To those of you who are not familiar with my work on YouTube, Instagram, Twitter, as well as my website, eddyjoemd.com my name is Eddy Joe. I am an Internal Medicine trained, board certified Critical Care Physician. My passion is taking care of the critically ill patients. This post is going to go through, as the title states, a day in the life of an Intensive Care Physician/Intensivist.
Many necessary disclaimers, of course. I work in private practice where I typically do not have students, residents, or fellows working with me. I do take requests to rotate with me and have had students rotate with me. For the most part, I do not have nurse practitioners with me either, at least not for the first half of my day. This is not applicable to every job, of course. Your market may vary. I am not a pulmonologist and I do not have a clinic.
The purpose of this post
The purpose of this blog post on a day in the life of an Intensivist is to educate those who are considering going into critical care medicine. A window, of sorts, as to what their life will potentially be like when they complete their training. It could also potentially be helpful for nurses, respiratory therapists, pharmacists, and other members of the team understand certain workflows. Ultimately, I want you to know what has worked for me in these three years that I have been practicing on my own outside of training.
When I work days, my shift starts at 8am and theoretically ends at 6pm. I typically arrive 10-15 minutes early every day to receive checkout from my partner who was there overnight. I take pride in getting them out the door on time. After all, no matter how you look at it, night shifts are hard. They had a 14 hour shift, mine will be 10. I also subscribe to the philosophy where, if you arrive on time you’re late.
Preparing for my day
At 8am I walk into the unit running. There is no time to be wasted. It is my choice every day to wake up an hour before I leave the house so I have time to drink my coffee, read the news or an article, and ramp up my day. Work is for work. The more productive I am at the beginning of my shift, the more time I have to dedicate to personalized attention to the patients throughout the rest of the day.
You also have to take into account that in critical care, no two days are alike. One has to be prepared for a code blue, a rapid response, a call from the ED, a call from a consultant, surgeon, or hospitalist to break up your flow. If you are slacking off at the beginning of your day, this wave of work will potentially wash you out. You know who ends up suffering because you did not use your time wisely? The patient. I don’t do that.
Hitting the ground running
As soon as I cross the doors of my medical-surgical ICU which is 20 beds, I take a quick lap of the unit to “survey the scene” of sorts. I check in with every single nurse, RT, as well as the charge nurse. They have already been there for an hour. They work really hard to triage questions appropriately to the things that need to be addressed right there at that moment or things that could wait until rounds. An example of this is something who needs a second vasopressor for hypotension versus a notification that the potassium is 2.9 and needs replacement. In this process I also eyeball the patients. A quick glance in the rooms will trigger certain alarms in my head.
I look to see how the patient is doing clinically, take a quick glance at the ventilator (if applicable), look at all the pumps and make a mental note of everything that the patient is receiving (pressors, sedation, IV fluids, antibiotics). Believe it or not, this whole process takes much less than 10 minutes. Remember, I am triaging things in my mind. The purpose here is not to fix absolutely everything. If the family is in the room, I greet them, and respectfully let them know that I will be back to talk to them. Same for the patient. They’re part of the team and need to be treated with the utmost respect.
A deep dive into the patients chart
After this process is complete, I sit down on my computer where I have a critical care trained pharmacist sitting immediately to my left. She is of utmost importance to my clinical decision making for the patients and, after some quick pleasantries, we get straight to work. I print out my patient list and start opening the charts. Depending on acuity, I may jump around looking at the sickest patients first and triage them again.
Much of the work was knocked out while I was eyeballing these patients, but this provides me an opportunity to focus in on all the details. After all, critical care is about the details. I look at all the vital signs throughout the night, look at their urine output, look at what the trends are with their vasopressors (whether going up or down). I make small notes of my sheet if necessary of things I want to discuss in rounds about this.
Reviewing the labs
Continuing on I look at the labs. It’s not just important to see the results of the labs from that day, but to also compare and trend them to the labs of previous days. I say this because a creatinine that was 0.5 the day before and 0.9 today is not going to raise any red flags in the EMR, but if you look at the trend as well as a decreasing urine output charted in the EMR, you can prepare for things to get potentially worse tomorrow. It is our duty and responsibility to be the best. The imaging is reviewed as well as the microbiology data. The microbiology could be tricky because the sensitivities populate at odd times of the day. We need to stay on top of that. Are they receiving enteral nutrition is another component I check.
Ventilator, high flow, NIV settings are reviewed. I formulate a plan for all of these patients to help them get off of their respective devices. The medications are reviewed one by one and adjusted. This is where having the pharmacist next to me is so helpful. She leans over and tells me “let me know when you’re on bed 8”, for example. The competitor in me tries to catch and address the issues before she does. A little playful competition is always fun. I write down on my patient list a small blurb on each patient as to what my objective is for that day.
Your patient list is your brain
Those of you who are in practice or training know that you cannot lose your list. Your list is your brain. This process of the day takes me up to 9am. I try my best to have all the patients completed to be completely ready for rounds at 9am. I sometimes have time to walk through the ICU a second time and knock out some of the physical exams.
Starting multidisciplinary rounds
At 9am, my extremely helpful nursing staff has a computer ready to go for me. Traditional multidisciplinary rounds are done with a spin to it. RT, RD, pharmacist, the charge nurse, bedside nurse, the case workers, and other members of the team join in on the fun. I despise those traditional 4-6 hour academic internal medicine style rounds.
In training, generally speaking, someone presents the entire case. XYZ is a XX year old XX with a past medical history blah blah blah. Nope. None of that when I am there. Again, I already went through the patients chart, labs, everything. Why waste time doing this? It’s a waste of everyones time, especially if the patient has been there for several days. As an aside, I invite the family members to participate during rounds. I also leave the door open so that the patient, if able, can listen in to our discussions. Everyone is typically grateful to be a part of this, even though you should let them know ahead of time that you’re going to be switching over to medical lingo.
The time not spent in presenting the past medical history and such is spent teaching. I’ll get more to that in a moment. I basically start off by asking the nurse “what do you need from me to help you better take care of this patient?” After all, the nurse is there the whole day and has already been there for 2 hours by the time that I arrive at the bedside. The nurse KNOWS what’s up. It’s a completely open forum where anyone can ask questions and make suggestions. After all, I will never pretend to know absolutely everything. I need everyone to be on the same page regarding the goals we are trying to achieve to get this patient better.
Critical care professional are at the top of their games. From experience, they are hungry for knowledge and always want to do their best. Open communication benefits everyone. Don’t be that clinician who says “do x, y, or z just because I say so” and walk away. People won’t be too fond of you.
Typically speaking, having a 20 bed ICU as mentioned earlier, I go from bed 1 to 20. On the following day, I may go from bed 20 to 1. I do this to mitigate fatigue towards the end of rounds. I tend to be a bit high-energy and, as you can expect, sometimes it drains. If someone needs me to start rounds in bed 8, for example, because they are the one of highest acuity, then I start there. I also do this so that the nurse of the patient in bed 20 doesn’t feel neglected because they’re always the last one.
Getting back to rounds themselves. Here is where the case is presented and strategies are discussed. My preference is to use this time to teaching. Every decision I make tends to be rooted in data and evidence. The team has to understand why we are doing what we are doing. It leads to improved buy-in and morale.
I can’t say I perform a thorough physical exam on every patient at this time, but depending on how much time I have, I knock out the physical exam here. 9am is also in the spontaneous awakening trial window of this patient to help me better conduct a neurological exam and communicate what is going on with the patient. The ventilator settings are reviewed and I double check every single medication that the patient is receiving intravenously. Some nurses have asked me why I do this. The truth is that any one of us can make a mistake at any time. It makes me feel better to do it. I also glance at patients enteral nutrition. See what rate they’re receiving and clarify when was the last time they had a bowel movement. These components are more challenging to find in the EMR. I need the nurses for this.
As mentioned before, I welcome families and patients to participate during rounds. This is a good time to present them with short snippets of what is going on. I explain to them that I will be swinging by again after rounds to answer their questions. I purposefully try not to speak too in depth with them at that time because it is typically like drinking water through a fire hydrant. They cannot take in all that data. What this does is allow them to have some tidbits of information to sit down and process. When I return, they will hear the same information again and will be more likely to remember it. At least that’s how I feel about it.
Generally speaking, I finish rounds in an hour. Maybe an hour and 15 minutes. There’s nothing worse than those long eternal rounds. This allows everyone to get back to work quickly, myself included. The ICU is a very volatile setting. You need to be prepared for the crashing patient, new admission, and other variables to alter your workflow. If an admission comes in during rounds, eyeball the patient, give the nurses what they need to stabilize them, and get back to rounds. Either way, the process of transferring in the patient, switching beds, placing them on the monitor, etc are not instantaneous.
Now that rounds have been completed, I sit down at my computer and start knocking out notes. This is where I get back up to examine the patient (if not already completed) as well as speak to the family. I try really hard to complete this task as quickly as possible as it is the most mundane part of the day. Here, I am basically triple checking all my work. I had already looked at it during pre-rounds. I looked at it again during rounds. And now I am checking myself again. It bears repeating but critical care is all about the details. You need to be thorough. If someone needs an ultrasound or some bedside assessment, this is where I do it.
Speaking to families are one of the most important components of critical care. You could be the smartest and best physician in the world but if you can’t or don’t communicate with families, you’re basically no one. Many patients in the ICU do not have good outcomes. You need to earn the trust of families that what you’re telling them is accurate, honest, and done so in a respectful manner. The saying goes that the days in the ICU are the worst days in the life of that patient. If you don’t communicate the severity of the illness to the patient and their family and then something bad happens, they’ll look at you like “where did you screw up”?
Something I always tell the families of patients is that “bad things happen fast, good things happen slow” or “this is going to be a marathon, not a sprint”. I also throw in “we’re praying for the best here but we also have to prepare for the worst”.
Knocking out procedures
Yes, there are emergent procedures that need to be taken care of 100% at that moment. Things like intubation or central lines. But a thoracentesis or paracentesis can wait a little bit. I try to front load my day with the rounds and notes to open up time do perform the routine procedures and not rush through them.
Concluding the day
During the morning rounds I order follow up labs on patients when necessary. Please don’t forget to review these. Try your best to not leave things hanging for the physician, nurse practitioner, physician assistant coming in to cover nights. Again, you’re going to sleep in your bed while they’re going to be up at the hospital. Don’t make their life any more challenging than it needs to be. Don’t leave scut work such as lines and other procedures for them to do. You won’t like it if they do it to you. Follow up on the notes from the consultants if they haven’t spoken to you already. Double check all the microbiology labs as those sometimes populate randomly in the day.
Before signing out to my night shift partner, I take one last walk through the ICU to say goodbye to the team and ask them if they need absolutely anything else before I go. I personally hate walking into my night shift and get asked a million questions that could’ve been answered 20 minutes earlier by the clinician who knows the patient inside out. I always make sure to thank everyone for their help on my way out. It’s impossible to do my job without them. This concludes the boots on the ground portion of a day in the life of an intensivist.
Signing out from a day in the life of an intensivist
I’m not going to get too deep into this but signing out in the real work is quite different than in academia. At the end of the day, I don’t need to know if they have a history of hypertension. I need to know what issues may arise throughout the night or what’s trying to kill that patient. Hope this helps you understand what a day in the life of an intensivist looks like.
Learn about Lactic Acid and it’s uses in the critically ill HERE.
Hope you all got something out of what a day in the life of an intensivist is.
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