ICM as an ED trainee

Hi all,

I’m returning to ED from my 6 month secondment in ICU/HDU and I’ll share my experience in critical care as well as a few tips on how we can maximise the effectiveness of our interactions with our critical care colleagues from the resus side of things!

Firstly, we have a lot of skills as ED trainees which make us highly effective in a critical care setting including:

-Critical thinking, in particular when it comes to a patient in extremis

-Clinical procedures and skills such as CVC, Art lines, vascath insertion and airway management

-Excellent team players

-And at the same time, autonomous physicians comfortable in making decisions

All of these skills are highly valuable when it comes to your ICU/HDU rotation

Here are my top tips to get the most out of your rotation:

1) Put yourself out there- volunteer for tasks both in ICU/HDU. You are normally assigned certain patients but ask to insert/change lines either side of the critical care floor. The same goes for patient transfers to and from scan. You can ask for supervision starting off but generally it’s a well supervised environment and this is a great way to learn. Some weeks pass with little to no exposure to procedures so make the most of these opportunities

2) Carry the pager - expanding on a theme here, again volunteer to be the one to do this. This involves taking referrals from all over the hospital from various specialities looking for a critical care review. This is a great way to engage your critical thinking and learn who/what gets taken to critical care from around the hospital. These experiences will allow to you to practise systematic review and management of patients from A-Z all while addressing the pertinent question - “why does this patient need higher level care?” You carry the pager while on call of course, but doing this in day time hours will allow more exposure and all with a consultant presence

3) Ask questions - and I mean ANY questions. All specialities have a different focus and ED is no different. Intensivists are clever people, but they can assume our physiology knowledge is as good as theirs! Speaking for myself, that is NOT the case. So if they’re waxing lyrical on ventilation settings and your vacantly nodding, stop. Ask WHY/HOW/WHEN ect. This will get you out of tight spots on call but also make you better when you do get back to resus

4) Ask for help - this is the MOST important one! Lots of referrals come into the HDU service (which is mainly the side of the service on which Mater trainees will operate) and heaps of these are beyond HDU care and require ICU beds. Patients will deteriorate under your care overnight all the time, your colleague in ICU for the evening is there to help you. Same goes for that tricky CVC in a volume deplete patient or a crashing patient on the ward

Looking at critical care from an ED trainee perspective point of view, there are some things we can do to streamline the process of referral and give our sickest patients the best chance.

1) What is the clinical question? Or alternatively what intervention can critical care provide unavailable elsewhere? If you can answer this, you have a solid referral. Examples NIV for resp failure, inotropes for sepsis, CRRT for AKI and acidosis, intubation for low GCS ect. Always frame your referral in this way and you’re onto a winner. Opening a referral with a simple sentence “I’d like to refer John Doe to HDU because I feel he needs ionotropic support” is a great way to start prior to launching into the presenting complaint as it clarifies the situation immediately.

2) Crush them bugs! Escalating antibiotic therapy in shocked septic patients in resus is also a great way to get on top of a situation and in some cases avoid a need for a critical care bed at all. Looking at old micro result on the patient centre, getting an aminoglycoside in early or involving clinical micro early- all of these are valid in the shocked patient. Clinical micro are happy to take any calls on these type of patients from resus. Below is a chart of spectrum of activity of various antibiotics on the typical classes of bacteria. NB beware the MRSA/VRE patient- these may need additional cover on top of the usual suspects.

3) Use that probe! Echo for septic patients is not only useful but now almost an essential and something I certainly need to work on. Lots of patients presenting with various illnesses will have some degree of myocardial depression when very unwell. Using a probe to look for any signs of same will be useful with regard to guiding fluid resuscitation and realistically predicting who will need inotropic support in the case where large fluid volume will likely result in overload. Knowing this early will also help you get ahead of the curve allowing you to refer to critical care early

The single most important thing in resus and referring on to critical care? Good communication!

Keeping channels of communication open, being courteous and helpful, and most of all keeping the patient at the centre of it all, that is all anybody wants.

I hope some of this is useful and I hope to use some of this in practise in the coming months.

Written by Dr Catherine Lloyd

Peer review by Dr Cian McDermott

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