eat Lunch, Bring Snacks, Coffee, Water and Use the bathroom…. A UTI won’t help anyone! Lol.??