July is just around the corner. For hospitals it’s a dynamic time. A changing of the guard. Graduating residents moving on and new interns, fresh out of medical school with their clean and crisp long white coats, moving in. Out with the old, in with the new. The ICU rotation for medicine residents and medical students is stressful under the best of circumstances but always an additional challenge early in July. I remember as a resident, trying to glean from my peers who had already completed their ICU rotation, picking their brains for tips and tricks on how to survive and succeed. But often what we are looking for is not what we need the most. Acid base disorders and ventilator management seemed so daunting. But in hindsight, learning how to manage and treat specific diseases and conditions was not the hard part. Learning how to survive, mentally and physically, the rigors of the ICU and growing as a physician were much bigger challenges.
- Start your day early. This is easy to do for your first week in the ICU when you are filled with all that nervous energy. But how about on day #22, when you are desperate for an extra five minutes of sleep in the morning? Unfortunately, a delay of ten minutes at five am translates to an extra hour on the end of your day. At five am, you have unfettered access to patients and computers. You have time to talk with the overnight nurses and listen to their impressions and concerns. Use the time to actually think about your patients before rounds instead of just accepting the role of a glorified data collector.
- Escape the EMR. Nowadays, it is easy to bury our faces and get lost in the electronic medical record. We present on rounds looking at the screen, reciting labs and data. But that is all it is. Reciting and reading. Not processing and synthesizing. The EMR can be an excellent data base. But it is horrible for facilitating independent thinking on your complex patients. Learn to present your patients while looking your team in the eye.
- Don’t just do something. Stand there. This was one of the most helpful phrases I learned during residency. Often, there is so much pressure to “do” something. Your pager will alarm non-stop with requests from nurses and therapists to do something about decreasing urine output or dropping oxygen saturations or a heart rate that is increasing. You will be tempted to respond with action. Give Lasix. Order an x-ray. Push an IV beta blocker. But don’t substitute reflexive action for thoughtful deliberation. Take time to process and integrate new data. Go and re-examine your patients. And then…
- Make decisions. As best you can, make a thoughtful decision and take decisive action. What do you really think is going on? What do you want to do? Do you think the new infiltrates on x-ray are from edema or pneumonia? Is the patient’s blood pressure low from sepsis or a failing heart? Make a hypothesis and test it. “I think he has low urine output because he is hypovolemic. Therefore, I will give three liters of saline in 30 minutes and reassess his blood pressure and urine output.” In a half-hour you will either know: A) The urine output is better and your hypothesis was correct. B) He is now worse and in pulmonary and your hypothesis is wrong. C) There has been no change in the patient and you need more information or help or both. The more decisions you make, the more confidence you will gain in your developing clinical judgement. Whether right or wrong, you will learn and grow as a physician. Just make sure you are thoughtfully wrong.
- Do not give good news to families. This is a tough one. You will work so hard. A critically ill patient or a code blue transfers to the ICU. You place a breathing tube. You place venous and arterial lines. You shock the heart back into a regular rhythm. You now have a blood pressure. Your patient is now pink instead of blue. For the last hour you and your team have not left this small room, doing everything in your power to prevent this patient from dying. And now you go and tell the family that the blood pressure is stable on new IV medicines, his breathing is better with the tube and machine, and he is resting calmly on sedation. We know what we mean. The patient, relative to the hour before, is no longer rapidly deteriorating. But the terrified and anxious families hear “stable” and “better” and “resting.” These words are best reserved for patients transferring out of the ICU. Families need to know that their loved one is still critically ill. On life support. They are one of the sickest of the sick. They may die. We need to be mindful of our own human nature. A desire to convey the positive. We want our patients and their families to trust us. We want them to know we are working hard, constantly thinking about the patient. But we must be careful not to give false hope or fuel overly optimistic expectations.
- Attend all end of life discussions and goals of care conferences. Do NOT miss these. They are easy to skip. I know you have notes to write and scut to do and sleep to catch up on. But you need to participate in as many as you can. As a medical student or first year resident, you will not run them. But one day you will. Watch. Not just your attending or senior resident, but the families as well. How are they coping and processing? Listen to how things are said. It can be clumsy and awkward, natural and comfortable, or something in-between. Listen. Watch. Observe. Remember what works. Steal it, adopt it, mold it into your own words. Get rid of what doesn’t. It will never be easy, but it will get easier.
- Self- care. Not a candy bar. A meal. Something that actually contains protein, along with the usual carbs and fat. Make time. In the ICU everything seems like an emergency. Begin learning what can and cannot wait. Drink fluids, keep hydrated. Pee, a lot. Your urine output should not be less than your patient’s. Sleep. Get sunlight when you can. Make contact, even if briefly, with the outside world through voice, not text. Stay connected.
- Recognize wins. Learn to retrain your brain. As physicians we tend to focus and dwell on what went wrong. The challenging families. Frustration over missing labs. The hours it took to place a line. Complications of our interventions. The bad outcomes. The deaths. This is where our brains go when we are most tired and beaten down after an exhausting and non-stop twenty-four hours. But in doing so, we miss out on celebrating our wins. We successfully shepherd so many patients through the treacherous and complex world of critical illness. We navigate them through the ICU. But we fail to value our role in this as a win and instead view it as a baseline expectation. We need to learn that there is nothing given about a patient’s course. If we blame ourselves for the bad, then we must take credit for the good. On that long tired drive home, we need to open our eyes and celebrate the numerous victories and successes to which we have become immune.
- Check yourself. Check your colleagues. Everyone is nervous in the ICU. Even your attendings. Trust me. Many project a façade of confidence. But behind that mask are often fears, anxiety, self-doubt and deep sadness. Take time to check your own mental reserve. Share your thoughts. Those around you are probably feeling the same. If you are having trouble, talk to someone. Your senior resident. Your attendings. Your program director. Your family. Anyone. But please do not keep silent and battle on alone.
- Share your journey. Don’t keep it to yourself. Write about it, journal it. Process with your fellow residents. Share your excitement and victories with your spouse or partner or family. They may not always understand exactly what you are going through, but help make them part of your journey. Then reread your words down the road. Listen to your nervous voice and recognize how you have grown. Let your family remark that you no longer comment on sleepless nights and annoying EMRs, but now make important decisions in the middle of the night. It is often through the eyes of others that we can see the true growth in ourselves.
“There are no mistakes. The events we bring upon ourselves, no matter how unpleasant, are necessary in order to learn what we need to learn; whatever steps we take, they’re necessary to reach the places we’ve chosen to go.” Richard Bach