Rotation 2: Less Is More In Critical Care

Posted by Unknown at Wednesday, August 09, 2017

Less is more. That was the recurring theme of this rotation. Less is more, especially in the ICU. I just finished up critical care in Detroit and “less is more” is the phrase I kept hearing from my preceptor, my attendings, and even some of the medical residents. During my first week, my preceptor and I were sitting down talking about possible interventions for a specific patient and he said, “Less is more in critical care. If you walk into a patient’s room and you don’t know what to do, the patient has a greater chance of survival if you just close the door and do nothing.” I always kept that in the back of my mind when working up patients. The exciting part was that during my second week, the new medical residents were starting their residencies. I learned that they had a tendency to take a more conservative approach with their interventions because they wanted to be safe. Because of that approach, I have had many situations where I had to try to convince a resident to discontinue a drug or decrease the dose, depending on the situation.

Because I was in Detroit, I dealt with a much sicker patient population than what we see in Ann Arbor. I would say that’s what made me most nervous when starting this rotation. It was my first inpatient rotation, it was my first rotation overall, and I was doing a specialty. Because it was critical care, I was trying to prepare myself for the worst of the worst. As I’m writing this, I can tell you that I have seen almost every type of patient out there on this rotation. From gunshot wounds and stabbings to drug overdose to cardiac arrests and COPD exacerbations; I’ve seen it all and I was learning so much.

Here is an insight to what a normal day looked like for me:

6:30 AM-7:45 AM—Arrive to hospital and work up patients

7:45 AM-8 AM—Pre-rounds discussion with preceptor

8 AM-11 AM—Rounds with MICU team

11 AM-Lunch—Post-rounds discussion with preceptor

1:30 PM-4 PM—Topic discussion, clinical questions, updates on patients

Throughout my rotation, I had 4 different attendings. Each attending had a different starting time and different pace during rounds. I had to learn how to manage my time for each attending. Towards the end of my rotation, I had to show up at the hospital at 6 AM because my attending started rounds at 7:30 AM. I needed time to work up old patients and new patients (and sometimes that still wouldn’t be enough time to prep).

I was extremely lucky with my preceptor for this rotation. He was very knowledgeable and he always challenged me. On my first day, he said, “I’m going to ask a lot of pathophysiology questions. You’re going to hear ‘why?’ from me a lot. You’ll be tired of it by the end of this rotation.” And boy, was he right! I had to explain the rationale for anything and everything that had to with a patient. Whether it was my dosing recommendations, the side effects the patient may be experiencing, why the patient is improving, why the patient is not improving—I had to explain it all. Most of the time, I didn’t know the answer. Sometimes he would explain it to me, sometimes he would make me look it up and explain it to him after lunch, and sometimes he would make a topic discussion out of it. Looking back at those moments, I’m glad he challenged me that way! Pathophysiology was never my forte but understanding the “why” behind everything allowed me to be innovative with my recommendations.

One of the things that stood out to me the most during this rotation was how the nurses and physicians appreciated pharmacists. I admired the respect they had for my preceptor and his recommendations. I enjoyed watching some of the residents and attendings lean on my preceptor for his input and really depend on him. If he disagrees with something, they will listen to him. If he has a warning, everyone on the team will make note of it when monitoring the patient. It was refreshing to see. I have been told by multiple attendings that I was lucky to placed with my preceptor because I was going to learn so much from him and they were right!

I learned so much on this rotation and by the end of the 5 weeks, I felt like there was still so much more I needed to learn. I feel like this rotation has prepared me well for my upcoming inpatient rotations. If all my rotations are going to be like this one, then I’m in for a ride this year!