Happy Labor Day!
Oh my goodness I have so many things I want to blog about, I don’t know where to start first! I think the most appropriate topic to start with is that I finished my ICU rotation this past weekend. It feels so strange that I will never rotate through the ICU again. I will never take care of those types of patients again. I hate to say it, but I’m almost sad!?
I actually enjoyed my month in the ICU so much more than I had anticipated. I did my sub-internship as a medical student in the ICU and it was nothing like my month here at Mayo. You can read all about my sub-I experience here.
For one, as a medical student I didn’t have anywhere close to the responsibilities I had as an intern. Even though I was doing my sub-internship, my days were often slow and I was even bored at times. This past month, my days were so busy I didn’t have a moment to spare between walking into the hospital at 6am and walking out 12-14 hours later.
Another huge difference was that as a medical student in the ICU, I had to go to all the codes in the hospital. If a code was called overhead, I stopped everything and RAN. I think I did close to 10 codes that month and I hated it more than I can explain. I think codes are the worst part of medicine and I will be happy if I never have to participate in one again. I talk about my conflicting views on codes in my post from the ICU last year.
At Mayo, there is a special team for codes and so unless it is YOUR patient who is coding, you don’t go to the codes. I was only involved in two codes all month (two too many) but it was much better than 10.
Anyway, here’s a breakdown of what the rotation was like:
Every morning I got to the hospital at 6am. We have a team room for all the ICU residents. There are 6 interns and 4 seniors on the team. The interns rotate days off so there are always 2 interns there all day, one intern there overnight and there the next morning for rounds, and one intern who comes in at noon to help with afternoon and evening admissions. So for the majority of the day, there are 3 of us there working together. The senior residents also have a rotation schedule so there is always at least one senior there, but often there are 2 or 3. Mayo also has fellows in the ICU who rotate days so you might have a different fellow every few days, but there is always one for your team.
First thing each morning, I printed off a list of the patients. Our team had a max of 16 patients and normally had about 12-14 patients each morning. We split the patients between interns, so generally we each had 5 patients in the morning and the overnight intern took any new admissions from the night. I would ask the overnight intern about what happened with my 5 patients overnight. If I was on call that day, I would transfer the team pager over to me so the night intern could be done.
Then I would look up all my patients on the computer and start my daily progress notes. I found it easiest to start my notes right away. If I waited until the afternoon to start my notes, I would end up staying late trying to finish them. In the “subjective” part of my note, I would bullet point anything pertinent that morning; labs that had changed (say their hemoglobin was trending down and I thought they might need a transfusion), any microbiology that was positive (say their blood cultures came back growing staph), any new imaging (say they had a chest X-ray that morning or got a head CT overnight because they were confused), and any consults (say cardiology had come to see them that past evening and made some recommendations about blood pressure management).
After doing that for all 5 of my patients, I usually had about 15-20 minutes before rounds started, so I would quickly go see all my patients. I would check with the nurses to see if they had anything new to report or needed anything. I would do a quick physical exam on my patients and ask them how they were feeling (often my patients were sedated and ventilated, so I couldn’t talk to them).
By 8am rounds would start. The interns all took around our “computers on wheels” (COWS) or “workstations on wheels” (WOWs- more politically correct 😉 ) so we could put in orders for each other while rounding. I also loved having the computer because I would just look at my note while presenting the patient to make sure I didn’t forget anything. And if the consultant asked you a question, you could quickly look it up on the computer.
Rounds generally lasted until 11am. Sometimes we would get an admission during rounds which made everything chaotic and difficult. Since the interns are in charge of writing orders and writing notes, we have A LOT to do when a new admission comes. We have to see the patient, get the history, ask the patient about code status, talk to family, put in all the admission orders, put in initial test orders, write the admission note- it’s a busy time! If we didn’t get an admission during rounds, I would try to finish my notes as fast as possible before lunch.
At noon, Mayo has a medicine conference for all the residents. On my neurology rotation last month I was able to go every single day. On ICU, there were lots of days that were just way too busy for us to stop and go to lecture. Most of the interns and residents would run down to grab food but come right back upstairs to keep working. I was always glad I brought my lunch on busy days like those 🙂
New admissions would roll in throughout the afternoon. The intern on “short call” would admit until 2pm. The intern on “long call” would admit until 4 pm. The “afternoon intern” would come in at noon and admit until 8 pm. The overnight intern would come in at 6pm and admit until 6am the next day. Each intern could only admit 2 during the day or 4 overnight. So, you never had more than 7 patients which was great.
ICU patients are super sick and so things change in an instant. I felt like I was constantly getting paged about my patients, putting in new orders, checking up on labs, or other tests, calling family, etc. It was never ending.
The days were so busy, but it was wonderful because they FLEW by! I never felt like the day was long or drawn out. It was go-go-go until it was time to go home.
And even though the days were crazy busy, we didn’t work too many hours! I was totally expecting 80 hour weeks (which my colleagues on cardiology and medicine both experienced) but my busiest weeks were only about 65 hours. It helps because when you do your overnight call you don’t come in until 6pm, so you have all day that day to relax, and then you leave the next day at 10am and have the rest of the day off. In addition to those 2 pre and post call days, you get an entire day off. And, you have the afternoon shift when you don’t go in until noon, so it’s a pretty sweet schedule.
I was able to wrap things up and leave the hospital by 6pm-8pm every night. I stayed until 7pm often but never past 8. Overnight is a really busy call. There are almost always 2 or more admissions, (I had 5 one night), and the patients are sick so you are busy returning pages and following up on labs and other tests. On neurology, I slept almost the entire night each time. On ICU I didn’t go to sleep once. I didn’t even try. Technically there are call rooms, but I think most of us just accepted that we would be up all night.
In the morning after being on call, you present your patients first during rounds and then you can leave! Some mornings I was out by 8:30 or 9 which was delightful!!
What I learned:
SO MUCH. I learned so so much. Since I’m going in to ophthalmology and will never had to manage ICU patients again, I didn’t stress out about studying too much. I just decided to try an absorb as much as possible without putting any pressure on myself because in all reality, it doesn’t matter if I don’t know how to work a ventilator 🙂
But, even without trying I managed to come out of the ICU knowing all about peak pressures and plateau pressures and FiO2 and tidal volumes. I feel much more comfortable managing severe sepsis, and I can make little decisions without running everything by my senior residents. At the beginning of the month I was so nervous to do anything. I wanted to check with my resident before putting in any orders. Even if my patient was low on potassium and I just wanted to replete their levels a little bit, I wanted to tell my senior resident. Now I feel much more confident doing those kinds of things.
Mayo physicians practice evidence based medicine big time, I’ve found. I thought IU (where I went to medical school) was big on evidence based medicine, but Mayo is at a different level. Evidence based medicine means practicing medicine according to what scientific studies show. It means making clinical decisions based on data. It means that if someone loses a lot of blood and their hemoglobin goes from 14 to 8 and you want to transfuse them, you wait until their hemoglobin is 7 or until they are symptomatic because studies show that giving blood above a cut off of 7 doesn’t help and can actually do harm.
There was never a time during rounds that a consultant (what Mayo called attending physicians) didn’t cite some paper. The pharmacists rounding with us ALWAYS talked about new studies and data to support their decisions. The senior residents talked about new trials whenever they debated a treatment plan. Every single day I had 3-4 new papers emailed to me by the pharmacists, residents, and consultants. I had to make a specific folder in my inbox just for papers that I need to read. I couldn’t keep up!!
It’s actually incredibly inspiring to see how knowledgable everyone is at Mayo and how much they value current literature and practicing as up-to-date as possible. No wonder it’s the number one hospital in the country!!
What I gained:
I swear, my skin did not like the ICU this month. Maybe it was stress? I didn’t feel too stressed… hopefully my skin will behave again now that I’m starting a low-key research month.
– A few extra pounds.
Remember my goal of only eating sweets 1-2 times a week? Yea- it was more like 1-2 sweets a day. Whoops! There were so many sweets in the team room at all times and you all know I can’t say no.
– A ton of medical knowledge.
– Procedure experience. I was able to perform a paracentesis, removing fluid from the abdomen:
Thoracentesis, removing fluid from the lung:
Image from wikipedia.
And I placed a central venous catheter, an IV in the internal jugular vein.
– Inspiration for the practice of medicine (I’m always feeling so inspired by the Mayo physicians)
– Lastly: A deep love for so many of my patients. Seeing a patient come in incredibly ill and get better is one of the most rewarding experiences and I feel so lucky to be a part of the healing that happens in the ICU.