MICU Orientation

The very basics

The medical ICU is based out of the 9-North in the CCD. Rounds start at 7 AM
You will get your service signed out to you on the night before you start.
See “MICU MegaTeam Service Rules”

Intern’s guides to the MICU

See Intern’s Guide to the MICU which contains some duplicative information as below, but everything duplicated is worth reviewing twice

Presentation tips for MICU:

- Practice your presentations! Presenting a complex patient is a learnable skill. However, if you only do it on rounds, you will struggle to do it well. Practice with your resident, attending, fellow, etc. and ask for feedback. Listen to the other residents; what skills can you pick up from them?
- Start with the most important problem!
  - Are they in the unit for their stable heart failure or because of DKA? (The answer is probably DKA…so list DKA as their first problem! Chronic, stable problems should be listed last)
  - Give away the diagnosis if it is known. “Shortness of breath” should not be the presenting complaint if “hypoxic respiratory failure, ARDS, and septic shock” is known to be the most likely etiology.
- Efficiency is key. There are many complex patients, so avoid repeating extraneous data that was already presented (or is superfluous). Rounds will go faster, stay focused on the pertinent issues, and be a better learning experience.
  - 2 examples of extraneous information:
  - E.g. “… Endocrine: problem #1) Hypothyroidism: Well controlled. TSH pending. Continuing home dose of levothyroxine…”
    (These types of problems are not too important for their ICU stay!)
  - “In summary, this is a 68-y/o man with hypertension, tobacco abuse, and COPD presenting with fevers, chills, and a positive RVP for Parainfluneza presenting with ventilatory failure…”
    (Did you already go over all of this information in your presentation? Jump straight to the problem list.)
- ICU typically has system-based presentations with problems for each system**. Many attendings prefer to hear about the relevant physical exam, data, etc. within the context of each system followed by the plan:
  - ***All attendings are different, so ask if you have questions about the preferred style
    - E.g. “Cardiovascular system – Heart rate ranged from 90-120, BP from 80-110 / 40-60 on norepinephrine and vasopressin. The urine output picked up to 5.2 liters over the last 24 hrs, lactate has fallen from 7 to 3.2. There were no telemetry events. Physical exam was unchanged / showed… The plan is: #1) Septic shock – Likely due to pyelonephritis and complicated by hypovolemia. MAP is > 65 so we will turn off the vasopressin… (#2) Atrial fibrillation – Controlled on diltiazem drip. Transitioning to PO dilt today… Respiratory system: … Ventilator settings, vital signs, blood gas, chest x-ray…”
    - Look over the X-ray before rounds! (a) It is obvious when someone is looking at it for the first time and (b) you ordered it for a reason! Are the lines and tubes still in place? Is the edema better?
  - Make a plan and try not to focus on the numbers!
    - Things can change so quickly, and someone can look up the numbers more quickly than you can say them. It is better to have an understanding of the data than to have every last piece of it.
    - Example: Your patient is suffering from hyponatremia, hyperkalemia, gap acidosis, and acute kidney injury. It is better to know how you’re treating the K+, why the acidosis is present, and how you’re working up the AKI than to know the Na+ is 128, K+ is 5.9, etc.
    - If your patient doesn’t need daily/BID CBC, BMP, x-rays, etc, then don’t order them!!

MICU-specific Logistics

Supplies – Most supplies can be found in each ICU’s “Clean Supply” area. It is helpful to familiarize yourself with the location of common supplies so you can find them quickly when the time comes. Don’t be afraid to ask if you need help finding something! The unit RNs can help find things or the unit clerks can order from central supply if it isn’t available in the unit. Try to avoid “borrowing” from other units as they have to re-order to maintain their own stock. If crucial things are missing, let your attending and the unit clerk know so they can re-stock for the future. Refer to the Intern Guide for the supplies you will need for various procedures.
Who does what –
1. Pharmacists – Always present on rounds. A PharmD resident is also available by page overnight (6338) for urgent issues.
2. RNs – Has the most direct contact with the patient of anyone in the unit. Work closely with them to inquire about responses to therapy, inform them of the plan, alert them to big changes (e.g. procedures, road trips, etc.). In return, they’ll let you know about acute changes in the patient’s condition, etc. Respect each other and make an effort to get along with them; chances are they have more experience than you!
3. Respiratory Therapists – Usually one is assigned to each unit, but they’re available by page/phone (ask any RN an they can give you the #). They can help you with getting a ventilator, HFNC, or BiPAP
  troubleshooting a ventilator, delivering inhaled medications (bronchodilators, nitric oxide), etc.
4. Unit clerk – Can help you re-order supplies, get outside records, death packets, etc.
5. Research personnel – They usually won’t be there at night. But when they’re around, respect them the way you would anyone else in the hospital. They know to stay out of your way when things are getting crazy.
Backup / Supervision –
1. The NF intern is overseen by the Call resident and the NF resident. If both residents are occupied, contact the Bridge, MROC or other medicine housestaff (e.g. GENS resident) for help. They’re all here to take care of the patients!
2. You should feel comfortable contacting the MICU fellow and attending overnight. They need to know if there are major changes in the patients overnight or if you have questions on newly admitted patients. They can also help you troubleshoot some of the logistics of getting things done (e.g. how to get IR in the middle of the night for embolization of an unstable GI bleed.)
3. All Admissions / evaluations MUST BE RUN BY THE FELLOW! It is unacceptable and dangerous not to involve your supervising physicians in your evaluations. Don’t worry about waking them up overnight. They are on call and would rather hear about the patient from you now rather than be surprised that a new patient was admitted without them knowing about it! You may NOT reject a patient without talking to the fellow (and possibly the attending too).
Ultrasound – This is a useful and valuable tool. Please be careful and respectful of the MICU’s policies on its use. Do NOT lend it out for use outside of MICU patients!