critical care residency log

[CritCarePAmom]

Thanks for all this insight. I love reading about your experience. I am starting a very similar sounding Critical Care residency in April. I have some time off before. What do you suggest for preparation?

[CSCH]

The most important advice I can give you is to read The Ventilator Book by William Owens. Maybe twice. Maybe three times. It's short, easy to read, and has all the info you need to get started on day 1 with vents. (That man owes me money for the number of times I have recommended his book to some intern.)

If you want more reading, Marino is the classic. I like how opinionated he is. When you first start out, you don't have experience upon which to build your own opinions, so I think it's good to borrow opinions and try them on for size. The full-size is good, but frankly the "mini" Marino is probably all you need.

However (similarly to before PA school), I think it's really important to just enjoy your time off. Residency is exhausting, and there's no reason to go into it tired because the exhaustion is cumulative. Go travel or visit friends and family, or enjoy the hobbies you won't have time for. Or just sleep. I dream about sleep

[CSCH]

Also, you need to read House of God. But start it when you're at least 4-5 months in. It's a great book, but it'll really hit you right in the feels if you read it while you're in the midst of residency and you can really relate to the characters. It took me months to finish because of so little free time, but literally everything he goes through I went through (emotionally--and no, not *literally everything*).

Another thing I've been musing on today is the way I move around the unit these days. Everything used to be scary. Everything. Now I know what I know, and I know what I don't know. I can recognize most real emergencies, and I know when I can walk down the hall to the patient's room and when I need to run. The machines aren't scary, and neither are their beeps. Questions from nurses don't feel like I'm being pimped (even being pimped doesn't feel like I'm being pimped anymore). But on the flip side, the real emergencies get my blood pumping much more than they used to. As I've taken on more and more responsibility, my spidey senses have become more acute, and there are certain vitals/labs/imaging/etc that (I think I stole this phrasing from someone) make my butt pucker. I always imagined myself going through this process and becoming increasingly more objective, thinking through things in a clear and efficient way. And I'm not saying I haven't grown that skill. But the funny thing is that I've also become much more instinctual, and I've stored all this factual knowledge in a casing of emotional knowledge, and the emotional side is the first thing to appear in my mind. Am I explaining this at all well? Maybe someone else has experienced this and can explain it better.

[GetMeOuttaThisMess]

3 minutes ago, CSCH said:

Also, you need to read House of God. But start it when you're at least 4-5 months in. It's a great book, but it'll really hit you right in the feels if you read it while you're in the midst of residency and you can really relate to the characters. It took me months to finish because of so little free time, but literally everything he goes through I went through (emotionally--and no, not *literally everything*).

"Jo" was a collaboration of several residents, all others were based on individuals known by the author who was a Harvard grad.  A GI specialist that I used to occasionally work with here in Dallas knew the author, as well as the others for whom the characters were based on.

[LT_Oneal_PAC]

30 minutes ago, CSCH said:

Also, you need to read House of God. But start it when you're at least 4-5 months in. It's a great book, but it'll really hit you right in the feels if you read it while you're in the midst of residency and you can really relate to the characters. It took me months to finish because of so little free time, but literally everything he goes through I went through (emotionally--and no, not *literally everything*).

Another thing I've been musing on today is the way I move around the unit these days. Everything used to be scary. Everything. Now I know what I know, and I know what I don't know. I can recognize most real emergencies, and I know when I can walk down the hall to the patient's room and when I need to run. The machines aren't scary, and neither are their beeps. Questions from nurses don't feel like I'm being pimped (even being pimped doesn't feel like I'm being pimped anymore). But on the flip side, the real emergencies get my blood pumping much more than they used to. As I've taken on more and more responsibility, my spidey senses have become more acute, and there are certain vitals/labs/imaging/etc that (I think I stole this phrasing from someone) make my butt pucker. I always imagined myself going through this process and becoming increasingly more objective, thinking through things in a clear and efficient way. And I'm not saying I haven't grown that skill. But the funny thing is that I've also become much more instinctual, and I've stored all this factual knowledge in a casing of emotional knowledge, and the emotional side is the first thing to appear in my mind. Am I explaining this at all well? Maybe someone else has experienced this and can explain it better.

All so true. House of God becomes more relevant every time I read it.

the best metaphor I’ve seen for this kind of thinking, which really describes all types of thinking, is that we have an emotional reaction that immediately sets our decision making on an initial pathway. It can be overcome with logical reasoning, but this takes much longer and takes effort to come over the emotional reaction. The metaphor is your emotional reaction is like an elephant. Based on paths you’ve taken before, when it comes to a fork in the road it starts to lean where you should go. You pulling on the reins is the logical reasoning.

personally I rather liken it to muscle memory. It’s the thing that reacts when you are woken at 2 am on your 30 hour shift when you can’t even begin to logical process in reasonable time.

[CSCH]

Thanks, Lt Oneil -- That's exactly what I was trying to say. My amygdala is starting to retain medical knowledge haha

[CritCarePAmom]

On 12/29/2018 at 12:09 PM, CSCH said:

The most important advice I can give you is to read The Ventilator Book by William Owens. Maybe twice. Maybe three times. It's short, easy to read, and has all the info you need to get started on day 1 with vents. (That man owes me money for the number of times I have recommended his book to some intern.)

If you want more reading, Marino is the classic. I like how opinionated he is. When you first start out, you don't have experience upon which to build your own opinions, so I think it's good to borrow opinions and try them on for size. The full-size is good, but frankly the "mini" Marino is probably all you need.

However (similarly to before PA school), I think it's really important to just enjoy your time off. Residency is exhausting, and there's no reason to go into it tired because the exhaustion is cumulative. Go travel or visit friends and family, or enjoy the hobbies you won't have time for. Or just sleep. I dream about sleep

Thanks for the recs!

[franklyrelative]

Hey,

I just want to say thank you for these posts and updates. I enjoyed reading through your year of residency and hope to hear more of your story. I'm currently an ICU nurse in pediatric cardiology and what you say about hemodynamics really rings true. I'm still learning a lot, and I have had thoughts of going to the PA route for rural medicine. However, after reading your experience, I think the idea of being a PA in critical care sounds like a suitable role for me also. I enjoy critical care nursing, but I also see myself in the role of calling the shots. I hope to read more of about your writings and what happens after the residency!

One question I have is, what is after residency?

[CSCH]

After residency, I take two weeks off to recover, and then I start my permanent position at a MICU. I'm very excited to be working there! Down the road, I'd like to precept and teach, but also flesh out a few hobbies and get back in shape. I also definitely see myself picking up extra shifts from time to time in the various units I've rotated through in order to keep up the unit-specific skills I've gotten to learn through the year. (Being used to working pretty much every day, I think I'm going to have to really adapt to having so much free time!)

[CSCH]

Just wanted to follow up post-residency.

I'm two months into my permanent position (and already off orientation), and now more than ever I am grateful for having done a residency. There were moments when the year seemed long, but now in hindsight it flew by. A single year was such a small sacrifice in comparison to what I got: an incredibly broad base of knowledge, procedural competency, relationships with other professionals (many of whom are now friends), and a lot of confidence. My only regret is that it was all over so quickly. If you're reading this like I was, sitting in my PA classes wondering if I should consider a residency, the answer is yes.

[tdhanani]

Hi CSCH,

I just wanted to say all your information regarding the residency was so incredibly helpful. I'm a new grad and have my first round of interviews tomorrow so hopefully I can be in your shoes a year from now! Thanks!

[Jerobe]

Thanks, @CSCH for sharing your experience! Was MICU your favorite type of ICU to work in during your rotations through all of the units and why? Also, now that you do MICU full time, do the skills translate to the other units and would you feel comfortable picking up per diem in the other types of units (say CVIC, CTICU)

[CSCH]

Hi @Jerobe 

Yes, MICU wound up being my favorite unit, partly because of the range/variety I see in the MICU, but also in large part because of the specific staff of the unit I now work in where I was lucky enough to have my first rotation.

I can and have picked up in other units. Some are super-specialized (like the CVICU at my sister hospital that does ECMO, heart and lung transplants, etc) and I wouldn't feel comfortable picking up there unless I had additional training and was doing it on a regular basis. But I've definitely picked up outside of MICU and I think the combo of residency plus working in a broader unit have made that possible for me.

[dphy83]

On 11/18/2020 at 7:44 PM, CSCH said:

Some are super-specialized (like the CVICU at my sister hospital that does ECMO, heart and lung transplants, etc) and I wouldn't feel comfortable picking up there unless I had additional training and was doing it on a regular basis.

Would you say that the reverse is true? For instance, if you worked primarily in CVICU would it be easier to work proficiently in the MICU or SICU on a PRN basis?

Edited November 21, 2020 by dphy83

[Dlenoci]

2 hours ago, dphy83 said:

Would you say that the reverse is true? For instance, if you worked primarily in CVICU would it be easier to work proficiently in the MICU or SICU on a PRN basis?

Hey there! So like the original poster, I also underwent a multi-disciplinary critical care residency program. Throughout residency, I rotated through various units including MICU, SICU, CVICU, Neuro, and even Trauma. I ultimately accepted a permanent position in the CVICU within my institution, which has a strong mechanical circulatory support and heart/lung transplant program. 
 

Although this could be considered highly specialized, my having gone through the residency program allowed me to foster a skill set that can be adaptable across multiple critical care settings. I frequently pick up extra shifts in different ICU’s across my institution, mainly ones I had rotated through as a resident. Admittedly, I do not feel the most comfortable at times when facing a new patient population, new team, new work flow; however residency taught me how to adapt (actually adapt) quickly. More importantly (and often not spoken about), residency allowed me to build relationships with various teams (Attendings, APP’s, nurses, respiratory, radiology techs, clerks, etc.) early on, which has made changing environments frequently relatively easy.

Hope that helps!

[CSCH]

I second the above. If you do a residency, you can pick up anywhere. I’d say most CVICU people would not be comfortable picking up in a MICU/SICU, but it’s presumably easier to go narrow to broad than trying to jump into something super specialized.

[MediMike]

11 hours ago, CSCH said:

I second the above. If you do a residency, you can pick up anywhere. I’d say most CVICU people would not be comfortable picking up in a MICU/SICU, but it’s presumably easier to go narrow to broad than trying to jump into something super specialized.

That's debatable. I went from CCU/AHFT to generalized MICU/SICU and had quite a few "Waaaaaaaaah?" moments.

Of course going from academics to the community where it's all "Bicarb and albumin" was a bit of a change as well...

[CSCH]

Hahahaha yes there’s some weird practices out there lingering around from the Stone Age. I get lots of admissions for smaller hospitals and it’s alternately amusing and infuriating to comb through the records and find out what did or didn’t happen at the transferring facility 

[ohiovolffemtp]

9 hours ago, CSCH said:

Hahahaha yes there’s some weird practices out there lingering around from the Stone Age. I get lots of admissions for smaller hospitals and it’s alternately amusing and infuriating to comb through the records and find out what did or didn’t happen at the transferring facility 

I'm sure this happens.  As someone who works in a rural CAH, I continually find that we don't have certain meds.  For example, just found out that we don't have ertapenem - though I've used it here before.  No phenergan, precedex, limited IV antihypertensives, etc....

[LT_Oneal_PAC]

3 hours ago, CSCH said:

Hahahaha yes there’s some weird practices out there lingering around from the Stone Age. I get lots of admissions for smaller hospitals and it’s alternately amusing and infuriating to comb through the records and find out what did or didn’t happen at the transferring facility 

I’ve been there, trying to decipher what happened at the OSH. Now, I get equally frustrated when I spend 30-45 minutes curating the most perfect note for the ICU, and the tertiary center (that we share a note system with) completely butchers what actually happened in their note. sometimes my jaw just drops wondering how they hell they came to some conclusions they did.

[GetMeOuttaThisMess]

Read the HOG sequel and you’ll really want to bail from medicine.