First Week

Welcome to your ICU rotation.

This can be an intense month in terms of hours, teaching, reading, patient volume, severity and complexity of illness, emotions, and of course, learning.

In order to be successful in your rotation, you will need to demonstrate the following:

• Initiative
• Teamwork
• Attention to detail
• Curiosity

Patients in the ICU are typically very ill and require complex thinking and integration of pathophysiology and hemodynamics.

Climb the learning curve faster by

1. Creating 5 differentials.
2. Focusing on the Assessment/Plan.
3. Presenting without reading your notes.
4. ASK questions.

Approach

I teach 3 fundamental concepts that I strongly believe are vital in the approach to the critical care patient:

1. Zoom in and zoom out.
2. Sense of urgency.
3. Reason for ICU.

Zoom in and zoom out.

Rounding on the ICU patient requires mental flexibility in switching one’s focus between the clinical details (zoom in) and its clinical relevance to the patient’s big picture (zoom out). Immediate focus will be required on incoming granular data/details such as ABG results, critical lactic acid levels, skin exam changes, ventilator breathing patterns, etc. The relevance of those details become important when applying to the patient’s overall illness, organ systems, discharge planning, or end of life goals of care strategies.

Sense of URGENCY

One of the most difficult aspects of ICU care for the new learner is how to classify the situation before them as an emergency or otherwise. A sense of urgency is a skill that can be developed over time. Not everything is a crisis in the ICU, and of course, it shouldn’t be.

Reason for ICU

When rounding on the ICU patient, the new learner should ask themselves 2 questions each and every time:

1. WHY is the patient in the ICU today?
2. WHAT needs to be done to move them out of the ICU today?

There are various reasons why a patient will be designated ICU status. Of course, critically ill is the most common. In its simplest definition, critical illness is life- or limb-threatening condition.

Study ACLS 💙

I HIGHLY recommend you to fully review and memorize the ACLS algorithms. Inevitably, there will be a Code Blue. This is your opportunity to perform CPR and to assist the code team and me with task completion and diagnosis. You may participate with my supervision.

How to Read CXRs 🩻

I recommend you complete Felson’s Chest Radiology workbook in the first few days of your rotation.

During your rotation, there are usually many X-rays to review, and you will benefit the most if you have completed this workbook as early as possible.

Amazon.com: Felson’s Principles of Chest Roentgenology E-Book eBook : Goodman, Lawrence R.: Kindle Store

Amazon.com: Felson’s Principles of Chest Roentgenology E-Book eBook : Goodman, Lawrence R.: Kindle Store

Follow

Of course, many great websites exist. Radiopedia. MRIOnline. CTisis.

Be sure to gain access to Radiology Requisites and have this read during the rotation.

Presenting the ICU Patient

You will receive patients to follow daily.

I expect oral and written patient presentations. Ideally, after continued practice, a student can work towards oral presentation without memory tools.

Many students bring their laptop or iPad for self-study and write-ups.

• Chief Compliant
• History of Present Illness
• Past Medical Hx
• Past Surgical Hx
• Review of Systems
• Allergies
• Home Medications
• Inpatient Medications
• Vitals
• Ventilator/Noninvasive Settings
• Drips & Rates
• Physical Examination
• Lines & Tubes & Drains
• Labs
• Imaging
• External Data Review
• Assessment
• Plan

Medicare requires 3 R’s for all inpatient Consults:

1. Request for E/M (“Reason for Consultation”)
2. Render Service (“See patient, provide care”)
3. Reply to Referring Physician (“Write note, communicate with referring physician”)