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.

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?

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.)

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.

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.

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.

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.)

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.)

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.

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?

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. 

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 :)

No comments:

Post a Comment

Thank you for replying :)
I appreciate your time and thoughts!