Communication
Good communication is an absolute necessity in critical care. If there is a concerning patient in the SICU or a new admission an attending from the division of trauma and surgical critical care should be notified. First the SICU attending on for the week should be notified and then if this person cannot be reached the in house trauma attending should be notified. Cellphone numbers of each trauma/ICU attending are posted in the SICU at the resident computer if they cannot be reached by pager. Attendings need to be notified of new admissions and concerning patients.
What is a concerning patient?
- Worsening mental status with inability to protect their airway or concern for CVA
- New vasopressor requirement
- Possible need for intubation
- IVF bolus total > 1.5 L
- Specific surgical concerns; i.e. recent emergency AAA repair with signs of colonic ischemia, esophagectomy with concern for leak
The in house trauma/ICU attending should be immediately notified and requested to come to the SICU for any patient with an emergent airway issue or cardiac arrest.
The SICU or in house trauma/ICU attending should be notified of any procedures to be done, including arterial lines even.
Communication most importantly can improve patient outcomes, is necessary medicolegally, and reduces the chances of the SICU team appearing disorganized to the primary surgical team.
Rounds
Rounds will start per the attending’s schedule which can be variable.
Expectations on rounds of the presenting resident or student:
-24 hour events
-Physical exam findings, especially those pertinent to the operation, i.e. appearance of wounds, drain output quality, and the general appearance of the patient. How does the patient look?
-A plan for each system that involves more than a “hunter/gatherer” approach. Sometimes residents present that a patient is on pressors but do not state their MAP goal, how they feel the patient’s end organ perfusion is. What are the goals for the ventilator wean for that day? The patient is on an insulin sliding scale but is it effective?
Medical students are expected to present any patients they are following. 4th year medical students should have at least 2 patients at all times.
Conferences/Teaching
Every effort should be made to attend the Tuesday and Wednesday afternoon teaching sessions in the stepdown conference room run by the SICU fellow that occur all year. These are scheduled for 1pm but due to the dynamic nature of the ICU are often bumped back by a half hour or an hour or so. In these cases the SICU fellow will notify the ICU teams. Residents and students off service may also attend these sessions.
All residents should attend MICU/SICU conference which occurs twice a month on Wednesday 8:00 am and weekly Friday morning SICU fellow’s conference at 7:15 am.
Outside preparation
There is no substitute for outside reading, use of video materials, blogs etc. One of the most productive ways to gain and retain knowledge on SICU topics is to do directed study. If a patient develops alcohol withdrawal find 30 minutes when on call or postcall to read an article or find an online presentation and take some notes on pharmacologic options, benzodiazepines versus dexmedetomidine. There are so many good resources between the reading list on clinical key that we have provided, the 50 articles list on Dropbox, your Pubmed account, and excellent blogs like Pulmcrit, Life in the Fast Lane, and Deranged Physiology among others. There are also a lot of video materials and presentations on EAST’s website, AAST website, SIS website, SCCM. We cannot make one truly comprehensive list of resources as residents and students have different learning styles and approaches.
Some general hints
Work well with the nurses, request their opinion, learn their names. They will provide you with a lot of valuable information.
When in doubt go to the bedside. Despite our advances in ability to view data on the computer a lot is still gained by careful observation of the patient-general appearance, signs of distress, the abdominal exam, wounds. Additionally one does not want to be known as a surgeon who is “always at the desk” or in the call room.
Keep families informed, introduce yourself. Find ways to maintain humanity in stressful times.