Thursday, November 18, 2010

ICU Medicine (MICU) The sickest of the sick


It is the middle of November, and I have started a new rotation.  I am now working in an inner-city Medical ICU, it is called MICU.  These kind of rotations are always slightly horrendous because the hours are extraordinarily long, the patient pathology and acuity is extraordinarily complex, and it's just all around an intense experience.  You're dealing with the sickest of sick patients with the worst of the worst diseases and often they are dying, so how this rotation works is generally I report at 4:30 or 5:00 in the morning to the Medical ICU floor and pick up anywhere from three to four patients for that day; some of them might be patients I've been following from the day before, some of them might be brand new patients that came in overnight, some of them might be patients that somebody else was following the day before.  Essentially I go in and examine each of these patients and check with the nurse who was there overnight with them about any new events or new complaints, and I write up a note that kind of explains what is going on with the patient and their disease, processes, and any new findings like laboratory findings, vital signs.  A lot of these patients are on breathing machines or respirators/ventilators, and I might have to adjust the ventilators depending on the labs that have returned whether the patient is acidotic or alkalotic, and I have to check all of the sites where they have tubes or catheters placed and look for any signs of infection or other problems.  So, I do this.  It takes a couple hours and so by 7:00 or so, I present to the senior residents my findings and what I found and then they kind of go from there and present to the attending physicians kind of the course of the patient's evaluation and treatment and then we meet and then while they're doing that I continue to write my notes for the day which unlike emergency medicine notes, tend to be very long and elaborate, small volume novels written about every aspect of the patient's treatment and care.  So this takes a little bit and somewhere around I don't know 10:00 or so in the morning while I'm in the middle of this, we meet with the attending physicians and round on the patients; all of the patients on the ICU. 

This particular ICU has 16 beds, and there's generally three or four interns and two seniors and so we have the patients divided up and then we go and see each of the patients with the attendings or the physician who's in charge.  We get quizzed and grilled about their condition and differential diagnoses and what could be going on and what medications should we start or what settings should we do or what kind of imaging studies do we need or labs, etc., etc., and we might be rated about the course of treatment or evaluation, and we look at any films like X‑rays, CT scans that have recently been done and we're asked and grilled about the findings, and so we look at the X‑ray and attending physician will say okay what is this here, what causes this finding, where is the catheter or central line on this X‑ray or whatever, and so you kind of have the whole pain there while the attending physician grills you and might say well what kind of bacteria can cause this pathology, and okay well what kind of antibiotics are best for this pathology, and you may know the answers, you may not. 

The supervising physician will keep going until he stumps you no matter what, so this takes an extraordinary long period of time and you kind of go through and everyone takes their turn getting abused and then once that is done, three or four hours later into the afternoon and you go back over the patients that you were managing and examine them again, writing more notes on them, and you might change any course of therapy or add therapy depending on recommendations from the attending physician, and oftentimes, many of his recommendations are why don't you get infectious disease involved or pulmonology involved or nephrology or cardiology depending on the illness the patient has, and so you spend the afternoon tracking down the various specialist and telling them about the patient and asking them to see the patient and following up on different things.  So as this goes on, somewhere around 5:00 or 6:00 at night, everything is finished up, and you're allowed to leave.  So you get there at 4:00-4:30, leave 6:00 sometimes 7:00 and then every fourth or fifth night you have the pleasure of being on call, so when you are on call, you come in that day at the same time 4:00-5:00, and you follow the same schedule I just explained.  However, at about 5:00, 5:30-6:00 when everyone else is starting to leave, you take sign-out which is where the physicians taking care of the patients that you are directly in charge of will update you on their condition and what kind of things are going to happen overnight or what you should look for, what you should treat and then they leave.  Now, generally there's two physicians on call; a senior resident and junior resident like myself, but instead of covering 14 beds, we're covering 28 beds because we also cover while we're on call the floor that is right next to the Medical ICU which is the progressive CCU or progressive Cardiology Care Unit, so there's 14 beds there with patients who have severe coronary or cardiac illness and so overnight as a junior resident you are covering the PCCU or the Cardiac Care Unit which are all patients you are unfamiliar with because you've been working the days over on the other ICU.  So, that's kind of how it goes, and so when you're on call, you stay and you get there at 4:00 in the morning, and you stay all the way through the day, through the evening taking new admissions and putting in orders for patients that need stuff, coding patients, or you're running CPR or announcing patients dead or whatever may occur overnight, and like I said admitting all the new patients that come in overnight, and this basically keeps you up all night so the next morning, 24 hours later at 4:00 or 5:00 when the team comes back, you start the day like you would any other day picking up new patients and examining them, write notes on them, and the difference is you stay until about 11:00 the next day, and you do presenting to the attending physician and then once 11:00 or noon hits, you are free to go and then you go home, go to sleep, and start all over the next day. 

This is how the ICU works. In addition to my daily responsibilities, I do call every few days for the CCU.  I started the rotation this week and it's my fourth day on the ICU. I have had one call so far and a whole bunch of interesting cases and very, very sick patients. You may be asking yourself why does an emergency medicine physician, need ICU training? Given the current disaster of emergency room crowding we end up housing some of these patients for a long period of time so not only do we have to know how to stabilize the very sick patients, get them on the breathing machine (ventilator) but we also have to know how to continue to manage these patients because these patients will not actually leave the emergency department for even up to a day and so while they're in the emergency department, as our patients as an emergency physician, we have to know how to continue to manage their critical illness before they get up to the ICU, so it's great training but it's a different flavor of medicine. It is important as an ED physician that you have good ICU training. 

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