ICU 101 with John Galvin and Anne Burgess

WEBVTT
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and welcome to this month's episode of Style
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Points. Today we're doing something slightly
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different than usual. We're giving a primer on
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how to approach your first day of the ICU with
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soon -to -be CA1 John Galvin and soon -to -be
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CA2 Anne Burgess. They do a great job outlining
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all the different aspects of what we do with
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ICU management. We don't have an RSI this month,
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but I'll give my co -host Nate Moore a pass.
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I suppose that having a beautiful baby and starting
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a family might take precedence over doing a podcast
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segment. Maybe we can get a son Christopher as
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a special guest in a future episode of the podcast.
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Major congratulations and much love to Nate and
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Mary. Without further ado, here's John and Anne
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with ICU 101. Welcome to Style Points. I'm John
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Galvin. I'm a first -year resident here at the
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University of Cincinnati in the anesthesia residency
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program. I'm joined by CA1, one of my seniors
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here in the anesthesia program, and Burgess.
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Happy to be here. Thanks for joining. You're
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interested in critical care. Yes, I am. Awesome.
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Well, today, I think a great topic to talk about
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is starting in an ICU rotation. I think every
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intern... has a little bit of trepidation when
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they're approaching the ICU for the first time.
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Some of us may have never been in an ICU before.
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So I really appreciate you having this conversation.
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What got you interested in critical care? Sure.
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So I'm about at the end of my CA one year. So
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I have a little bit of a rotation under my belt
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at this point. But I actually, my interest started
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in the ICU prior to actually anesthesia. So when
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I was a medical student, I loved rotating in
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the ICU. Sick patients, lots of physiology to
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think through, and it's a high -stakes environment
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that I felt really drawn to. In looking at the
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different paths to critical care, anesthesia
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is the fastest, but I also feel it has the opportunity
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for more balance. The ICU is a very emotionally
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hard place to be. We take care of very sick patients
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and not all of those patients get better. So
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I wanted to think kind of for longevity's sake,
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what's something I could see myself doing forever?
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And anesthesia, I felt like brought a really
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good balance of you get to take care of those
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sick patients in the ICU. And I find a lot of
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satisfaction in taking care of those patients.
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But you also get to kind of temper that with
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general anesthesia, which can also provide some
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similar intellectual stimulation, if you will.
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But you get to bank, I think, easier wins in
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the OR sometimes, which I think for the purpose
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of, you know, having an emotionally balanced
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career, I think is very helpful to have the option
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to do kind of the whole breadth of things. That's
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awesome. Diversifying. getting a lot of different
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experiences. And no better way to do that than
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in an ICU setting where you get to see a lot
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of really sick patients, learn some cool pathologies.
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I think importantly, we need to set up for people
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starting on their first day what to expect. Can
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you talk a little bit about what to expect on
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your first day in the ICU? Sure. And I think
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I'll back up a quick step to kind of talk about
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what our critical care team looks like here at
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UC. Critical care anesthesiologists are going
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to have a different role at every institution.
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I think our role here at UC is very helpful and
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interesting and impactful. We mostly live in
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the cardiovascular ICU. typically working with
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cardiothoracic surgery and cardiology, but also
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have our hands in our burns unit, our ENT unit,
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to help our other colleagues be essentially critical
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care consultants. So we end up getting a lot
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of different hands on different pathologies in
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different places in the hospital and get to continue
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care with surgeons and surgical teams that we
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work with in the OR. We get to continue to help
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their patients post -op with whatever they have
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going on, in addition to very sick cardiology
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patients. As for the first day, first days are
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always really hard. I've always struggled with
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first days. I get very anxious before first days
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just because you have no idea what to expect.
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Tips getting oriented to the unit, what to do
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before your first day, all of that. It's a big
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question. I could talk for a very long time on
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all of the things to do, but ultimately showing
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up ready to learn on your first day. We have
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handoff at 630 here. That may be different depending
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on where you're at, but listening for what's
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going on with your patients. Paying attention
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to kind of the important things that your overnight
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team is telling you. There's no formal handoff
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process that you may have on your medicine rotations.
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You're just showing up and you're listening to
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what your overnight team has said. Things change
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very quickly in the ICU. So things, even if you
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did research on them the night before, things
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are bound to change. So showing up just ready
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and open minded on your first day is kind of
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the biggest obstacle to traverse when showing
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up in the ICU. Thank you for giving some of the
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background. I think I was thrown off because
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I kind of being here at UC, our mascot at University
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of Cincinnati is the Bearcat. So I thought that
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was interesting that this unit is called the
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Seacat. And I wasn't sure if that was just a
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UC specific thing, but. Yes. Critical care anesthesia
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team. Yes. Very UC specific. We love all of our
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cat jokes, but CCAT does stand for critical care
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anesthesia team. And that I believe is a very
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UC specific thing. Very cool. I think it was
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really cool on my first day too, as you mentioned,
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getting to work with all these different teams,
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you really get to build relationships with. people
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that are rotating on different specialties and
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that only serves you better when you're in the
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or when you're working with cardiac surgery residents
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when you're working with the attendings and then
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when you know you're meeting a cardiac surgery
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patient for the first time and you see one of
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your senior residents coming up from the or and
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giving you handoff it's it's a really neat position
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to be in to hear from them and see how things
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work with the transition from the or to the icu
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looks like and what those next steps are. Absolutely.
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Critical care is a team sport. And understanding
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who all is in your unit is a helpful thing to
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know prior to starting your rotation. So here
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at UC, and again, caveat is that this can be
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different at every institution. But our cardiovascular
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ICU here is an open unit, meaning there can be
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multiple different primary teams. And then also...
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With the addition of all your consultant teams.
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So in contrast, our medical ICU here is a closed
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unit, meaning every patient in the MICU is primary
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MICU. Whereas in the cardiovascular ICU here,
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you can have cardiology primary, cardiothoracic
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surgery primary, as well as our own team CCAT
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can be primary as well. So there's a lot more
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of a teamwork dynamic working between all of
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those teams, helping coordinate care for. very
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complex patients who are very sick. So understanding
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that there's several teams that are involved
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and sometimes your rounding structure is going
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to depend on how many shared patients you have.
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We try and round with those teams so we can all
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coordinate that care together. It's not always
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perfect, but understanding that you're going
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to be working with the other teams and you may
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not be the one presenting. You may not be the
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one putting in orders, but your role still very
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much matters. It's helpful to know prior to showing
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up. There's going to be a lot of cooks in the
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kitchen. Okay, so first day, get there early.
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Just to recap, showing up on time, showing up
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a little early is great. That way you can settle
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in a little bit. I liked, you know, on my first
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day, I got there like 10, 15 minutes. Absolutely,
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yeah. Typically the overnight team, they have
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a sheet that... has the census on it and that
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way you can kind of familiarize yourself with
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the organization how morning handoff is going
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to go and then you can listen to rounds kind
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of get oriented by that time you probably know
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if you have a patient that you're going to be
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following and then you can even focus in that
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much more during the handoff let's talk a little
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bit about you know you mentioned the structure
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of the team we have Obviously, if you're an intern
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rotating for the first time, are there other
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anesthesia residents that are rotating with you?
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Who else is going to be taking care of these
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patients with you? Who can you ask for help?
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Tell me a little bit. Absolutely. We have a big
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team, especially depending on the time of year.
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We have two critical care fellows within the
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Anesthesia Critical Care Fellowship. So they
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will be there at any given time. But we also
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have rotating fellows. that come from pulmonary
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correct care, from neuro correct care. Those
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are a great touch point regardless of the time
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of year. And then typically, especially as a
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junior, you'll typically have a senior resident
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alongside with you. I was fortunate to have two
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co -residents on my last rotation up there, which
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was super nice. And then we also have an incredible
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team of advanced practice providers, both nurse
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practitioners and PAs who have been doing this
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for a very long time. and are very familiar with
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our post -op cardiac patients, the unit, and
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are very, very helpful, especially for new learners.
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So do not hesitate to engage them in help. Right.
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A lot of them have worked in the ICU either as
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a nurse or in some other role before. And I thought
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that was really neat because they had even more
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insight into what questions to ask, maybe like
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differentiating different disease states. Yeah,
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their perspective was super useful. Absolutely.
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Okay, now we've talked about the structure of
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the team, what to expect on the first day. And
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I think it's really important after you've gotten
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handoff to organize the rest of your morning.
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You have about an hour, sometimes more than that,
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sometimes less, depending on the attending. you
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know knowing what to expect in terms of what
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kind of patient i'm taking care of and what should
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i be looking for um i have come across a couple
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of mnemonics in anesthesia we use our ms maids
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to help set up our room knowing how to set up
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a case before you know the the surgery happens
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i think there's other mnemonics that are great
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one that i came across was this fast hugs bid
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And we'll have a link to this as well. But the
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F is for feeding and fluids. The A is for analgesia.
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The S is for sedation. The T is for thromboprophylaxis.
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The H in HUGS is for head of bed elevation. The
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U is for ulcer prophylaxis. G is for glycemic
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control. And S is for SAT, SBT, which stands
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for spontaneous awakening trial or spontaneous
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breathing trial. And then lastly, the BID is,
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B is bowel regimen, I is indwelling catheters,
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and D is de -escalation of antibiotics and delirium.
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So we can go into this a little bit more. I think
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maybe we can just talk about why each of these
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things is important to look for. um but before
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we dive in do you have any thoughts about what
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mindset you should be in after you've gotten
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handoff and you're about to go see your your
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first patient what you should be looking for
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so i think whenever you're seeing patients either
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in the icu or on the floor or wherever having
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a process that is familiar to you consistent
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to you is going to be the best thing you can
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do for yourself we have Kind of similar paradigms
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even in the pre -op evaluation. If you do it
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the same way every time, you're less likely to
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miss things. What I would immediately start with
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is, is this patient stable? If they are not stable,
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then you loop and help. You talk to your fellow.
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You say, hey, I have this concern. I see this
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hemodynamic trend. Can you come with me to go
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see the patient? And then you can kind of go
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through your same list. But if they're stable,
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then you can kind of take a minute. You have
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like an hour and a half. It's more than enough
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time, even if it doesn't feel that way at first,
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to go assess your patients or start by chart
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reviewing. You can kind of go either direction.
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But as long as it's the same for you every time,
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that's all that matters. Okay. Do you, I mean,
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what is your preference? Do you like to chart
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review first? What's the first thing you look
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at when you're looking into a patient? Is it
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their last progress note? Is it their history?
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What do you think? I know it's probably patient
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specific, but tell me a little bit about your
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process when you're taking care of a new patient
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on your first day. I'm a little bit of an anomaly
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because I like to go see the patient first. I
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think there's a lot of benefit in going to lay
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eyes on a patient to see what they look like,
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to see what drips they have running, what their
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ventilation settings look like. I just want to
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see all of that first. The information in the
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chart may not be the most up -to -date information,
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and it will change quickly in the ICU. Not a
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lot of people have that method. I like it because
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especially at the time of day, By the time you
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get to go see the patient, oftentimes the night
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nurse is still there. So you can very quickly
00:15:11.259 --> 00:15:13.179
get their understanding about what their concerns
00:15:13.179 --> 00:15:16.240
have been over the last 12 hours, which I think
00:15:16.240 --> 00:15:18.299
is a very helpful starting point, especially
00:15:18.299 --> 00:15:20.580
if you're brand new to this unit. They have a
00:15:20.580 --> 00:15:23.899
lot of information. Utilize your resources. I
00:15:23.899 --> 00:15:26.879
discovered that a weekend when I was getting
00:15:26.879 --> 00:15:30.100
there first thing and I could catch the night
00:15:30.100 --> 00:15:33.679
nurse and it felt like I just had. I had all
00:15:33.679 --> 00:15:36.659
of the secrets on my presentation. I felt like
00:15:36.659 --> 00:15:39.740
I knew exactly what was going on. So I wasn't
00:15:39.740 --> 00:15:41.539
guessing. I wasn't getting it secondhand from
00:15:41.539 --> 00:15:43.899
somebody that was like, oh, I thought this was
00:15:43.899 --> 00:15:46.720
maybe important. But now you're hearing it right
00:15:46.720 --> 00:15:49.860
from the source. Yeah. I find that very helpful,
00:15:50.000 --> 00:15:53.299
both to engage with the care team, look at the
00:15:53.299 --> 00:15:57.419
patient. You have an understanding from handoff,
00:15:57.440 --> 00:15:59.320
kind of what things you should be looking for
00:15:59.320 --> 00:16:02.429
in a physical exam. So I like starting there
00:16:02.429 --> 00:16:05.049
and then bringing one of our computer on wheels
00:16:05.049 --> 00:16:07.809
and just pre -charting right outside of the room.
00:16:08.330 --> 00:16:10.570
The disadvantage of that is that you're not in
00:16:10.570 --> 00:16:13.269
the workroom. You can't, you know, immediately
00:16:13.269 --> 00:16:17.769
bounce ideas off the fellow. But also if the
00:16:17.769 --> 00:16:19.269
patient's sick, your fellow is probably there.
00:16:19.950 --> 00:16:22.250
So they're around anyway to talk to. They're
00:16:22.250 --> 00:16:26.029
pretty easy to find. That is my method. Not a
00:16:26.029 --> 00:16:27.870
lot of people do that, but it works well for
00:16:27.870 --> 00:16:31.049
me because I just, I want to see stuff. I want
00:16:31.049 --> 00:16:34.070
to touch stuff. I want to be able to see it with
00:16:34.070 --> 00:16:37.769
my own eyes because far too many times as an
00:16:37.769 --> 00:16:40.669
intern, especially I would chart review. I had
00:16:40.669 --> 00:16:43.070
this great idea of a presentation for this patient
00:16:43.070 --> 00:16:45.090
and then I show up and things are totally different.
00:16:45.639 --> 00:16:47.759
They have to say, well, my presentation does
00:16:47.759 --> 00:16:51.080
not matter because everything is different. So
00:16:51.080 --> 00:16:53.320
we're just going to restart and start from square
00:16:53.320 --> 00:16:55.580
one. And that's part of what I actually love
00:16:55.580 --> 00:16:57.740
about the ICU is things change quickly and you
00:16:57.740 --> 00:17:02.620
learn to adapt. That's great advice. I think
00:17:02.620 --> 00:17:06.660
something that helped me as I got more familiar
00:17:06.660 --> 00:17:11.210
with how rounds and presentations worked. I could
00:17:11.210 --> 00:17:14.250
actually tailor here at UC, we use Epic. I could
00:17:14.250 --> 00:17:17.309
actually tailor some of the tabs in the morning.
00:17:17.470 --> 00:17:19.730
And this is a great question you can ask a senior
00:17:19.730 --> 00:17:24.849
or a fellow. You can ask how to organize your
00:17:24.849 --> 00:17:26.789
tabs so that when you're doing chart review,
00:17:26.910 --> 00:17:30.009
you can see vitals. We have this great tab called
00:17:30.009 --> 00:17:33.289
the comp and it shows drips, what they're running
00:17:33.289 --> 00:17:36.410
at. But again, sometimes those are not up to
00:17:36.410 --> 00:17:39.329
date. So it's good to go see in person and have
00:17:39.329 --> 00:17:42.480
an idea. Because then, again, that number may
00:17:42.480 --> 00:17:44.579
change by the time you're presenting the patient.
00:17:44.740 --> 00:17:48.519
So it sounds overwhelming because you want to
00:17:48.519 --> 00:17:51.480
stay as up to date as you can. But just remember,
00:17:51.740 --> 00:17:54.359
you know, there's multiple places where you can
00:17:54.359 --> 00:17:57.940
find information. And I think at the end of the
00:17:57.940 --> 00:18:02.019
day, if you have a concern or if you just don't
00:18:02.019 --> 00:18:04.759
know what to do, it's more than OK to ask, especially
00:18:04.759 --> 00:18:09.220
in your first days in the ICU. Let's talk a little
00:18:09.220 --> 00:18:14.059
bit about this FAST -HUGS BID mnemonic. I think
00:18:14.059 --> 00:18:18.160
knowing what to look for, you talked about your
00:18:18.160 --> 00:18:20.359
approach to the physical exam, seeing the patient
00:18:20.359 --> 00:18:23.039
for the first time, pre -charting. Let's talk
00:18:23.039 --> 00:18:25.880
about maybe why some of these things are important
00:18:25.880 --> 00:18:27.779
and what's going to come up, what you may get
00:18:27.779 --> 00:18:30.079
questions about when you're presenting on rounds.
00:18:31.059 --> 00:18:35.259
For FAST, the first letter is F for feeding and
00:18:35.259 --> 00:18:41.140
fluids. We typically want our patients to eat
00:18:41.140 --> 00:18:45.299
by mouth. We don't want them to be getting TPN.
00:18:45.940 --> 00:18:49.319
Ideally, the sooner they're able to eat by mouth,
00:18:49.359 --> 00:18:51.700
the better. Sometimes that means an NG tube.
00:18:52.019 --> 00:18:57.059
And then as far as fluids, they may need maintenance
00:18:57.059 --> 00:19:01.440
fluids. But also in the cardiac ICU, these are
00:19:01.440 --> 00:19:04.079
patients that may struggle with volume overload.
00:19:04.240 --> 00:19:07.230
So you want to opt for volume overload. Any thoughts
00:19:07.230 --> 00:19:11.609
on feeding fluids? You're absolutely right. Early
00:19:11.609 --> 00:19:15.789
enteral feeding is shown to have mortality benefit
00:19:15.789 --> 00:19:18.789
in the ICU. So we really want to provide, even
00:19:18.789 --> 00:19:20.869
our sick patients, there's evidence to show that
00:19:20.869 --> 00:19:26.049
they have benefit from getting nutrition. I think
00:19:26.049 --> 00:19:29.529
a very key point to kind of tack on to the nutrition
00:19:29.529 --> 00:19:37.269
piece is your access for nutrition. because NGs
00:19:37.269 --> 00:19:42.309
don't just get magically placed. So even if,
00:19:42.329 --> 00:19:44.630
you know, they're coming in flaming hot, they're
00:19:44.630 --> 00:19:47.630
really sick, there's a lot going on, you have
00:19:47.630 --> 00:19:50.809
to think about, we want to feed them eventually.
00:19:52.349 --> 00:19:56.029
So we should probably set things in motion to
00:19:56.029 --> 00:19:58.890
set them up for that. So thinking about your
00:19:58.890 --> 00:20:02.299
access for nutrition is important. And you're
00:20:02.299 --> 00:20:04.759
absolutely right with the fluids. Volume status
00:20:04.759 --> 00:20:07.079
is going to be one of the first things you talk
00:20:07.079 --> 00:20:09.839
about for almost all of these patients. And how
00:20:09.839 --> 00:20:14.299
you assess that is definitely a learning curve
00:20:14.299 --> 00:20:18.099
because you're going to have your exams, you're
00:20:18.099 --> 00:20:20.799
going to have invasive devices that help show
00:20:20.799 --> 00:20:23.400
you kind of what central pressures are. And everybody
00:20:23.400 --> 00:20:25.440
has kind of a different approach to how they
00:20:25.440 --> 00:20:28.289
systematically walk through that. But you will
00:20:28.289 --> 00:20:32.190
certainly be asked about volume and what you
00:20:32.190 --> 00:20:34.269
want to do with those patients. And it is a very
00:20:34.269 --> 00:20:37.789
important part of their care and recovery. Yeah.
00:20:38.509 --> 00:20:42.190
Okay, let's move on. The next letter is A for
00:20:42.190 --> 00:20:46.809
analgesia. How do we assess pain in the ICU?
00:20:47.130 --> 00:20:50.349
Some of these patients are intubated. What's
00:20:50.349 --> 00:20:54.089
going on? How's the patient feeling? There are
00:20:54.089 --> 00:20:56.170
standardized scores that our ICU nurses will
00:20:56.170 --> 00:21:00.230
have. Typically for our intubated sedated patients,
00:21:00.390 --> 00:21:03.589
we like to keep them comfortable. So they keep
00:21:03.589 --> 00:21:05.990
all of the lines and things and tubes where they
00:21:05.990 --> 00:21:09.369
need to be. So you'll typically see things like
00:21:09.369 --> 00:21:12.690
your CPOT scores, your RAS scores for sedation.
00:21:16.119 --> 00:21:18.200
If you just look up what the tools are and what
00:21:18.200 --> 00:21:20.740
kind of comprises them, it's a helpful way to
00:21:20.740 --> 00:21:22.940
understand what the ICU nurses are evaluating
00:21:22.940 --> 00:21:27.039
and kind of help direct whether they need more
00:21:27.039 --> 00:21:30.920
sedation, less sedation, because ultimately you
00:21:30.920 --> 00:21:33.160
want to keep them in a place where you can also
00:21:33.160 --> 00:21:36.119
wean that to get an appropriate neuro exam, to
00:21:36.119 --> 00:21:39.059
do appropriate spontaneous awake trials, see
00:21:39.059 --> 00:21:41.619
how they do with SPTs and things like that. Awesome.
00:21:41.680 --> 00:21:43.640
And you already alluded to the next letter, which
00:21:43.640 --> 00:21:48.440
is sedation. Yeah, the RAS score, the CPOT, those
00:21:48.440 --> 00:21:50.619
are also things that you can find in the chart.
00:21:50.980 --> 00:21:55.339
Typically, the nurse will be updating that throughout
00:21:55.339 --> 00:21:59.039
their shift. So you can see if things are getting
00:21:59.039 --> 00:22:00.980
progressively better, things are getting progressively
00:22:00.980 --> 00:22:04.980
worse. So you know, do we need to adjust this
00:22:04.980 --> 00:22:08.200
person's sedation? Do we need to adjust this
00:22:08.200 --> 00:22:12.079
person's pain? We've been talking about the RAS
00:22:12.079 --> 00:22:15.460
score. So the RAS score is the Richmond Agitation
00:22:15.460 --> 00:22:20.380
Sedation Scale. It basically is just a subjective
00:22:20.380 --> 00:22:24.559
measure of a patient's awakeness or sedation
00:22:24.559 --> 00:22:29.279
going from super combative, which is up in like
00:22:29.279 --> 00:22:33.339
the plus four range, all the way to they're unarousable,
00:22:33.480 --> 00:22:37.680
which would be a negative four or five with kind
00:22:37.680 --> 00:22:41.380
of neutral being your zero. Okay. So we're typically...
00:22:42.000 --> 00:22:44.940
shooting for like a negative one to zero, which
00:22:44.940 --> 00:22:48.839
is comfortable, but also arousable. You can get
00:22:48.839 --> 00:22:51.660
them to maybe move in extremities like that.
00:22:51.960 --> 00:22:55.339
Yes. But it also depends on the patient, which
00:22:55.339 --> 00:22:57.680
is going to be the answer to almost every patient
00:22:57.680 --> 00:23:00.740
in the ICU. But if you have a patient with really,
00:23:00.839 --> 00:23:03.279
really sick lungs and you're having trouble ventilating
00:23:03.279 --> 00:23:08.019
them and they're on like a infusion of a paralytic,
00:23:08.099 --> 00:23:10.539
for example, their RAS score is going to be much,
00:23:10.559 --> 00:23:13.150
much deeper. because you don't want them arousable
00:23:13.150 --> 00:23:16.329
and paralyzed right the next letter is going
00:23:16.329 --> 00:23:21.009
to be t for thromboprophylaxis obviously very
00:23:21.009 --> 00:23:24.289
important for us to prevent blood clots but also
00:23:24.289 --> 00:23:26.630
something to consider when you're thinking about
00:23:26.630 --> 00:23:29.890
anticoagulation is the bleeding risk and some
00:23:29.890 --> 00:23:33.819
of these patients have just had surgery and They
00:23:33.819 --> 00:23:36.799
may have sutures and wounds and things that could
00:23:36.799 --> 00:23:39.539
possibly bleed. So that's an important consideration.
00:23:39.720 --> 00:23:43.039
But again, they're not moving. We need to make
00:23:43.039 --> 00:23:45.180
sure that they're not throwing clots, things
00:23:45.180 --> 00:23:49.859
like that. Yeah. What I'll add for this bit is
00:23:49.859 --> 00:23:52.859
a lot of our post -surgical cardiac patients
00:23:52.859 --> 00:23:56.160
specifically, a lot of our anticoagulation is
00:23:56.160 --> 00:23:59.319
going to be a very cooperative discussion between
00:23:59.319 --> 00:24:03.539
us and the cardiac surgery team. And they will
00:24:03.539 --> 00:24:06.819
have opinions, rightfully so, for when it's safe
00:24:06.819 --> 00:24:09.539
and appropriate because there's a very, very
00:24:09.539 --> 00:24:11.579
important risk -benefit conversation specifically
00:24:11.579 --> 00:24:16.539
for those patients. H is the next letter on this
00:24:16.539 --> 00:24:20.160
fast hugs mnemonic. H is for head of bed elevation.
00:24:20.559 --> 00:24:23.980
Why do we want the head of the bed to be a little
00:24:23.980 --> 00:24:26.119
bit elevated? And how, I mean, are we sitting
00:24:26.119 --> 00:24:29.180
these patients straight up or what are we doing
00:24:29.180 --> 00:24:31.180
with the head of the bed? They tend to be at
00:24:31.180 --> 00:24:36.259
about 30 degrees -ish as best we can, and it's
00:24:36.259 --> 00:24:39.140
all to protect lungs for the most part. We care
00:24:39.140 --> 00:24:42.599
very much about lungs in the ICU. It's one of
00:24:42.599 --> 00:24:48.519
our ways to prevent pneumonia and kind of help
00:24:48.519 --> 00:24:54.400
mitigate any reflex issues that we may have with
00:24:54.400 --> 00:24:58.599
our important airways. Which is a great segue
00:24:58.599 --> 00:25:01.839
into the next letter. U is for ulcer prophylaxis.
00:25:01.900 --> 00:25:05.259
We are constantly trying to keep patients from
00:25:05.259 --> 00:25:09.579
getting stomach ulcers, peptic ulcers. What are
00:25:09.579 --> 00:25:12.319
some of the risk factors for getting peptic ulcers?
00:25:12.559 --> 00:25:15.119
Why is it so important? One of the biggest things
00:25:15.119 --> 00:25:20.480
that we think of with our GI ulcer prophylaxis
00:25:20.480 --> 00:25:24.640
population, anybody who's mechanically ventilated
00:25:24.640 --> 00:25:28.200
is going to be high risk. So pretty much anybody
00:25:28.200 --> 00:25:32.220
who has an endotracheal tube will also have GI
00:25:32.220 --> 00:25:36.920
ulcer prophylaxis. Some institutions will have
00:25:36.920 --> 00:25:39.960
different policies as well, which is always going
00:25:39.960 --> 00:25:43.960
to be the case, especially in ICUs. Our cardiac
00:25:43.960 --> 00:25:47.700
surgery population, for example, will get GI
00:25:47.700 --> 00:25:50.539
ulcer prophylaxis even after they've been extubated.
00:25:51.519 --> 00:25:54.279
Um, for reasons that I won't necessarily get
00:25:54.279 --> 00:25:56.559
into, but, um, I've certainly been there and
00:25:56.559 --> 00:25:57.880
we're like, we're going through the checklist
00:25:57.880 --> 00:25:59.259
at the end of the presentation. I'm like, do
00:25:59.259 --> 00:26:01.779
they actually have an indication? Their indication
00:26:01.779 --> 00:26:04.000
is that they have cardiac surgery. Um, and I
00:26:04.000 --> 00:26:06.640
don't have a great explanation for that, uh,
00:26:06.740 --> 00:26:11.019
beyond they have their studies, uh, they have
00:26:11.019 --> 00:26:14.799
their reasons. Uh, so we, we keep them. My understanding
00:26:14.799 --> 00:26:18.319
is also being on steroids can increase your risk
00:26:18.319 --> 00:26:20.930
in a lot of these patients. again after surgery
00:26:20.930 --> 00:26:22.809
they may need to reduce inflammation so they
00:26:22.809 --> 00:26:26.029
may be on a steroid regimen what's great about
00:26:26.029 --> 00:26:30.170
the rounds just taking a pause here is that you'll
00:26:30.170 --> 00:26:33.670
have a pharmacist typically so they'll also be
00:26:33.670 --> 00:26:35.869
helping you you alluded to the checklist at the
00:26:35.869 --> 00:26:38.390
end of some of these presentations that's in
00:26:38.390 --> 00:26:41.470
our notes they'll help us know what medications
00:26:41.470 --> 00:26:45.559
are on know what the risk factors, why we may
00:26:45.559 --> 00:26:48.200
need to be on anticoagulation in the first place,
00:26:48.359 --> 00:26:51.039
whether or not that's indicated. They're very,
00:26:51.099 --> 00:26:52.819
very helpful. So if you have questions about
00:26:52.819 --> 00:26:56.720
what medications, what is indicated or not, they're
00:26:56.720 --> 00:26:59.640
constantly thinking about these things. Absolutely.
00:26:59.900 --> 00:27:02.720
Like I said earlier, it's a team sport up there,
00:27:02.799 --> 00:27:06.099
and you have so many helpful teammates beyond
00:27:06.099 --> 00:27:09.099
just your critical care team. You know, we have
00:27:09.099 --> 00:27:12.180
pharmacists, we have perfusionists and ECMO specialists,
00:27:12.339 --> 00:27:14.799
we have respiratory therapists, and your nurses
00:27:14.799 --> 00:27:16.980
are incredible. There's so many incredible resources
00:27:16.980 --> 00:27:20.039
to help you understand what's going on with patients
00:27:20.039 --> 00:27:22.180
and to help you think through kind of what they
00:27:22.180 --> 00:27:27.960
may need next. The next letter in our fast hugs
00:27:27.960 --> 00:27:32.220
BID mnemonic is glycemic control, which is G.
00:27:33.539 --> 00:27:37.720
What is our goal? glucose level in these patients?
00:27:39.140 --> 00:27:43.319
Typically, we like to keep them below 180. And
00:27:43.319 --> 00:27:47.500
our cardiac surgery patients specifically, there's
00:27:47.500 --> 00:27:49.920
evidence that within at least the first 24 hours,
00:27:50.180 --> 00:27:53.200
and I don't remember exactly, but having very
00:27:53.200 --> 00:27:55.599
tight glycemic control does improve outcomes
00:27:55.599 --> 00:27:59.819
for them. It kind of depends on the attending,
00:27:59.920 --> 00:28:03.619
but I'm a big fan of insulin infusions if they're
00:28:03.619 --> 00:28:07.160
needed. I think it's a very efficient way to
00:28:07.160 --> 00:28:09.440
keep people very tight and then can give you
00:28:09.440 --> 00:28:12.119
a very quick understanding of what their need
00:28:12.119 --> 00:28:15.180
is going to be to transition them off an infusion
00:28:15.180 --> 00:28:19.519
to long acting things. But for most people, below
00:28:19.519 --> 00:28:24.980
180 is the goal. And the ICU experience for the
00:28:24.980 --> 00:28:27.799
human body is stressful. So you will see some
00:28:27.799 --> 00:28:29.480
hyperglycemia just in the setting of stress.
00:28:29.859 --> 00:28:33.490
There was one. trial that I think gets brought
00:28:33.490 --> 00:28:35.809
up over and over again so you can earn brownie
00:28:35.809 --> 00:28:38.950
points with your attending is the NICE sugar
00:28:38.950 --> 00:28:41.509
trial. So that's a good one to look up. That's
00:28:41.509 --> 00:28:45.950
where some of this data has been. That's where
00:28:45.950 --> 00:28:49.750
some of this data comes from. And it's just a
00:28:49.750 --> 00:28:52.990
great resource when you're giving your presentations
00:28:52.990 --> 00:28:59.390
to maybe cite one of these. When you're giving
00:28:59.390 --> 00:29:03.369
your presentation, it's helpful to give your
00:29:03.369 --> 00:29:07.329
citations it may be helpful to get brownie points
00:29:07.329 --> 00:29:11.349
the next letter is s for spontaneous awakening
00:29:11.349 --> 00:29:15.390
trial and spontaneous breathing trial um we need
00:29:15.390 --> 00:29:17.230
to wake these patients up they need to get out
00:29:17.230 --> 00:29:20.470
of the icu at some point so this is this seems
00:29:20.470 --> 00:29:23.750
a little bit like an art almost because we want
00:29:23.750 --> 00:29:26.869
the patient to be comfortable but we also want
00:29:26.869 --> 00:29:28.829
to make sure that they're heading in the right
00:29:28.829 --> 00:29:30.390
direction, that they can wake up, that they're
00:29:30.390 --> 00:29:33.049
able to breathe on their own at some point. Tell
00:29:33.049 --> 00:29:36.670
me a little bit about what constitutes a spontaneous
00:29:36.670 --> 00:29:39.049
awakening trial or a spontaneous breathing trial.
00:29:39.269 --> 00:29:42.150
Sure. And this could certainly be its own series
00:29:42.150 --> 00:29:45.990
of lectures. It absolutely is an art. Most importantly,
00:29:46.130 --> 00:29:48.890
coordinating these two things together, I think,
00:29:48.890 --> 00:29:52.789
is really important. A patient will likely fail
00:29:52.789 --> 00:29:55.890
a spontaneous breathing trial if they're sedated
00:29:55.890 --> 00:30:02.109
to Mars. Um, and similarly, uh, you know, it's
00:30:02.109 --> 00:30:05.750
not exactly comfortable to have an endotracheal
00:30:05.750 --> 00:30:08.950
tubing. Um, so if you're not trying to put them
00:30:08.950 --> 00:30:10.750
on some kind of pressure support mode through
00:30:10.750 --> 00:30:13.650
a breathing trial while you're weaning sedation,
00:30:13.750 --> 00:30:15.670
that can also be really uncomfortable and you're
00:30:15.670 --> 00:30:18.609
more likely to fail. Um, cause I would probably
00:30:18.609 --> 00:30:24.829
freak out. Um, so understanding kind of the dance
00:30:24.829 --> 00:30:27.250
of those two things happening together and understanding
00:30:27.250 --> 00:30:32.210
the time it takes for sedation to be formally
00:30:32.210 --> 00:30:36.269
weaned. A lot of these patients are on some kind
00:30:36.269 --> 00:30:40.170
of combination of propofol, fentanyl, etc. So
00:30:40.170 --> 00:30:43.349
making sure you're giving them a fair shot at
00:30:43.349 --> 00:30:46.789
properly waking up, but also maybe layering medicines
00:30:46.789 --> 00:30:50.529
like we use Presidex sometimes to kind of smooth
00:30:50.529 --> 00:30:55.140
the process of keeping them chill, but awake
00:30:55.140 --> 00:30:57.880
enough to get an appropriate neuro exam, to feel
00:30:57.880 --> 00:30:59.460
like you have a good understanding of if they
00:30:59.460 --> 00:31:01.759
could properly protect their airway without an
00:31:01.759 --> 00:31:04.319
endotracheal tube. Coordinating those things
00:31:04.319 --> 00:31:07.319
is certainly an art, but working with your respiratory
00:31:07.319 --> 00:31:09.980
therapists and the members of your team who are
00:31:09.980 --> 00:31:12.599
very familiar with this process is going to be
00:31:12.599 --> 00:31:15.819
the best thing that you can do to help understand
00:31:15.819 --> 00:31:20.000
this process. And ultimately, Even if you're
00:31:20.000 --> 00:31:21.460
like, there's no way we're going to extubate
00:31:21.460 --> 00:31:24.180
this person today, their lungs still want an
00:31:24.180 --> 00:31:27.859
SBT. It's still important to give them the chance
00:31:27.859 --> 00:31:30.059
to kind of exercise those muscles and to get
00:31:30.059 --> 00:31:32.660
stronger rather than just parking them on a vent
00:31:32.660 --> 00:31:34.500
and leaving them there. Because otherwise, you
00:31:34.500 --> 00:31:36.880
just don't have a good way to get them off. Right.
00:31:36.880 --> 00:31:39.339
And that, you know, leaving people intubated
00:31:39.339 --> 00:31:42.579
for longer periods of time predisposes them to
00:31:42.579 --> 00:31:45.619
a higher risk for pneumonia. All the things.
00:31:46.059 --> 00:31:52.500
Not good things. So, and now there's a difference
00:31:52.500 --> 00:31:56.220
between, is there a difference between spontaneous
00:31:56.220 --> 00:31:59.640
breathing trial and fast track extubation? Because
00:31:59.640 --> 00:32:02.720
that was something that came up even in my first
00:32:02.720 --> 00:32:07.480
day. Sure. And fast track extubation may be a
00:32:07.480 --> 00:32:10.680
Cincinnati specific term, I'm unsure, but typically
00:32:10.680 --> 00:32:15.920
we refer to our patients who did pretty well
00:32:15.920 --> 00:32:19.480
post cardiac surgery. We think we can probably
00:32:19.480 --> 00:32:24.299
get successfully extubated post -surgery. Most
00:32:24.299 --> 00:32:27.000
of our cardiac patients, with a select few exceptions,
00:32:27.259 --> 00:32:30.579
will come to the ICU still intubated. But if
00:32:30.579 --> 00:32:32.900
we feel like they'll be able to be extubated
00:32:32.900 --> 00:32:36.000
within, I think it's four or six, maybe six to
00:32:36.000 --> 00:32:40.119
eight hours, they can qualify for what we call
00:32:40.119 --> 00:32:44.880
fast track extubation, which is kind of... escalating
00:32:44.880 --> 00:32:47.920
the process of getting them weaned off sedation,
00:32:48.099 --> 00:32:51.200
getting them to a point where they could complete
00:32:51.200 --> 00:32:54.259
a spontaneous breeding trial. And there's a very
00:32:54.259 --> 00:32:56.420
specific protocol that our respiratory therapists
00:32:56.420 --> 00:33:00.039
will run. So we're less involved with that than
00:33:00.039 --> 00:33:03.400
what we are in the OR, because we kind of do
00:33:03.400 --> 00:33:08.319
our own SBT, air quotes, in the OR before we
00:33:08.319 --> 00:33:10.660
extubate people. But it's much more formal in
00:33:10.660 --> 00:33:15.829
the ICU. So they have to do the 30 -minute trial,
00:33:15.970 --> 00:33:19.910
make sure they can ventilate and oxygenate appropriately
00:33:19.910 --> 00:33:23.450
before extubating. Very cool. I remember watching
00:33:23.450 --> 00:33:27.970
this process happen, and the nurse is there kind
00:33:27.970 --> 00:33:30.309
of monitoring how the patient's doing. The respiratory
00:33:30.309 --> 00:33:32.950
therapist is in and out of the room. They may
00:33:32.950 --> 00:33:36.509
be running one or two spontaneous breathing trials
00:33:36.509 --> 00:33:39.529
at the same time. But as you mentioned, it's
00:33:39.529 --> 00:33:42.170
a time intensive process. They want to make sure
00:33:42.170 --> 00:33:44.470
that it's safe before they're pulling the tube.
00:33:44.690 --> 00:33:46.509
Absolutely. And sometimes family's in the room
00:33:46.509 --> 00:33:50.410
too. So I've gotten in the process of if I'm
00:33:50.410 --> 00:33:52.470
popping in and there's family there, I'll talk
00:33:52.470 --> 00:33:54.950
them through what we're doing as well. Because
00:33:54.950 --> 00:33:58.430
it can be pretty alarming maybe isn't the right
00:33:58.430 --> 00:34:01.349
word. Definitely jarring to watch somebody trying
00:34:01.349 --> 00:34:05.670
to breathe off with assistance and then trying
00:34:05.670 --> 00:34:09.079
to wean off of it. Yeah. So trying to, you know,
00:34:09.079 --> 00:34:12.199
set expectations both for the patient and for
00:34:12.199 --> 00:34:14.860
their family, I think is, I mean, it's a helpful
00:34:14.860 --> 00:34:17.119
lesson in the ICU in general, but specifically
00:34:17.119 --> 00:34:22.579
having family watch an SBT for sure. The last
00:34:22.579 --> 00:34:26.480
three letters are BID. The B is for bowel regimen.
00:34:26.519 --> 00:34:31.500
Obviously good to keep people regular. And making
00:34:31.500 --> 00:34:34.059
sure that when they're on medications, these
00:34:34.059 --> 00:34:37.019
opioids, things that can slow down their gut
00:34:37.019 --> 00:34:39.780
motility, you know, think about anticholinergics
00:34:39.780 --> 00:34:43.619
as well. Just making sure that that's not causing
00:34:43.619 --> 00:34:45.340
issues as well, because that can get you into
00:34:45.340 --> 00:34:47.880
a lot of trouble in the ICU when patients aren't
00:34:47.880 --> 00:34:51.219
able to get up, move, exercise, and keep themselves
00:34:51.219 --> 00:34:53.460
regular. Absolutely. And it swings the other
00:34:53.460 --> 00:34:56.760
direction too. If they're going too much, you
00:34:56.760 --> 00:34:59.139
can miss things like if they're high risk for
00:35:01.019 --> 00:35:03.579
C. diff or things like that. You have to kind
00:35:03.579 --> 00:35:08.360
of keep a tally on those things as well. I is
00:35:08.360 --> 00:35:12.619
for indwelling catheters. What can you tell me,
00:35:12.639 --> 00:35:15.019
what kind of catheters are we talking about?
00:35:15.159 --> 00:35:17.679
Are we just talking about Foley catheters or
00:35:17.679 --> 00:35:19.980
are there other types of catheters that we need
00:35:19.980 --> 00:35:24.019
to be addressing every day? There's so many lines
00:35:24.019 --> 00:35:27.460
that you see in the ICU. And that part can certainly
00:35:27.460 --> 00:35:29.639
be overwhelming at first. You're going to have
00:35:29.639 --> 00:35:33.059
vascular access lines. You're going to have Foley
00:35:33.059 --> 00:35:34.639
catheters. You're going to have endotracheal
00:35:34.639 --> 00:35:37.940
tubes. And you should be evaluating any invasive
00:35:37.940 --> 00:35:42.139
line every single day. They have more stringent
00:35:42.139 --> 00:35:46.849
rules on how long we like to keep lines in. So
00:35:46.849 --> 00:35:49.010
you have to review when things were placed, how
00:35:49.010 --> 00:35:50.750
long they've been there, if they really need
00:35:50.750 --> 00:35:54.030
them. We try and take as many tubes out as possible
00:35:54.030 --> 00:35:57.670
to normalize patients, reduce the risk for delirium,
00:35:57.809 --> 00:36:00.929
and then ultimately trying to normalize these
00:36:00.929 --> 00:36:03.130
patients as quickly as possible to get them out
00:36:03.130 --> 00:36:05.969
of the ICU. But you're going to be evaluating
00:36:05.969 --> 00:36:09.610
central lines, whether they're supposed to be
00:36:09.610 --> 00:36:14.289
for continuous renal replacement or pressors.
00:36:14.969 --> 00:36:19.289
If they have an invasive PA catheter, colloquially
00:36:19.289 --> 00:36:22.010
known as SWANs. We love SWANs here at UC, but
00:36:22.010 --> 00:36:25.610
that's an institution to institution thing. So
00:36:25.610 --> 00:36:28.710
whether you really need that invasive monitoring
00:36:28.710 --> 00:36:30.730
is a question we should be asking every day.
00:36:31.469 --> 00:36:35.530
Similar with arterial lines and then making sure
00:36:35.530 --> 00:36:38.510
you have enough vascular access as well. All
00:36:38.510 --> 00:36:39.949
of those are things that you should be going
00:36:39.949 --> 00:36:44.090
through every single day to try and, you know.
00:36:44.539 --> 00:36:47.659
The more attached they are to things, the more
00:36:47.659 --> 00:36:49.980
likely they are to suffer from things like delirium
00:36:49.980 --> 00:36:52.699
and the longer they're going to stay in the ICU.
00:36:53.440 --> 00:36:59.099
I remember walking into a post -cardiac surgery
00:36:59.099 --> 00:37:03.320
patient's room, seeing this tower with all of
00:37:03.320 --> 00:37:07.199
these pumps, all the infusions, all the lines
00:37:07.199 --> 00:37:11.610
going to the patient. If being in the OR and
00:37:11.610 --> 00:37:14.489
having to learn all of the cord organization
00:37:14.489 --> 00:37:18.489
isn't overwhelming enough, you're in the ICU
00:37:18.489 --> 00:37:21.590
setting and so many of these drips are very important.
00:37:21.889 --> 00:37:25.889
But as you said, getting out of the ICU is a
00:37:25.889 --> 00:37:29.230
goal that every patient has. And we want to figure
00:37:29.230 --> 00:37:32.690
out how we get them detached from the machines
00:37:32.690 --> 00:37:35.230
and the pumps and the medications and all those
00:37:35.230 --> 00:37:37.309
different things. Yeah. And I will certainly
00:37:37.309 --> 00:37:41.400
add for... All of those things, I don't think
00:37:41.400 --> 00:37:43.900
I got there at the end of my intern year. But
00:37:43.900 --> 00:37:46.800
after I did my month of cardiac, I was much more
00:37:46.800 --> 00:37:48.860
comfortable with the infusions that were running,
00:37:49.019 --> 00:37:52.219
the kind of access that you have, and why you
00:37:52.219 --> 00:37:54.940
need it. A lot of that didn't really click until
00:37:54.940 --> 00:37:58.340
after I was the one doing the cardiac case. And
00:37:58.340 --> 00:37:59.960
conveniently, with the way my schedule worked,
00:38:00.079 --> 00:38:02.460
I went straight from cardiac into my next round
00:38:02.460 --> 00:38:05.639
of CCAN. So I kind of got to see the full picture,
00:38:05.780 --> 00:38:07.800
which was a hard two months, but a very, very
00:38:07.800 --> 00:38:11.260
good two months to really understand what are
00:38:11.260 --> 00:38:13.280
we doing for these patients? Why do we have the
00:38:13.280 --> 00:38:15.940
access that we have? What infusions are we running
00:38:15.940 --> 00:38:19.699
for? Why? All of that clicked much more later
00:38:19.699 --> 00:38:21.880
in training. So if you don't get it all as an
00:38:21.880 --> 00:38:25.380
intern, that is very normal. That's reassuring.
00:38:25.579 --> 00:38:30.500
I think one thing just on the note about lines,
00:38:30.800 --> 00:38:34.630
sometimes these lines can... go bad or they stop
00:38:34.630 --> 00:38:38.670
working you know you'll hear things like oh this
00:38:38.670 --> 00:38:42.230
a -line is over dampened or under dampened those
00:38:42.230 --> 00:38:45.050
are things that you know it takes time to understand
00:38:45.050 --> 00:38:48.150
a little bit more i will say you know this is
00:38:48.150 --> 00:38:50.570
a good opportunity to mention there's procedures
00:38:50.570 --> 00:38:54.050
that you can do in the icu occasionally so certainly
00:38:54.050 --> 00:38:56.809
during rounds when you're talking about reevaluating
00:38:56.809 --> 00:38:59.550
lines you may hear somebody say hey this person
00:38:59.550 --> 00:39:02.139
actually needs a new a -line because this one
00:39:02.139 --> 00:39:04.619
isn't working as well. That may be an opportunity
00:39:04.619 --> 00:39:08.579
for you to do a procedure. Do you have any comments
00:39:08.579 --> 00:39:11.840
or thoughts about doing lines, doing your first
00:39:11.840 --> 00:39:14.650
line, things like that? Our fellows are awesome.
00:39:14.829 --> 00:39:16.449
They're typically going to be the ones that are
00:39:16.449 --> 00:39:18.929
walking you through it. It's very different doing
00:39:18.929 --> 00:39:22.289
lines in the ICU than the OR. The procedure is
00:39:22.289 --> 00:39:24.429
the same, but it just feels very different. I
00:39:24.429 --> 00:39:27.929
don't have a good explanation for why. And patients
00:39:27.929 --> 00:39:30.789
are just sicker in the ICU than typically what
00:39:30.789 --> 00:39:34.070
we'll find in the OR, I feel, or at least they've
00:39:34.070 --> 00:39:36.349
had attempts at access. So the access itself
00:39:36.349 --> 00:39:38.829
may be more difficult. So cut yourself some slack
00:39:38.829 --> 00:39:43.230
if it doesn't go super well. If it's an A -line
00:39:43.230 --> 00:39:45.269
that people have had trouble with, it's also
00:39:45.269 --> 00:39:47.730
okay if you struggle at first, but we're all
00:39:47.730 --> 00:39:51.809
there to learn. So always asking for help, being
00:39:51.809 --> 00:39:54.869
very proactive in asking to do things is only
00:39:54.869 --> 00:39:57.949
going to do you good. Being an enthusiastic learner
00:39:57.949 --> 00:40:02.409
is how you learn quickly. So I would certainly
00:40:02.409 --> 00:40:05.110
emphasize that. This is the kind of rotation,
00:40:05.269 --> 00:40:08.329
as with any rotation, the more you put into it,
00:40:08.369 --> 00:40:10.690
the more you show up and want to learn and want
00:40:10.690 --> 00:40:13.050
to do things, the more you're going to get out
00:40:13.050 --> 00:40:14.710
of it. And the better physician you're going
00:40:14.710 --> 00:40:17.809
to end up being. So things like arterial lines,
00:40:17.909 --> 00:40:22.210
central lines. Intubations, typically, we won't
00:40:22.210 --> 00:40:25.110
really participate in just because the fellows
00:40:25.110 --> 00:40:28.349
will typically do that here. And truthfully,
00:40:28.389 --> 00:40:31.050
we get plenty of them in the OR that I don't
00:40:31.050 --> 00:40:33.769
feel that's a place you need to take your energy.
00:40:34.409 --> 00:40:36.829
But I did get to do my first brunk in the ICU
00:40:36.829 --> 00:40:42.250
as an intern on a healthy patient, which felt
00:40:42.250 --> 00:40:44.309
really cool at the time. And now that we're a
00:40:44.309 --> 00:40:48.550
little bit deeper, it's not quite as novel. You
00:40:48.550 --> 00:40:51.369
certainly get exposure to all of those things,
00:40:51.449 --> 00:40:53.769
not quite in the volume that you get down in
00:40:53.769 --> 00:40:56.849
the OR, but it's nice to see how things are done
00:40:56.849 --> 00:40:59.889
a little bit differently. I was really impressed
00:40:59.889 --> 00:41:03.989
and grateful that so many of the specialists,
00:41:04.230 --> 00:41:07.110
the respiratory therapist, the perfusionist,
00:41:07.230 --> 00:41:09.010
you know, if you want to learn a little bit more
00:41:09.010 --> 00:41:13.039
about how a ventilator works. and you're watching
00:41:13.039 --> 00:41:15.639
how things get set up before a patient gets intubated.
00:41:15.719 --> 00:41:17.539
You see the respiratory therapist bring all that
00:41:17.539 --> 00:41:20.059
equipment in. It's great to maybe spend some
00:41:20.059 --> 00:41:21.860
time talking to the respiratory therapist how
00:41:21.860 --> 00:41:25.639
things work. I actually remember doing a learning,
00:41:25.860 --> 00:41:28.679
like a lecture with one of the respiratory therapists.
00:41:29.000 --> 00:41:30.820
And this may be an opportunity for you where
00:41:30.820 --> 00:41:34.460
you actually get to feel what it's like for that
00:41:34.460 --> 00:41:39.239
mechanical ventilator to be blowing air into
00:41:39.239 --> 00:41:42.840
your body. and just how uncomfortable that can
00:41:42.840 --> 00:41:44.820
be. And then, you know, if you want to learn
00:41:44.820 --> 00:41:46.960
more about ECMO, there's perfusionists. They
00:41:46.960 --> 00:41:49.780
can tell you how the machine works. It's just
00:41:49.780 --> 00:41:53.659
really great that the ICU has people that are
00:41:53.659 --> 00:41:57.420
willing to teach. And as you said, you know,
00:41:57.420 --> 00:42:00.940
being open to education, asking questions, you're
00:42:00.940 --> 00:42:03.619
going to pick up a lot during this rotation.
00:42:04.380 --> 00:42:08.719
Absolutely. The intensive care unit is a very
00:42:08.719 --> 00:42:11.380
overwhelming place. But you're not there alone.
00:42:12.239 --> 00:42:14.619
And that's, you know, if you hear nothing else,
00:42:14.719 --> 00:42:17.320
that's what I want people to really take home
00:42:17.320 --> 00:42:20.079
is you're not taking care of this patient alone.
00:42:20.260 --> 00:42:23.199
You're on a team that's working with other teams,
00:42:23.280 --> 00:42:25.699
that's working with a whole set of professionals
00:42:25.699 --> 00:42:29.760
within the ICU. So you're certainly not alone.
00:42:30.360 --> 00:42:33.099
And there's plenty of help should you need it.
00:42:33.320 --> 00:42:36.019
And asking questions is going to be the best
00:42:36.019 --> 00:42:38.579
way that you figure those things out. So always
00:42:38.579 --> 00:42:42.179
communicating. What you know, what you don't
00:42:42.179 --> 00:42:45.679
know, asking questions. That's all we really
00:42:45.679 --> 00:42:48.539
need from you, especially as an intern. That's
00:42:48.539 --> 00:42:52.559
really helpful. We didn't get to talk a ton about
00:42:52.559 --> 00:42:55.480
D, but in a way we actually did. We talked about
00:42:55.480 --> 00:42:57.780
de -escalation. There's all kinds of things that
00:42:57.780 --> 00:43:00.659
we de -escalate. The other D being delirium.
00:43:00.679 --> 00:43:02.980
You alluded to that as well and some strategies
00:43:02.980 --> 00:43:08.019
to mitigate in -hospital delirium, keeping patients.
00:43:08.699 --> 00:43:13.639
um safe keeping them alert and and liberating
00:43:13.639 --> 00:43:17.460
them from the icu and i want to thank you so
00:43:17.460 --> 00:43:21.500
much for this conversation i love the passion
00:43:21.500 --> 00:43:24.340
that you bring to critical care and i really
00:43:24.340 --> 00:43:28.360
appreciate you taking time to help you know this
00:43:28.360 --> 00:43:31.260
next set of interns get oriented to the unit
00:43:31.260 --> 00:43:34.159
um any other pearls that you wanted to share
00:43:34.159 --> 00:43:41.409
i'd probably just leave you with uh My most consistent
00:43:41.409 --> 00:43:44.070
piece of advice, and this baby applies outside
00:43:44.070 --> 00:43:48.250
of the ICU as well, but honestly, communicating
00:43:48.250 --> 00:43:54.429
with everyone is what is going to keep patients
00:43:54.429 --> 00:44:00.010
safe. Being very honest about what you think
00:44:00.010 --> 00:44:02.750
is going on and talking through your thought
00:44:02.750 --> 00:44:06.550
process is going to help both your team and...
00:44:07.230 --> 00:44:09.289
the rest of the care team. So I've certainly
00:44:09.289 --> 00:44:12.489
been in situations where, you know, a nurse has
00:44:12.489 --> 00:44:15.409
a huge concern. I don't share the concern, but
00:44:15.409 --> 00:44:20.230
if you talk through it and be honest about kind
00:44:20.230 --> 00:44:23.050
of where you're at, what you're thinking, oftentimes
00:44:23.050 --> 00:44:26.010
you can diffuse all sorts of tension within the
00:44:26.010 --> 00:44:32.170
unit and getting help is easy. But you have to
00:44:32.170 --> 00:44:35.650
ask for it. Those are some great style points,
00:44:35.750 --> 00:44:39.449
Anne. Really appreciate that. I'll leave you
00:44:39.449 --> 00:44:41.849
with a couple of references that I found helpful
00:44:41.849 --> 00:44:45.309
as well. Obviously, this Style Points podcast,
00:44:45.690 --> 00:44:49.630
we have other episodes. There's one with Dr.
00:44:49.809 --> 00:44:52.949
Zadie, who is an ECMO specialist. So I would
00:44:52.949 --> 00:44:55.329
recommend listening to that episode if you want
00:44:55.329 --> 00:44:57.610
to learn a little bit more about how ECMO works,
00:44:57.809 --> 00:44:59.929
what kind of patients are on ECMO, because you'll
00:44:59.929 --> 00:45:02.710
for sure see one or two during your month in
00:45:02.710 --> 00:45:07.280
the CVICU. There's also a great lecture from
00:45:07.280 --> 00:45:10.179
Dr. Jones about liver transplant, because you
00:45:10.179 --> 00:45:12.719
may see some liver transplant patients in the
00:45:12.719 --> 00:45:17.039
ICU as well. Outside of this podcast, there is
00:45:17.039 --> 00:45:20.780
ACRAC, the Anesthesia and Critical Care Reviews
00:45:20.780 --> 00:45:24.179
and Commentary podcast by Jed Wolpaw. He has
00:45:24.179 --> 00:45:27.940
a couple of great episodes. There's one on ERAS,
00:45:27.940 --> 00:45:31.039
or Enhanced Recovery After Surgery, for cardiac
00:45:31.039 --> 00:45:36.190
surgery patients. And I would just use the search
00:45:36.190 --> 00:45:40.150
bar to find those episodes. But if you have questions,
00:45:40.289 --> 00:45:43.010
as you mentioned, Anne, there's all sorts of
00:45:43.010 --> 00:45:45.369
resources. You'll be getting emails, I'm sure,
00:45:45.409 --> 00:45:47.869
before these rotations start. So never fear.
00:45:48.710 --> 00:45:51.590
There's more information to come, always. Yeah.
00:45:51.610 --> 00:45:53.889
Thanks again. Of course. I'd probably tack on
00:45:53.889 --> 00:45:56.730
the ICU one -pagers to the references. Oh, yes.
00:45:57.090 --> 00:45:59.449
There's one for like almost everything. And they're
00:45:59.449 --> 00:46:03.219
super helpful from ECMO, Impella's. Ventilators.
00:46:03.219 --> 00:46:06.760
Yes. Even just evaluation of shock. They're all
00:46:06.760 --> 00:46:09.440
super helpful. I would highly recommend. ICU
00:46:09.440 --> 00:46:14.219
one pagers. Good tip. That's it for this month's
00:46:14.219 --> 00:46:16.820
episode of Style Points. Thanks to John and Anne
00:46:16.820 --> 00:46:18.880
for putting it together. They did a great job
00:46:18.880 --> 00:46:21.139
of running through a lot of the basics. Something
00:46:21.139 --> 00:46:22.780
like this would have definitely been helpful
00:46:22.780 --> 00:46:26.239
to me when I was starting in the ICU. If you're
00:46:26.239 --> 00:46:28.519
a fan of the show. please consider giving us
00:46:28.519 --> 00:46:31.079
a five -star rating or review, or just tell your
00:46:31.079 --> 00:46:33.500
friends about the podcast. If you want to email
00:46:33.500 --> 00:46:36.360
us, please reach out at stylepointspodcast at
00:46:36.360 --> 00:46:40.079
gmail .com. Lastly, there's no way I was going
00:46:40.079 --> 00:46:42.300
to end the podcast without congratulating my
00:46:42.300 --> 00:46:44.980
NBA team, the Oklahoma City Thunder, on winning
00:46:44.980 --> 00:46:47.360
their first title in a hard -fought battle with
00:46:47.360 --> 00:46:50.619
the very respectable Indiana Pacers. I did my
00:46:50.619 --> 00:46:52.960
residency in Oklahoma City, and I've been a big
00:46:52.960 --> 00:46:56.809
fan ever since. Take a deep breath. Open your
00:46:56.809 --> 00:46:58.429
eyes. We're all done.