A Day in the ICU I

Usually I get to the ICU at 6:45. I get sign out from the interns and residents who were on the night before and quickly run the list of patients, especially if I'm on call and have to know who's really sick, who could potentially leave the ICU, etc. I go see my assigned patients and make a plan for the day. As I think about the changes in management for each patient, I remember one of my ICU attendings at UCSF who decided that every patient should have one (and only one) "big move" for the day. Were we trying to take the breathing tube out? Should we broaden antibiotics? Can we put in a central line and start vasopressors? Of course, some patients require more aggressive management and some could easily handle multiple changes in their plan, but I took this to heart. ICU patients are complicated, and changing too many variables can muddy the picture and lead to unanticipated consequences. So for each of my patients, I come up with my "big move" for the day.

We round at 8. The ICU is filled with portable computers on wheels and most of us take one as we go from bedside to bedside. The computers allow us to pull up X-rays and put in orders for each patient in real time. At first, I didn't like the computers as it felt a little impersonal, everyone's faces aglow behind the screens, but now I realize how much more efficient that is. As a large team of 6 (weekend) to 14 people, we discuss each patient in depth and formulate the plan for the day. We get the post-call intern and resident out as soon as possible. Some attendings set aside time to do dedicated teaching.

I alluded to this on a previous post, but patients are really diverse. Most medical patients are admitted because of cardiopulmonary instability; they are failing to breathe and require a ventilator or they are actively bleeding and have poor blood pressure or they have a widespread infection with hemodynamic collapse. Sometimes, we have neurology patients with strokes requiring close monitoring. Our post-operative cardiac patients are often on lots of drips (IV medications that deliver an infusion over time), our post-operative ENT cases have tenuous airways that may close off with swelling, our post-operative general surgery cases are often liver resections with large fluid shifts and blood loss. The range of cases is really fun and really educational.

Morning rounds usually lasts 2-2 1/2 hours, depending on the acuity of the patients. Then we get as much "work" done as possible; we call our consultants, we put in orders, we adjust lines, we intubate and extubate people, we write our notes. Then we have a daily lecture on a core ICU topic such as pain management, end-of-life issues, ventilator settings, pulmonary artery catheters, or post-op cardiac surgery. Although the unit is excruciatingly busy, it is wonderful that we have time set aside for learning. The fellows and attendings usually cover issues during our lecture.