Crunch Time

The ICU and You, some Do’s and Don’ts

Some of you will rotate in the ICU as medical students and most of you, whatever your specialty, will do at least one critical care month during your residency. Here are just a few general tips. I have made most of the mistakes described below. Keep in mind that your level of autonomy will vary depending on your program. At a big academic program you will likely be tightly supervised and always have immediate skilled back-up. At a smaller program, especially when you are on call, it might be just you and your senior resident with an attending on home call.

1. Stay ahead of your patients. They are in the ICU for a reason and this is usually because they are too unstable to be cared for on a general medicine floor. Things happen quickly. A patient can look fine and two hours later require intubation emergently. If you had paid attention to his arterial blood gases and listened to your experienced ICU nurses you might have been able to intubate under controlled conditions with everything in place and everybody calm rather than during the unavoidable excitement of a code. This is especially important if your patient is a “difficult airway” as it is always nice to have anesthesia at least standing by if you look down the blade of the laryngoscope and see everything but the vocal chords.

2. Don’t be afraid to intubate. Generally, if you think you need to you probably do. If the patient asks you for the tube then that is a pretty good indication for the procedure, especially if the patient has been in the ICU before.

3. Don’t let the vent intimidate you. At first it seems that the ventilator has a bewildering selection of knobs and displays that seem to have no relation to what you read in your critical care book. It’s hard, at first, to keep the various ventilation modes and pressure or volume options straight in your head. You will usually have a respiratory therapist at the bedside when you intubate and they are usually happy to explain things to you. As a resident or medical student nobody will think the worse of you if you ask questions. You aren’t really fooling anybody, anyways. Everybody knows you are new. Know a few common parameters and this will give you some time to figure things out.

4. But don’t screw with the ventilator. Write an order and let the respiratory therapist do it. If you don’t know what setting would be appropriate ask her opinion.

5. Understand how to interpret ABG (Arterial Blood Gas) values. It seems kind of arcane in medical school but after a few times doing it for real it will start to make a little sense. You will at least know when to panic and when not to.

6. Don’t let your patients almost bleed to death before you decide to transfuse or drop their electrolytes to dangerous levels before you decide to supplement. Stay on top of the patient’s labs, correct aggressively, and then make sure you have a good idea why things are heading south.

7. Don’t believe the crap about “treating the patient, not the labs.” Or the monitor. Obviously the lab values and the monitor don’t tell the whole story but they do tell you a lot, particularly because the patient can compensate for a wide range of deficits before suddenly deciding they’ve had enough. “Looks good” does not equal “Is doing good.” Get that family medicine, touchy-feely philosophy out of your head. These patients are sick and it’s better to be a pessimistic but alert bastard than Little Mary Sunshine.

8. Don’t be timid. If the patient needs a procedure then do it. Don’t dither looking for excuses to put it off because you are afraid of it. The ICU procedures that you will be expected to do are placing central lines, arterial lines, chest tubes, and endotracheal tubes. You will also need to know how to do a lumbar puncture, thoracentesis, and a few other things.

9. On the other hand, think about it first. Not every patient needs a central line, for example. The nurses like them because it simplifies their management but sticking a large gauge needle into somebody’s internal jugular vein is not without the possibility of complications especially in ICU patients who are usually coagulopathic. You can easily nick the carotid artery, even under ultrasound guidance, and this can be a disaster as a patient can lose a lot of blood into the fascial planes of the neck and mediastinum before you even notice it. You might also give the patient a pneumothorax (“drop a lung”) as the needle is long and the apices of the lungs can be high. Good rule of thumb, if you’re sticking a needle in the neck and you’re aspirating urine, you might be too deep.

As much as I like ICU nurses, making their lives easy is not an indication for central venous access. Being too timid to put one in, on the other hand, is not a contraindication. If you don’t know how, call someone who does, have them show you, and then do the next one.

10. For God’s sake, never force the needle, the wire, or anything else. If it won’t go in, it won’t go in. If the wire hangs up, pull it back a little and try again. A well placed wire in a vein or an artery should slide smoothly with very little resistance. If it doesn’t, you are either not in the vessel or the vessel itself is calcified and tortuous. Admit defeat, pull out, and try again. But the patient is not a pin-cushion and if you are obviously screwing it up pass it off to somebody else if they are available. If not, pick another site and try again.

11. Be ready. Know your ACLS because you are going to use it. This month we have never had fewer than three codes overnight and we usually have more. We once had three patients coding at the same time. The senior resident cannot be everywhere and you are going to be expected to take charge. Still, the ICU nurses know what they’re doing so if you don’t know something, ask and take your cue from them. If they suggest something it’s probably because they know what they’re talking about. As you get more experience and if you pay attention you will get more comfortable. The ICU residents are typically on the hospital code team and expected to respond to codes on the other wards. You will usually find a crowd of people milling about. If someone is in charge let them know that you are available to intubate, put in lines, of do anything else they need. If no one is in charge, take charge and remember the basics.

12. One of which is that most patients will not be hurt by a liter bolus of fluid and fluid can make a big difference. A liter is not actually that much. Two liters is better (most of the time, know when it’s not). Giving a 250 milliliter bolus is like spitting on the patient. It’s worse than useless. 250 milliliters is about a cup or so. If you decide to give fluids be a man about it and don’t get all girlish.

Same with magnesium. Two grams won’t hurt anybody and if they are in V-tach when you get to the room you might as well have somebody push it. You never know. It could be torsades.

13. I know this is not always true but generally, you can’t do much to hurt somebody who is already dead. If you give them a little too much atropine or epinephrine it’s not going to make them any more dead. It’s likely that when you arrive at the room of a coding patient, you will know nothing about the patient so you have to stick to the basics of airway, breathing, and circulation. Take a breath, follow the algorithm. You can give CPR for a minute between shocks. Take advantage of this time to calm down and get in the rhythm of things.

14. But you have to assess the patient. Listen to the lungs, feel for pulses. If you can feel a radial pulse they have a systolic of at least 80 whatever the cuff says which is generally compatible with life.

15. Sepsis is big. It comes in many forms but it’s a killer, generally from end-organ failure due to hypoperfusion which leads to all kinds of unpleasantness. Generally you treat it with a lot of fluids, pressors, and anything else to keep the blood pressure up. Culture everything, look for likely sources, and cover with the appropriate antibiotics empirically. And don’t forget to check the urine as UTIs are the silent killer of the elderly. Most ICUs have standard sepsis orders (heck, they have standard orders for a lot of things) but go over them before you sign to both make sure you don’t want to change something and to familiarize yourself with the what needs to be done.

16. Pulmonary emboli kill a lot of ICU patients. Suspect them always in the patient who is acutely short of breath because an ICU patient is a setup for clots. The D-dimer is useless. It will never be low. Every ICU patient has an elevated D-dimer for a variety of reasons. If you ever find a low one this is man bites dog. Besides, people with long-standing thrombi can have a low D-dimer and still throw a clot to the lungs. Consider anti-coagulation for every ICU patient except those with GI or intracranial bleeds.

17. Don’t negotiate with families. Bargaining is one of the stages of grief and you may find the family trying to make deals with you over how long the patient can live. It’s best to just give them the facts and the prognosis. I mention this because at a smaller program with no attendings in house overnight it often falls to the residents to talk to the families. If you don’t know much about the patient (if you are cross-covering) then either arrange for the family to meet with someone who does in the morning or familiarize yourself with the chart and admit at the outset that you are not following the patient on a daily basis. One white coat is the same as another to many people and they may be offended if you don’t know their family member backwards and forwards.

18. ACLS is not a menu. Discourage the practice of offering certain items while withholding others. A lot of families want CPR, for example, but no endotracheal intubation. I guess this makes a little sense from an aesthetic point of view but since “Airway” is the first part of ACLS I suspect that not securing the airway is a violation of the standard of care. Some families are offered what is referred to as a “chemical code” where they want all of the ACLS medications (epinephrine, atropine, amiodarone, etc) but no chest compressions, no shocks, and no airway. There is no point to this. All those meds will just sit in the vena cava or the atrium, all dressed up with nowhere to go.

If a patient is to the point where further care is futile you need to tell the family this, respectfully of course, but bluntly and suggest that it is now time to make the patient’s code status DNR (Do Not Resuscitate).