MICU take home message

I just finished my last call in the MICU and I can say with certainty that I have found it both challenging, rewarding, and utterly exhausting emotionally and physically.  Challenging because I've done many procedures for the first time.  I did my first intubation on a nonparalyzed patient, I performed my first chest tube, I put in my first central line.  Also, given the resources that most ICUs have at their disposal your therapeutic options are virtually unlimited.  You can practice based on the most recent literature despite cost of drug therapy and because this is frequently a last measure, you can even make the argument for marginally experimental measures.  Xigris here I come.  I've learned how to put virtually everything in a drip - pressors, antibiotics, sedation, insulin, electrolytes.  The sky's the limit.  I enjoyed being the first responder to codes and knowing there was some sense of relief because the ICU team was there.  The team approach and daily rounding were enjoyable, which I can rarely say of any previous rounding experience.  I liked working closely with the families of the patient to explain what the options for management are and to discuss end of life care.

This was easily the most challenging aspect of the month.  The last patient that I declared dead was a metastatic esophageal cancer patient whose oncologist had not yet breached the topic of prognosis and end of life management.  As I navigated the family through the initial full code, to DNR, and eventually to do not escalate and comfort measures only, I realized that no other experience would rival this in complexity.  You need to read the situation for each individual family.  You need to assess whether it is appropriate to discuss the medical situation vaguely or whether a more technical narrative is desired.  You need to be sympathetic, but offer direction and you need to be certain at times when there is not much clarity about the actual events.  In this particular patient it was evident that there was a communication between the lungs and the gut (the NG tube was attached to a clean catch bag that filled with air in seconds), but it was unclear whether this was the cancer eroding the posterior esophagus or whether the friable surgical anastamosis site was coming undone.  What became clear to me throughout the conversation, however, was that the family did not need to know details and wanted to be allowed to mourn before making a CMO decision.  Eventually, they thanked me for everything we had done and I left with the feeling that even if there had been a medical error in his care - my chest tube had punctured the gut or the surgery had been botched, they would recognize that his end-of-life care was appropriate.  It's been difficult coming home from calls like these and moving on to my normal daily activities.

You most definitely bring your work home with you when you're in the ICU.  In the ED, I think it will be easier to walk away from these situations unscathed.  The low point was definitely a couple of days ago when I had been on this streak of all of my patients dying (some that I had carried for weeks) and was assigned a new patient that clearly would die on my shift.  I actually got tearful for a minute while rounding and had to pull myself together.  I'm happy to still have compassion and be able to feel these emotions for a patient, but at times I wish I could just get jaded already and at least be able to close the chapter with move on.

Here are some words of advice for the critical care rotations:
1. Know how to replete electrolytes - this will be an every day task and will eventually become reflexive - correct your Ca for low albumin and keep ventilated patient in the >2 Mg range
2. Love the ABG - you will do it over and over and over again
3. Sepsis is bread and butter ICU care - put in the line early, monitor CVP and SVO2 and transfuse away if needed
3. Do your research and you can make a case for most any treatment, if it is evidence based and your attending likes adventure
4. Communicate with families early, when you breach the topic of code status, it will be a lot easier
5. Pack an on-call bag with toiletries, snacks, water bottle, cell phone charger and ibuprofen - it's amazing what aches and pains will emerge when you're running around for 30 hours
6. Build a good relationship with your team - don't signout quick tasks and phone calls, give a good signout, and when you're on call get everyone else out on time
7. Never underestimate the value of the nursing evaluation - they have more experience with your patient and will help you preempt disasters if you listen well - have them get you when they turn your patient - you can auscultate and evaluate their decubs
8. Sleep when you can, I took melatonin at 5pm on my post call days and on 5pm the day after - it worked great
9. Try to keep some social obligations, you'll feel more in control of your schedule and you'll learn to love on call days for the prospect of post call lunches / breakfasts with friends and family
10. Learn what you can from your senior / fellow - you'll rarely get this much one on one time