Day in the life: ICU doctor

What do you DO all day??

If I tell (non-doctor) people I'm an intensivist, I often get blank stares and, if any replies, they generally fall into two categories:

  1. oh, you're an internist
  2. you're an emergency room nurse?


So I tell them I'm a yoga instructor!!

An intensivist is just another way to say: critical care specialist, ICU doctor, the person who runs the intensive care unit, code blue doctor, near-death finagler.

I joke with the nurses that I am a benign ruler in my little fiefdom: the walls of the ICU enclose my entire practice. When patients ask me to write them controlled substances (any prescriptions really, but I get opioid requests the most), I explain that I don't maintain any outpatient services. Other doctors come to me when their patients need heroic, lifesaving intervention. They request that I "review the case" and consult to give my recommendations: what medications can be finessed, what additional diagnoses should be considered, what extra studies need to be reviewed. Quite often: what other specialists should be involved.

I talk to patients and their families about end-of-life care, and what they want as extraordinary measures: so-- who they are, not as patients, but as human beings with dignity and decision-making autonomy (or who they were, before they got sick).

The question above is a REALLY weighty one, and one that doctors "volley" (argue) about quite a lot. It's a whole separate post.

What I want to chronicle here is: a day in the doctor's life. I plan it out with the items in my Doctor's Bag!

I work 12 hour "shifts", but really my shift begins the day before, when I come in to review the cases with the previous intensivist, from whom I am assuming care. I go through each patient's story, and ask questions in preparation for my shift the next day: why this diagnosis? What is pending? What should I look out for? What if x doesn't work-- is there a y option or do I need to start over? I like to farm the person's ideas for as much as possible, because:

  1. they are smart and I am trying to steal their brains, and 
  2. they've thought a lot about what is written "between the lines" or behind-the-scenes-- what is NOT included in their daily note. 


I try to arrive a bit early, because in residency I had this very jolly very evil attending who used to chuckle: "early is on time, on time is late."

Coming in early allows me a transition into a more "intense" mindset, and prepare my paperwork so I can jump in, right when my shift officially starts. It also gives me a moment to read up on any issues from the covering (overnight) doctor. I also like to change my shoes and coat Mr. Roger's style!!

As much as possible, I try to structure my day into timed increments, both because that's how I'm able to juggle a thousand ideas, and also because otherwise I will forget the more mundane items-- items which are still necessary to keep my practice running. I'll give you a historic example when this didn't happen: someone else didn't show up for work, and I was cajoled into emergently covering the shift. Well, scramble in I did: all the patients did well, the nurses were grateful, la dee dah.

Guess who got the ol' heave-ho?? My assistant! I completely forgot to do ALL of my paperwork, and she was scrambling to arrange all the back-end items I didn't do (very kindly- she is just lovely and incredibly on-top-of-it)! Of course, my day is filled with havoc and modifications, but if I have things written down, the empty checkbox is an absolute siren's call to me.

8a: 
begin pre-rounding: review new patient data from overnight, examine all patients and check in with all nurses (good nurses always know the secrets that are "beyond the vital signs"-- little observations that aren't hard facts exactly, but are EXTREMELY valuable in tracking subtle markers of disease).

I order additional labs and tests based on the new data, and start formulating the plan of the day for each patient by making a "goal sheet" for each person: what has to happen by the end of the day, and what were the results of each study?

10a: 
run "multidisciplinary rounds"-- this is basically a walking meeting where all the head honchos of each department-- social work, nursing, physical therapy, dietary, and most especially pharmacy-- report to me on their findings, questions, concerns, and plans for each patient. I make these rounds occur in front of each room.

If the patient's family is available, I encourage them to attend: they often have invaluable insights into the medical and personal history of the patient. They are also then "on the same page" as we are. Sometimes I think the most frightening part of the ICU is not knowing exactly what's happening to your loved one. (Note: the patients themselves are, definitionally, too sick to participate.)

11a: 
I try to keep rounds to about an hour, because that is as long as any human, medical or otherwise, has the ability to keep focused and useful (from what I can tell from my business-school reading).

At this point, I touch base with the primary attending of record. The "primary" is the person who is providing longitudinal care for the patient, as opposed to me: I am a consultant who is managing them as part of a team during their critical illness. The goal is that the patient will "downgrade" back into a "regular patient" by the time we're done with them, so the "primary" is the one who knows them before and after I do. I keep close chats with them to ensure that they are kept abreast of the hospital course.

noon: 
I do the procedures I had planned earlier (central lines, intubations, thoracentesis, arterial lines, etc). Then I eat while discussing the patients with the specialty consultants. My favorite are the infectious disease and renal consultants, because they are usually geniuses, and because they are very pragmatic.

1p: 
give my dictations to the scribe: a strange way of saying that I "write my daily notes" about the patient, their current status, and what I anticipate for the next 24 hours. I always tell my patients that I gather data in the minute-to-minute, but I analyze data over the day-to-day. That is: I'm assessing the trend overall, while continuously kibbutzing.

2p: 
check my hospital email, check in with my secretary, sign my notes, do my billing: try and sublimate all paperwork. At this point more information on each patient is coming in, so it begins to seem interminable. I am constantly stepping away from my desk to evaluate patients, as I always think the patients come before the paperwork. (As a community physician, I am doing all the work alone, without any residents, physician extenders, etc, of an academic center.)

4p: 
at this point there are usually new admits, who I will see and make recommendations on. I am still "continuously rounding" (i.e.: looking at people over and over again so that, for each patient, I have a thousand information points in a day.)

6p:
I eat while trying to anticipate the problems that will happen overnight, and make plans for them. I also write overnight orders, so the person coming on shift the next morning will have a good amount of data to start, and they can hit the ground running.

7p: 
I do my final rounds of the day, and check in with the night nurses. I sign out to the person covering overnight: what should they look out for, what is out of the ordinary that they should remember if plan z falls through. I plan for the next day: what do I need to follow up on? What should I make time for? Any extra considerations or thoughts left over from today?

8p: 
leave to go home. Each of these days is soul-fulfilling while I'm there: there is nothing else like being in the foxhole. There is nothing better than The Save. But it's not always possible. Even when it is possible, I deflate as I walk out of the hospital: I truly give it my all, and sort of drip drab out at the end of the day.

Imagine running a marathon for 12 hours, imagine taking the SATs for 12 hours, imagine having the most important heart-to-heart you've ever had with someone for 12 hours: that's what I do all day.

And I love it. 
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I'd definitely love to hear from you: what do you do to re-energize after a grueling day? The reality is that ICU (my specialty) has the highest rate of physician burnout, so I am extra-mindful about how I space my shifts and how I take care of myself. 

But overall: I am always looking into ways to be a better person, doctor, mom, wife, friend, etc :)




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