QHC Intern’s Guide to Surviving ICU

Prepared by: Rayhan Shariff, MD (Class of 2018)

Reviewed by: Ricardo Lopez, MD (Director of Pulmonary and Critical Care Medicine)
Vincent Rizzo, MD (Associate Program Director, Internal Medicine)
Contents: “work horse”. During the day there are two interns, one on short call
1) Introduction (until 4pm) and another on long call (until 8PM) with two residents (with
2) Your Role as the ICU intern the same call schedule –short and long call). During the night there is one
> Day Intern responsibilities intern and one resident. As an intern your responsibilities are many, but
> Night Intern responsibilities primarily it boils down to: KNOW YOUR PATIENTS. If you have mastered
3) Daily Workflow that, then everything else falls into place. Details pertaining to that are
4) Orders, orders and more orders explored in more details in the daily workflow section.
5) Presenting on Rounds
6) All about daily notes Day ICU Intern Responsibilities:
7) Breath! About Ventilators You should arrive at least an hour or so early to the ICU as there is a fair
8) About Pressors amount of things to follow up and go through upon arrival.
9) About Sedation - In the morning, you go through all the am labs, replace electrolytes and
10) Examining the ICU patient other things as needed (if not done by the night team already).
11) Conclusion - You also go over the daily imaging and address tube positions and
placements as needed (again if not done by the night team already).
Section 1: Introduction: - get sign-out from the night team and nurses about any acute events
Welcome to the MICU rotation! This will be one of the most daunting, but overnight, any interventions etc.
also educational, rotations in your PGY-1 year. Regardless of how you - You round on your old patients
may feel before and during the rotation, I will guarantee that you will - You review and round on the new admissions from overnight and be
come out of it feeling more confident and more knowledgeable in your prepared to present them to the ICU attending during rounds.
ability to manage critically ill patients and patients on the floors. Many of - You also order labs for the afternoon (as needed) and for the evening
you may have had ICU rotation as med students but others did not. I am (as needed) and also daily 3am labs (see section on workflow).
part of the latter, so my first exposure to the MICU was during my intern - You go over the plan with the residents and make sure all the
year. While your residents and co-interns are a great source of things/orders to be placed are completed.
information and guidance, there are certain things I wish I knew heading - You do your daily progress notes
in. Therefore, I made this guide as a compilation of stuff I wish I knew. - The short call intern goes home at 4PM if all their work is completed and
the long call intern receives sign out from telemetry and Step-Down unit
Section 2: Your Role as the ICU Intern: and covers those teams in addition to the ICU until 8PM when the night
One of the most important things to figure out is your role in the grand ICU intern arrives.
scheme of things in the ICU. As the intern on the team, you will be the
Night ICU Intern Responsibilities:
- Good news as night intern: there are NO DAILY PROGRESS NOTES;
unless there is an acute event.
- Bad news: you are covering the entire ICU; the SDU and telemetry unit
until morning team arrives and sign out is completed. So expect a lot of
pages.
- Additionally, the night ICU intern also gets called for “panic values” on
out-patient labs (these are patients from clinic). It is your responsibility to
contact them and drop a note documenting the notification. If you are
unable to reach the patient, you can call AOD and they will try to reach
out to them and escalate as needed. But again, document if you weren’t
able to reach the patient and had to involve AOD.
- You are responsible for following up all ICU patient’s Chest X-ray
imaging at 1AM (see work flow).
- You are responsible for following up any labs ordered for the evening for
ICU, telemetry and SDU patients (as per the sign out).
- You are responsible for following up labs for ICU patient’s at 3AM and
addressing any abnormalities.
Section 3: Daily Workflow:
Few things that are constant in the ICU at QHC.
 All intubated/tracheostomy patients get Chest X-rays at 1am and
daily ABGs without exception.
 All ICU patient’s get daily labs at 3AM (see orders for more
details)
I will outline a typical day in the ICU at the day intern:
6:45-7am: Arrive at the ICU
7am-9am: Go through and note all the labs from 3am; order any
electrolytes to be replaced; get sign out from the night team; review
orders and renew any expired orders. Review the chest x-rays.
Round on all your old patients and see new ones from overnight.
9am to onward: Round with the team; you present old patients in a SOAP
format and present any new patients to the ICU attending. You formulate
a plan with the team.
After rounds: Go over the plan with the residents; put in the right
orders/consults/follow-ups as per the plan during rounds; write the
transfer notes for any patients that are to be downgrades and do your
daily progress notes; order the routine 1am chest DX and 3am labs and
any evening labs (if/as needed).
Section 4: Orders, orders and more orders:
You are expected to place daily/routine ICU orders. Which includes:
- Daily Imaging orders – Chest X-ray for intubated patients for
the 1am to assess ET tube placement and check for any new
infiltrates/consolidations and resolution/formation of
effusions.
- Daily lab orders:
Daily ICU labs are typically ordered for 3am and 3pm. All
patient’s get 3am labs. For intubated patients they include:
ABGs in addition to daily CBC, BMP, Magnesium level, LFTs. If
your patient is on vancomycin, get vancomycin levels daily. If
your patient is on aminoglycoside, then get those levels. If
patient is admitted for status epilepticus and is on Dilantin or
Keppra; get levels; order phosphate, troponin and EKGs as
needed.
As mentioned before, night intern is responsible for following up the 3am
labs and replacing electrolytes as needed but regardless the day intern
should also review the labs and know exactly what was done.
Section 5: Presenting on Rounds:
Existing Patients:
Presenting old patients on rounds is akin to your SOAP note. You state
number of days in ICU, brief Past medical history and the reason for MICU
admission, overnight events, any acute events since yesterday, any
changes in meds; then your physical exam, labs; assessment and plan.
There’s a great format on QHC intranet on presenting on rounds.
New Patients:
Majority of the time, admitted ICU patients are sedated and intubated by
the time you see them, so collateral information is very important. Your
first stop should be the paper EMS report. When available, this gives you
how the patient was when the EMS reached them and what was done en
route to the hospital. Also a lot of ICU patients are from nursing homes,
therefore going through the paper from the facility will give you list of
medications, last set of vitals and any recent bloodwork that was done.
Always, always, always look up the patient on Quadra med. QHC only
switched to EPIC on April 2016. If the patient has been here before it will
provide you with invaluable information regarding previous work ups
such as ECHO reports and other imaging and labs that will allow you to
gather more information and paint a better picture of the patient when
presenting to the attending. And previous records also give you an idea
about the baseline functional status of the patient for appropriate
correlation.
A few things to keep in mind about presenting old patients are as follows:
 Where are they coming from? (Home vs. NH vs. other long term
care facilities)?
 If they had a line placed – where? What kind of line? How many
days? Why is it still needed? (answer to last question can be
because of poor access, administrating pressors etc.)
 LOS – length of stay – how long have they been here?
 Primary diagnosis – why are they here? What are we treating?
 Chronic issues – chronic medical issues, such as HTN, DM etc.
 If they have a Foley? – Why? There are a few indications for Foley
in ICU; the predominant ones being acute urinary retention, strict
I&Os and preventing infection of decubiti ulcers.
 Diet – what type of feed? Rate? Pre-albumin level*? Be sure to
follow up the dietitians note and change feeding as
recommended.
 I/Os – also note if patient had a bowel movement; you can also
ask the nurse.
 Blood glucose level – trend the finger sticks and note the trend;
ideally goal FS ~ 180 for ICU patients.
*Order pre-albumin level for all patients. If low it allows you to add
protein-calorie malnutrition to your assessment.
Section 6: All about daily Notes:
ICU notes are different from regular floor notes. The daily floor notes
follow the standard SOAP note format. ICU notes are an ongoing
narrative, meaning you carry-over the happenings from the previous day
and add today’s events to it. For example:
S: Initial Hx: (from HPI of original H&P)
ICU Day #1 (July 01, 2016): events of day one
ICU Day #2 (July 02, 2016): events of day two
O: Vitals:
Lines (day#?)
I/O for the last 24hr)
Vent settings (if applicable)
Physical Exam
 A: Assessment
P: System-based from Head to toe:
CNS – sedation?
CVS – pressors? Fluids? Diuretics? Central line
and why?
Resp – intubated?
GI – type of feeding? GI PPx?
Renal – electrolyte abnormalities? Fluids?
Diuretics? Foley and why?
ID – recent culture results; Antibiotics and day #
of antibiotics
Heme – any acute drops? Transfusions?
Endo – FS? Insulin doses standing and/or sliding
scale? Thyroid d/o if any
Code status: full code vs. DNR/DNI
Disposition: stay in ICU/transfer to floor or SDU
Contact: Name and phone No. of family; PMD.
This way someone reading the latest note will know what has been
happening with the patient since he/she was admitted to the ICU.
Section 7: Breathe! About ventilators:
A fair amount of patients in the ICU are sedated and on vents. The topic
of vents in and of itself is the subject of numerous books and you will
learn a lot about managing patients on vents from the rounds with the
attending and residents. But here is a brief and skeletal representation of
vents.
AC (Assist Control Mode): CMV + allows for patient to trigger
mechanical breaths at the set tidal volume; the set rate is a
minimum back up rate; downside is that if patient is anxious and
hyperventilating they will continue to trigger additional full
machine breaths and worsen hyperventilation.
SIMV: In this setting, you dial in a set tidal volume and set rate;
but spontaneous breaths from the patient can over-ride the
machine; however given the resistance (think of trying to drink
thick milkshake through a straw) of the circuit there is always
some PSV (pressure support ventilation) provided to overcome
resistance.
NIPPV: (pressure cycled ventilation) these include your CPAP and
BIPAP; used for patients that are alert and able to follow
commands; can be used in COPD exacerbation; CHF exacerbation;
OSA etc; can be programmed to have a back up rate or not as
needed.
You will frequently hear the term “ventilator bundle” during rounds for
intubated patients. What this means is that intubated patients must
have:
1. Head of the bed elevated at 30-45 degrees
2. Daily “sedation vacation” – off all sedations
3. GI prophylaxis – Nexium or Pepcid
4. DVT prophylaxis – Enoxaparin (Lovenox) daily if no renal
dysfunction; SC heparin if renal issues or IPCDs if actively
bleeding.
5. Oral care
6. Rotation and chest physiotherapy
Section 8: About pressors:
A fair amount of patients in the ICU are on vasopressors. We primarily
use dopamine, levophed and vasopressin as our most-common go to
pressors. However, you should have a working idea of the other pressors
and with their respective receptor of activity and notable adverse effects.
From NEJM Rotation 360 (Adapted from: Inotropes and Vasopressors, Circulation 2008.)
For Sepsis two key things have been shown to improve mortality:
- FLUIDS, FLUIDS FLUIDS!
- Early initiation of broad-spectrum antibiotics.
Section 9: About Sedation:
Patient’s in ICU that are intubated and sedated for comfort. On the other
spectrum, you have patients on sedation for management of delirium
tremens. But regardless of the reason for sedation, you should know the
common sedation infusions that are used, their specific purpose and their
effect on hemodynamic parameters.
Effect on Hemodynamics
Propofol Rapid on and off; drops BP and RR; can cause
propofol infusion syndrome; can cause
hypertriglyceridemia with prolonged usage.
Dexmedetomidine Can Decrease BP and cause bradycardia; used in
Aka Precedex DTs as patient can have sympathetic over-activation
Fentanyl Pain control; minimal effect on BP; 1st line for
ventilated patients
Ativan Commonly used in DTs, alongside precedex; can
cause high AG Metabolic Acidosis due to solvent
effect (propylene glycol)
Section 10: Examining the ICU Patient:
Examining the ICU patient is a little more challenging than your regular
floor patients. A good amount of patients are sedated and therefore
won’t be able to follow commands or really maneuver themselves to
make things easy for you. But physical examination is key in the ICU and
allows you to assess if the patient is improving.
On all ICU patient’s the following physical exams must be performed
every single day.
HEENT: always check the pupils; note their reactivity to light and
nystagmus (if any); check for any IJ lines.
CVS: listen for S1 S2 and any murmur, rubs or gallops.
Resp: if patient is intubated always look and note the ET lip line; for both
intubated and tracheostomy patients, advance the suction catheter and
suction patient; note the color, consistency and amount of secretions;
this also allows you judge patient’s cough and gag reflex and response to
therapy (i.e. are the secretions improving or still purulent); use saline
bullet (pink little plastic containers) to back wash the suction catheter.
Abdomen: note is the abdomen soft or distended; note any hernia or
scars; listen for bowel sounds; note is PEG tube is present.
MSK: Look for edema; note presence of ulcers on the heel, rashes, bullae;
track mark (if any)
Integument: Note if there are any decubiti ulcers and their respective
stages. ***
GU: Note for presence and type of urinary catheter (Foley vs Condom
catheter); note the color of urine.
***Nursing staff in the ICU are adept at documenting and noting ulcers.
Speak to them! Request nursing staff to call you when they are changing
the patient so that you can take a look at the ulcers as well. If they came
in with ulcers from nursing home or home, check the chart as it was
noted by the staff during initial assessment. For management of ulcers,
wound care specialist, Mr. Gonzalez should be contacted and his
recommendations to be followed.

Section 11: Conclusion:

ICU is a great rotation regardless of whether or not you see critical care in
your future. For some, this may spark a love affair that will lead to critical
care fellowship after residency. For others, this may be the only exposure
you get to caring for the critically ill in your career. Regardless, take
advantage of the rotation and use it to learn as much as you can and
become more confident as you continue your training to be a great
physician.