Introduction to an ICU rotation

So you’re going to start in the Intensive Care Unit (ICU, aka. expensive care unit). Congratulations! Obviously I’m of the opinion that ICU is just tops and have gone down the pathway of specialising in the same. I think that ICU offers a few benefits that most other specialities don’t.

1. Shift work – the downside is, as a junior it often means equal blocks of days and nights… there are less nights as you become more senior. The benefit is… when you’re at home, someone else is on shift in the unit. I.e. you can stop worrying about your patients and any jobs you didn’t get to (sometimes you can’t stop thinking about the cases).

2. Breadth of exposure – we are exposed to, and look after patients (the sickest patients) from all specialties, which means continuous learning, and makes for a very interesting job full of lifelong learning. Think about the most interesting cases from each specialty, the ones that those specialties see rarely — those are some of our bread and butter cases.

3. Critical Care Medicine – Think, medicine on steroids (almost literally thanks to some recent evidence coming though). We help to diagnose, resuscitate and stabilise patients, which may involve procedures (e.g. intubation, central line insertion, chest drains etc.), and some quick thinking on your feet. We also get to play with our critical care colleagues in the Emergency Department and in Anaesthetics.

4. Continuity of care – where I undertook most of my training we worked week on week off (the same as the consultants) which offered us the benefit of continuity with our patients and their families. This offered a phenomenal perspective – being able to witness those actively trying to die, to then potentially discharging from your service to the ward in just a few days.

5. Multidisciplinary work – we’re so lucky that in the ICU it is a core part of our work to treat patients with heavy input from phenomenal Allied Health colleagues (think; physiotherapists, occupational therapists, dietetics, pharmacists, social workers, speech pathologists etc.). We are able to learn so much from these wonderful professionals.

6. It’s a team sport – I can’t think of another specialty that works more closely with, and are so dependent on nursing colleagues. Yes, the anaesthetists have anaesthetic nurses… who may also be working between a couple of theatres… the ED have nurses that also have a large input and impact into patient treatment… but in ICU, our nurses have HUGE amounts of input into treatment and patient care, as well as the holistic care involving and offering insights into the family of the patient. Our nurses might not just have one 12 hour shift with the patient… but maybe a few per week… for a month or so of a patient’s stay — now THAT’s continuity. I continue to learn so much from our nurses. One common mistake a junior doctor can make, is to go into an ICU rotation assuming that because you have a medical degree you know more than the nurse at the bedside… it’s a quick way to be humbled by our colleagues who may have DECADES more experience and knowledge than you.

7. Family contact / Palliative Care – we are so privileged to be able to share in some patient’s (about 1:10-20) last moments with their families. I find palliative care a very rewarding part of ICU practice, and allowing patients to die with dignity is imperative (see this article: Dying with Dignity).

Whatever your specialty draw is, or wherever you end up, the skills you learn in ICU will be useful for your entire career. I hope you enjoy it!

• The Basic Assessment and Support in Intensive Care (BASIC) Course is highly recommended for all those starting out in ICU. For course dates, please see their website.
• Advanced Life Support 2 (ALS2), I would also highly recommend completing this course. For course dates, please see their website.
• Advanced Paediatric Life Support (APLS), also a great course, the Paeds version of ALS2. For course dates, please see their website.
• Paeds BASIC, as above. For course dates, please see their website.

Slightly more advanced…

• Neuroresus – great for all things neurocritical care, targeted towards those beyond the early ICU clinician stage. For course dates, please see their website.
• Cardiac Advanced Life Support (CALS) – similar to neuroresus, it is targeted towards those beyond the early ICU clinician stage. For course dates, please search the list of hospitals on the CALS website.
• There are Beyond BASIC courses on Dialysis… Mechanical Ventilation and more!

This section is more directed towards medical students.

We are frequently asked how a medical student can be useful or make the most out of the daily ward rounds in the ICU — rather than just being an extra body in the conga line on the march around the unit.

Try to get there about 15mins prior to the round starting (I’m a sucker for promptness arriving at least 10mins early daily, and have a real pet peeve for people even 1 minute late!) introduce yourself to the team. Be sure to include what year you’re in / how long you are attached to the unit. This will help the RMOs and registrars pitch the content more appropriately. It will also help them to tell you if there are any interesting meetings or events on for the rest of the week (if they don’t offer this information, just ask). You might also catch the really quick night-to-day shift handover (sometimes they only take a couple of minutes and are completed without the consultants there — this is, of course, site specific).

Medical students usually have things that they need to complete for the short placements — make sure that these are known to the consultant/registrars early. There’s nothing quite like springing a full patient review/presentation on a busy registrar on your last day!

As a rotating student, you will no doubt have other classes and things during the week – just make sure you let the team know, otherwise they will write you off as someone who isn’t interested.

Helping on the rounds:
– Look up the pathology before the round / on the round to help with speeding things up
– Ask to examine the patient
– Write the notes (if it is a small team, this can really help to speed things up, see the page below on how to approach writing notes for an ICU round — this can be very unit/consultant/registrar/RMO specific, so this is just a guide!)

Responding to MET Calls:
– Tag along with the MET Call team — it might be a different team to who you are with, just check at the beginning of the day, there might even be a spare pager for you to carry
– Assist in resuscitations, get hands on with CPR / placing a cannula / running a blood gas etc.

Probably the most important thing you can do…

… ask questions!! Just make sure the questions are appropriately timed and in number (peppering questions non-stop will really slow things down). It may be worthwhile writing questions down if the team are getting smashed and are really busy and you’re worried about asking at that particular moment. Every consultant/registrar has a different approach to all of this — so use your own sound judgement.

Make the most out of your short rotation in ICU! I promise you — ICU is more than just a ward round and complex ABGs (something I continue to try to convince my anaesthetic and ED colleagues)!!

Introduction to ICU Series Landing Page

DAY TO DAY ICU: FASTHUG, ICU Ward Round, Clinical Examination, Communication in a Crisis, Documenting the ward round in ICU, Human Factors
AIRWAY: Bag Valve Mask Ventilation, Oropharyngeal Airway, Nasopharyngeal Airway, Endotracheal Tube (ETT), Tracheostomy Tubes
BREATHING: Positive End Expiratory Pressure (PEEP), High Flow Nasal Prongs (HFNP), Intubation and Mechanical Ventilation, Mechanical Ventilation Overview, Non-invasive Ventilation (NIV)
CIRCULATION: Arrhythmias, Atrial Fibrillation, ICU after Cardiac Surgery, Pacing Modes, ECMO, Shock
CNS: Brain Death, Delirium in the ICU, Examination of the Unconscious Patient, External-ventricular Drain (EVD), Sedation in the ICU
GASTROINTESTINAL: Enteral Nutrition vs Parenteral Nutrition, Intolerance to EN, Prokinetics, Stress Ulcer Prophylaxis (SUP), Ileus
GENITOURINARY: Acute Kidney Injury (AKI), CRRT Indications
HAEMATOLOGICAL: Anaemia, Blood Products, Massive Transfusion Protocol (MTP)
INFECTIOUS DISEASE: Antimicrobial Stewardship, Antimicrobial Quick Reference, Central Line Associated Bacterial Infection (CLABSI), Handwashing in ICU, Neutropenic Sepsis, Nosocomial Infections, Sepsis Overview
SPECIAL GROUPS IN ICU: Early Management of the Critically Ill Child, Paediatric Formulas, Paediatric Vital Signs, Pregnancy and ICU, Obesity, Elderly
FLUIDS AND ELECTROLYTES: Albumin vs 0.9% Saline, Assessing Fluid Status, Electrolyte Abnormalities, Hypertonic Saline
PHARMACOLOGY: Drug Infusion Doses, Summary of Vasopressors, Prokinetics, Steroid Conversion, GI Drug Absorption in Critical Illness
PROCEDURES: Arterial line, CVC, Intercostal Catheter (ICC), Intraosseous Needle, Underwater seal drain, Naso- and Orogastric Tubes (NGT/OGT), Rapid Infusion Catheter (RIC)
INVESTIGATIONS: ABG Interpretation, Echo in ICU, CXR in ICU, Routine daily CXR, FBC, TEG/ROTEM, US in Critical Care
ICU MONITORING: NIBP vs Arterial line, Arterial Line Pressure Transduction, Cardiac Output, Central Venous Pressure (CVP), CO2 / Capnography, Pulmonary Artery Catheter (PAC / Swan-Ganz), Pulse Oximeter