ICU What To Do Guide - In Detail



There are 3 foundations for a successful ICU rotation:
1. Patient care comes first
2. Procedures and ACLS
3. Communication with the attending, consults and family.

Let's look at these 3 principles in detail:

Patient care
You never sleep on a patient problem that you are not sure what is going on with. You read books, check Up-To-Date, call consultants, and so on....but you must have an educated idea about the likely diagnosis and the differentials. You never think '"I'll go later" when a nurse is calling you to see a patient urgently. ICU nurses have only 1-2 patients to follow, they're very experienced and when they call you it is for a reason. That is why we have added an ICU FAQ section written by a nurse with 20 years experience - it is as useful as it gets if you are an intern.

Let's imagine an ICU scenario. The charge nurse is calling you - Mr. Jones (fiction name, don't forget HIPPA) fell off the bed, and then another page - Mr. Smith is tachying in the 150s. What to do? Dear Interns, does it sound familiar? The solution is here. In addition to asking your resident you can review the ICU FAQ. You will learn how to address common clinical situations that you will not find a quick answer for in the books.

Also always address the problem head on, never jump around it. Again if you don't know what is going on there is always somebody to ask even at 3 AM. Your attending would much prefer to be asked at 3 AM than to find the consequences of a bad management in the morning.

Procedures and ACLS
This is the big difference between the floor and the unit. Vitals signs are vital and you need to do whatever it takes to maintain them. This includes ACLS, line placement, fluids, pressors, mechanical ventilation. You need to be familiar with all these in order to provide the best patient care. There is no substitute for the experience and you should use every opportunity to get it. The old saying “see one, do one, teach one” is no longer valid. You can use our procedure guide section to see the educational videos. See 10 videos, do 10 procedures, teach 20. This should be the goal.

How to place a central line? Learn from the masters. Check out the NEJM educational video. There is a comprehensive procedure guide in the section of this website focused on procedures and ACLS.

Communication with the attending, consults and family
This is essential. Always inform your patient and the family what is going on. Often you'll be amazed to know how little your patient knows about his condition. Always discuss the code status. Advise. You're here not only to offer options but also guidance about the most appropriate decision.
Your attending and consultants are always there to help you. Inform them on time and use their immense fund of knowledge.

Imaging - EKG, CXR, CT scans
Another useful website is ICU CXR from the University of Virginia. It will answer such burning questions like "Is the central line where it is supposed to be?" or "Does he have a PTX?!"
When you have time you can review non-urgent X-rays and CT scans on the radiology website of the University of Virginia.

You can also browse through typical or not so typical EKGs here. This is a link to an arrhythmia simulator - try it out, you can pause, play and quiz yourself. Just click START on the welcome screen, you don't need a user name/password.

Resources:
Leading an on-call team - BMJ Career Focus 01/05
Tips on...Being a successful resident - BMJ Career Focus 01/05
Tips on...Surviving night shifts - BMJ Career Focus 02/05
Tips for interns - Medicalmadhouse

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