critical care residency log

[CSCH]

Since the "residency journals" already posted on this forum were extremely instrumental in my decision to apply for a residency program, I decided to pay it forward and do the same. As with previous posters, I can't promise any kind of consistency during the busy schedule, but I will try to check in every once in a while and share what I've been up to and what I've learned. I'm also going to follow the cues of those who have gone before me by choosing not to identify which residency program I am attending.

One of the things I was most interested in before I applied and during the application process was the experience level of current and previous residents. I myself knew I wanted to be a PA in college, majored in biology, and took a year off to work as an aide in a nursing home, which comprises the entirety of my past medical experience. Many of the people I've talked to in my program had more experience (several CC or EMED nurses or CNAs, some EMTs and paramedics; one was previously a transplant director), but all assured me that they felt everyone started out at about the same level, with their own strengths and weaknesses. They encouraged me to apply despite my lack of experience because the program would likely appreciate having a blank slate to work with (no "bad habits" learned at old jobs). It was addressed directly at my interview, and I got the impression the program directors felt exactly that way, and also that they valued soft skills (adaptability, attitude, and other unteachables) over hard skills. In fact, I decided to do a residency well after I'd already done my elective in school (outpatient GI) and so I never actually had a critical care rotation, just passing time spent in different units as part of IM and surgery rotations. Grades-wise, I believe my GPA was at or *slightly* above average at my school, but I knew I had very strong letters of reference from clinical preceptors.

Other things I wondered about before starting... Pay ($60,000). Hours (60+/week). Structure (rotating monthly through ICUs, with one month airway, one month divided between nephro and ID, and one month of elective). 
Why did I choose to do a residency? I had thought about residencies from the moment I learned about them, and shortly in my rotations, I felt very strongly that I wasn't going to be done with formal, structured learning when I graduated PA school. Taking the pay cut was worth it for me in order to get a great start in a really challenging field.
If there's some other question anyone has (if anyone reads this, lol), please feel free to comment below, and I'll try to respond in a semi-timely manner.

I'm starting off with bootcamp and then about a month in the OR learning procedures (lines, intubation, etc). I got my work phone and a big binder of info in the mail the other day, but I don't think it's going to feel real until I'm standing back in the hospital on day 1.

Edited December 14, 2018 by CSCH
submitted before complete...oops!

[lkth487]

That's great.  Is it adults or kids?

[EMEDPA]

great decision. you will not regret it.

[Randito]

Looking forward to see your updates as I don’t recall a previous critical care thread. I’m curious, how many programs you applied to? If more than one, what was it about this particular program that sets it apart or influenced you to accept the position?

Congrats on the acceptance!

[CSCH]

It is adults.

Thanks for the encouragement, EMEDPA. I'm really excited (and of course very nervous as well).

I applied to one other program and was accepted. I actually had a whole timeline of programs I was going to apply to, since they all have different application cycles and start dates, but I got my top choice right away. Between the two programs I looked at, I chose the one I'm at mainly for practical reasons (they were going to pay me more to live in a safer part of a less expensive city with better weather) because I really liked both programs equally. Most of the CCM programs I saw were extremely similar in terms of where you rotate, the hours, etc. This one I felt was a little bit more established. Both seemed to be well-supported by their hospital systems and included protected formal learning time with SIMs, special lectures for us, lectures attended with medicine residents and CCM fellows, M&M, etc. Both included SCCM material and a bedside US course in their curriculum, and both were planning to take residents to the annual conference.

[CSCH]

Coming up on the end of month in OR with anesthesia team. Met some amazing anesthesiologists and anesthetists. I now have about 50 intubations under my belt. I've been amazed at how quickly I was able to go from being extremely nervous about the procedure to pretty comfortable. I'm very grateful to have had the chance to practice under such controlled circumstances, so that if/when it's necessary for me to intubate emergently on the unit, I will have some baseline skills. I also put in my first arterial line last week. I'm also glad to have gotten to do my first while the patient was under, but I have to say I'm disappointed that I didn't get the chance to do a central line during this rotation.

OR was afternoons. My mornings have been lectures (starting off with a 1.5-week "bootcamp" of lectures on essential CCM topics) and "share days," where we spend time with other medical professionals with the goal of understanding their role, asking questions about their area of expertise, etc. I had share days with ICU nurses, RTs, pharmacists, dieticians, radiologists, and IR. The lectures have been great, delivered by a few physician experts and a few residency graduates. We also attend the anesthesia/critical care fellows lectures about twice a month (expert lectures on various topics, fellow presentations, journal club).

Earlier this week I had my first experience with pushback against a midlevel residency program (which I had expected to run into at least a few times). An attending, after I introduced myself as a PA resident, immediately launched into a rant about how residency is a term that only belongs to physicians. I was, of course, respectful of her opinion, but I maintain that residency is an appropriate title for this kind of program, whether it is for PAs, NPs, nurses, pharmacists, PTs, or physicians. (Frankly, the word has already strayed pretty far from the original concept of a newly graduated physician literally living at the hospital 24/7.) I think that calling this concept a residency is a nod of respect to medical education and the process by which it produces excellent clinicians.

But anyways. I don't let the little things get me down, and I am grateful every day that I chose to do this residency! Next up is my first actual critical care rotation in the MICU. I've heard good things about the staff here, so I can't wait to get started!

Edited May 29, 2018 by CSCH

[HopefulPA77]

I think this is awesome! I have worked as a Critical Care Tech in an Intensive Care Unit now for a little over 2 years and I start PA school in a month.  I have always wanted to do a residency program and of course I haven't started school yet; so, I know a lot can happen but I want to do Critical Care because I have just fallen in love with the specialty.  I was wondering if you had any advice for me as I get ready for PA school anything that I can do to make myself a better candidate to be selected into a Critical Care Residency program.  Hope the experience goes well for you and I can't wait to hear more about it!

[CSCH]

Congratulations, HopefulPA77! I think the fact that you know you're interested already puts you miles ahead of where I was. If you think it's what you want to do, I'd suggest having an elective in an ICU. That way you'll get a chance to see it from a PA's point of view, and it can help confirm that it's still what you want to do. Also, I don't know how many other schools do this, but at mine, IM clinics could count for our IM rotation, so I'd suggest that you also push to make sure you do inpatient.

Quick update: I'm currently in the MICU, and it's been going really well. I've been gradually trying to increase my patient load, but there is a bit of starting over with each different attending/affiliate. Some days, three patients feels almost too easy, some days it feels really overwhelming. Since this is my first rotation, I'm never actually taking a patient alone (they actually belong to the PA/NP I'm paired with for that day), but I try to keep the mindset that they are my patient, and I try to connect with their nurse early in the day so that questions come through me first, which forces me to make decisions on my own before I hear what someone else would do. Wednesday was a crazy day. I walked in to find one of my patients crashing, and the day didn't slow down a bit for the whole 12+ hours. Lots of learning, though. I've found a PA who I really click with, and who allowed me to attempt my first central line on our very unstable patient (in the end, it took the assistant of a third PA to get access, but she let me finish the procedure and put in the arterial line). I'm realizing that the (duh) key to getting the most out of my time is to spend a lot of my off-time studying so that when I first meet someone new, I can make a good impression right away by showing eagerness and answering questions correctly (or correctly enough--no one expects me to know everything), so that when opportunities arise, they'll let me jump in and do it myself.

Edited May 29, 2018 by CSCH

[CSCH]

Update from the neuro ICU. I've been racking up procedures, and learning a lot. Today was my second LP, and I've done several central and arterial lines, as well as a thoracentesis. By the end of MICU, I was taking 4-5 patients, and pretty much running them (though often running my ideas behind the other providers). Neuro is totally different. The culture in this unit is such that the fellows are *extremely* hands on, which can be a bit frustrating. However, there's so much value to my time there. Even though I don't imagine myself in a neuro ICU, I think having a comfort with neuro patients will take me a long way, as many people who never worked in neuro have commented that they are the one type of patient they feel least prepared to take care of (likewise, I've heard neuro APPs say that they don't feel as comfortable with a septic patient, or one with some kind of abdominal pathology--that's the point of residency, to make you versatile).

Still very glad to be here, still very glad I'm in a residency, still very glad I chose critical care.

[ICUPA]

Thanks so much for posting your experience. I am starting a critical care residency this fall and reading this helped ease my nerves a bit! 

[kidpresentable]

Really great stuff. How many hours/week have you been averaging in each rotation?

[CSCH]

Congrats PAstudent234! I'm so glad I did it, and I'm sure you will be too!

kidpresentable: I did 6 weeks each in MICU and neuro ICU. All other rotations will be one month.

Thank goodness neuro is long behind me. I was trying to be positive in my last post, but it really wasn't my thing, which, combined with the flow of the unit, resulted in me feeling quite bored much of the time. Now I'm finishing up my month of transplant/surgical ICU. This has been my first rotation on the resident team, meaning I'm placed with physician residents and have my own individual load of 3-7 patients depending on how many of us are there that day. Somehow I've gotten practically no procedures this rotation (but I did get my first paracentesis!), but I don't really mind because the learning and growing has been incredible.

The stress of the hours is starting to get to me, and yesterday I had my first day off after 9 straight days of work. The difficult part of this process is believing in myself and my ability to grow and adapt. Being on my own with patients means I feel responsible for every good and bad outcome, as well as for every crisis they face. This past week was humbling with the number of things that arose that I simply wasn't ready to deal with on my own yet. It created a lot of fear and self-doubt in me, and I wondered honestly if I had made a mistake, if I wasn't cut out for critical care after all. But after some talks with a recent grad of my program, I realized I was holding myself to an unrealistic standard. Yes, I should set the bar high, but it's ridiculous to set it so high I expect to be able to handle the same situations people with years more experience are able to. I've realized what a big leap it can be to get certain types of knowledge (mainly ACLS) from my brain into action, and that it's okay that I need to see things play out once or twice in real life before I'm ready to lead the decision-making. For example, now that I've seen a very unstable (and very unexpected and very unresponsive) SVT, the knowledge of what to do is burned into my brain in a totally different way than it was when I was studying ACLS guidelines over and over.

I'm just under halfway through this program, and it dominates my life in a way that makes it feel as if this is all I have ever done, but I often have to stop and remind myself that I'm just shy of 5 months in, 4 months actually in the ICU. Kudos to all of you critical care PAs who just jumped right into an ICU job. I cannot imagine taking on this challenge without residency. At times, I am utterly exhausted, mainly by the stress of my own incompetency. But when I get it right, when a new concept clicks, when I put together a really good plan for a patient and they start improving measurably, I'm floating on air for the next hours or days and it feels like I've found the one thing I was meant to do.

tl;dr - What a ride.

[druglife]

These updates have been a huge motivational factor in applying to PA school! I hope to be in your position in a few years. Sounds like an incredible experience and you'll have a killer skill set when it's all done.

Good luck and keep grinding it out!

[SERENITY NOW]

Really enjoy your posts - thanks for sharing.  If it makes you feel any better, I felt like I didn't know anything throughout the entirely of my residency program and honestly I still feel that way today a year and a half out.  Imposter syndrome is very real, especially for us as PAs trying to kick it in EM and critical care with the docs.  But then again, I see physicians who have been doing it for years find themselves in situations where they feel like they don't know anything either.  I think that is probably a healthy feeling that fuels us to never stop learning.  Put one foot in front of the other and don't sweat it...

[EMEDPA]

10 hours ago, SERENITY NOW said:

Really enjoy your posts - thanks for sharing.  If it makes you feel any better, I felt like I didn't know anything throughout the entirely of my residency program and honestly I still feel that way today a year and a half out.  Imposter syndrome is very real, especially for us as PAs trying to kick it in EM and critical care with the docs.  But then again, I see physicians who have been doing it for years find themselves in situations where they feel like they don't know anything either.  I think that is probably a healthy feeling that fuels us to never stop learning.  Put one foot in front of the other and don't sweat it...

this feeling never goes away. you can never know everything. I get humbled fairly frequently by the intensivists I work with over some piece of arcane knowledge they take for granted that I have never heard of before.

[Dlenoci]

Haven't really frequented the forums since starting school, but so happy I stumbled across this post. I'm about 7 months out from graduation and have just sent in applications to 2 Critical Care/Trauma residency programs. Waiting to hear back in the coming month!

Despite criticisms and doubts from my peers, I know undertaking a residency is the right choice, especially for this field of medicine (at least for me). It seems the only arguments voiced against it are the obvious pay discrepancy, which in my opinion shouldn't be enough to deter one from these opportunities. Don't get me wrong, I am DEEP into loans, but Im confident the skills and knowledge base I will build during a residency program will pay dividends for years to come. Its always been about building a career, and not simply getting a job. 

Eager to see more! Thank you for your efforts!

[CSCH]

And I thought I was tired last month...

I just completed my CCU month, with the longest hours I've had so far in residency. It was a rough month, and not my favorite, but totally worth it in the end. Having a cardiologist for an attending, rather than an intensivist (or anesthesiologist or surgeon--but they're different, too) means everything revolves around one concept: hemodynamics. I had never given the subject the thought it probably deserves, and I can honestly say that after a straight month of it, I see patients in a totally different light. I've dealt with heart failure patients before, but this unit was chock full of them, and it made me realize how many mistakes I'd made in the past with them. The other big learning point of the month was PA catheters (aka Swan-Ganz). Nobody else in critical care likes them right now (well, maybe sometimes CTICU/CVICU), but I'm glad to have spent a month with them to learn their strengths and weaknesses (it's all about the trends, baby--otherwise they're pieces of shit and random number generators at best). I also got to finish out my month with a week of nights, which was fantastic. The providers I was with at night were residency grads themselves, and they wanted me to get the full experience, so I got to keep the unit phone and any time a decision needed to be made they would direct the nurse to me for my plan. Even without any crazy events the first three nights, having to take care of all the little things for an entire ICU worth of patients was a great learning experience. The last night, we had a patient roll in hot (right at shift change, of course, and of course much hotter than advertised by the transferring unit) and I got to make a lot of management decisions on a pretty tenuous patient. I'm realizing now that this patient would have terrified me even just two months ago, but the thing about residency is you grow in such leaps and bounds, that suddenly you're in a totally different place than you'd started and you're not entirely sure how you got there. All I know is, these days I run a lot fewer decisions by the people around me, because I know what I know, and I can mostly handle most patients. I also know what I don't know (btw, I think this is one of our greatest strenghts as PAs), and I've gotten better at knowing who to ask and how to hold things together until I can get an answer. I was also encouraged by a PA on the unit to start looking for ways to grow as a mentor, and I got a few opportunities to do some teaching with a PA student and medical student who were rotating with us.

Now for most of the next two months, I get to live that cush consult service life. 9 to 5! What will I do with all this free time? Might be a good time to reset some healthy habits (I'm looking at you, midnight hospital grilled cheese).

Edited October 13, 2018 by CSCH

[CSCH]

PS -- Dlenoci -- Go for it! Ignore everyone else and just do it. I'm so glad I did. (And no one else from my PA program went to residency.)

[kidpresentable]

This is so awesome. I love reading about the transformation you’re undergoing as a provider.

How much time did you have between graduation and starting the residency btw? If you don’t mind me asking, did you still have student loans when you started?

Enjoy the sweet schedule next month!

[CSCH]

I had about 2 months, which was just the right amount of time to get all my licensing stuff taken care of and also kick back a little. No, I didn't have loans. I'm very lucky.

[HopefulPA77]

On 9/4/2018 at 4:15 PM, CSCH said:

I had about 2 months, which was just the right amount of time to get all my licensing stuff taken care of and also kick back a little. No, I didn't have loans. I'm very lucky.

One questions that I am curious about is after the residency have they talked to you about possibly getting hired on or is that not considered really at all?

[CSCH]

I'm guaranteed a job within their system. Other residencies I looked at offered a signing bonus for residency grads if they stayed. Most systems that have residencies know how valuable you are to them afterwards and try to recruit you.

[CSCH]

Well, I survived a month of "off-service rotations" (aka nephrology and ID--good for learning but I'm glad I picked the field I did) and got back into the CVICU. I was surprised by how much I really loved it. Some of it had to do with the great team, and some of it had to do with the interesting patient population. I had several ECMO patients, lots of post-CABG, some vascular cases, some esophageal resections. The interesting part about this unit is that on weekdays they have an additional APP who's just there to take new admissions, usually fresh from the OR. I enjoyed working that shift because taking postoperative patients is all about the art of resuscitation, finding that right balance of fluids, pressors, inotropes, and pacing that gets them back online. For the uncomplicated cases, it's very satisfying when you get them to a good stable point, extubate them, and by the next morning they're sitting up in the chair looking great. On the other end of the spectrum, this unit had some *really* sick patients, some of whom had been transfers in from outside hospitals that just didn't have the resources to take care of them. We actually had one patient who died less than an hour after they were admitted, simply because they were so very sick.

Working nights in this unit was great, and the NP I was working with really let me run the show, which was fantastic. I'm reaching a point where I really want to spread my wings. At the start of residency, if you'd asked me if I'd accept a permanent nights position, I'd have said only if I had no other choices. But now, and after talking to a lot of other providers who did nights early in their career, I'm thinking I'd prefer a night position. During the day, there is great teaching, it is true. There are attendings and fellows and residents who each have their own opinions, and hearing all those opinions is really beneficial to shaping your own viewpoint. But it can also be frustrating at times. I haven't gotten to actually run any of my own codes. When a patient crashes, other people arrive in the room quickly, and they outrank me and often don't know me very well, so I'm hardly directing things. But at nights, it's totally different. When the nurse notices a change, they come to be directly and I get to make and enact my plan right away, no "waiting to discuss it during rounds." I think I've grown exponentially more on the nights that I've had than the days, even with the safety cushion of having another provider there. I really want to keep that growth going, and I want to rack up experiences with unstable patients, managing them on my own.

Upcoming is two weeks of echo, which I'm looking forward to because I really do want to practice my skills so I can become a better bedside echocardiographer, but I'm also dreading it because when I'm out of the ICU I really miss it.

[Notfall]

@CSCH so you mentioned you were averaging 60+ hours a week, as in 5 12 hour shifts? How long is the entire residency? Great posts btw, very straight forward educational!

[CSCH]

@Notfall  Hours vary a lot between rotations. My off-service rotations were 9-5 M-F. My ICU rotations have averaged 4-5(+) 12-hour shifts per week. My last two rotations have included 30-hour call, so that changes the math a little bit. It's a one-year residency, and basically I live at the hospital.

So, back to report on two high-intensity rotations. I already completed echo, which was kind of boring but has already been paying dividends in terms of my ability to do a good quick bedside echo, check IVC, etc. November was my month in the trauma surgical ICU. Things were *very* different there from what I'd been used to. This was the first surgical ICU I've been in that's actually run by surgeons, rather than having intensivists as attendings. (And I can tell you now that I VASTLY prefer intensivists.) Trauma is a different world, with a very different patient population and very different set of problems. I learned a lot about resuscitation-focused medicine, and I also really enjoyed working with PM&R. My team was amazing, and that was the only thing that made that month bearable. Our patient load was absolutely insane, and so the stress level was very high. I definitely hit a low point during the month where the hours and the workload caught up with me. My very first call night I had a patient actively hemorrhaging from an open pelvic fracture while the NP was dealing with a patient actively hemorrhaging from a stab wound to the heart.

This month has been MICU. Because of the hospital I'm at (the community/county hospital), the patient population is predominantly lower income with a lot of barriers to care, so we see a lot of complicated people with advanced disease, stuff that I don't usually see at the other hospitals. I have a really great team, and I've liked the attendings a lot. In this hospital, once you're admitted to an ICU, you belong to that team, no matter where your physical location is. Because of this, we wind up with a lot of patients "boarding" in the ED. This can be really challenging, and these patients are really hard to keep up with. Big things change, and you don't find out for a while. I spend a lot of my time taking the elevator back and forth between our unit and the ED. Doing call shifts has been really good for my skill of admitting patients. That has been one of my weaknesses/fears. I find getting a new patient that another ICU provider hasn't seen yet very intimidating. Any new ICU admit is full of crash potential, and it's my job to work them up fresh. What you're told by the person transferring the patient to you isn't always the full story. Sometimes they don't even have any labs or imaging yet. Coming up with an extended differential, placing all the right orders, and decided what the priority problem is can be very challenging. Somehow, up to this point in residency, I've done very little admitting of fresh patients, probably at least in part because my shifts have been majority days, and many new admits come at night. So I'm glad I'm getting this chance.

One of the really fun developments in these rotations has been seeing my progression from pure learner to part-learner, part-teacher. My team is comprised of one PGY-3 and two interns, neither of whom have been in the ICU before. It's been pretty cool getting to teach the interns ICU things and help them with procedures. I've even gotten to share some knowledge with my senior, although he's great and has a good amount of ICU experience himself--I learn a ton from him about medicine-y things.

This year has been amazing but quite exhausting. I think it finally caught up with me, because I'm typing this from home where I'm stuck sick with the flu (yes, of course I got my flu shot, but they're not perfect). I feel very guilty not being there with my team for their call shift tonight, but I do think I needed to slow down a bit. As this year has progressed, the way I've learned has changed a lot, and these days I spend literally no time actually "studying." It's been all experiential learning, and while I wouldn't give up a single minute I spent in the hospital to go read a book, I am looking forward to dropping the pace and having dedicated study time again. Now that I'm this deep in, a whole new world of potential knowledge has opened up for me!

Oh, and I might want to develop a few hobbies, too.