Tomorrow is my last day on the VAD and transplant ICU service and concludes my ICU requirements as a resident. I intentionally front-loaded my ICU rotations this year to rule in/out a critical care fellowship, and I’m happy to say that I’ll definitely be applying this winter. I’ve always been fascinated by the physiology of homeostasis… how the organ systems interplay to culminate in health or various pathologies. Teaching has also been a sincere interest of mine. As an intern, my upper-level residents remarked that I should have done internal medicine instead of anesthesia. That sentiment will be realized, in part, by becoming an intensivist. 🙂
Now what advice can I share about doing well on ICU rotations? Here’s how I prepared for attending rounds each day:
- Be familiar with your electronic health record (EHR). Create a progress note template which includes vital sign ranges, intake/output data, labs (listed as trends), scheduled medications, infusions, PRN medications, machine settings (ventilator, LVAD speed, Impella speed, etc.), prophylactic measures, and the like. I’ll post a template I made on our EPIC EHR later this week.
- Show up early, get sign out on your patients, and start pre-rounding with the sickest patient(s) first!
- Ask the nurse about any events or concerns. Glance at the infusions and outputs (Foley, chest tube, NG) while examining your patient. Proceed to start writing all of your progress notes before rounds.
- Be methodical! For every patient, I have this order:
- Comprehensive flowsheet to review vitals, infusions, and ins/outs. Also look for telemetry events.
- Lab data
- Imaging (new radiology – actually look at the films)
- Microbiology
- Glycemic control (insulin drip, sliding scale)
- Current medications/orders
- Any orders placed since I last saw the patient (via Order History/Review)
- Reading over the notes of consultants
- Type up your progress notes as if you were going to submit them before rounds. Pend them, copy the content into a Word document, shrink the text size so the note takes up no more than two pages, print it out, and you’re done for that patient. Now you have all your objective data in one place as well as the systems-based plan for your patient.
- As you round, scribble updates and changes in the margins using a checkbox system so you can mark off tasks as you complete them.
Though this process takes a lot of time at first, rounds are much smoother and less stressful. Since your notes will basically be done, your afternoons will be more relaxed, so you can place consults, do procedures, and take new admissions. 🙂
