ICU Fellow
I’ve been in this ICU for about 8 months, and I did my residency here as well, so I know all the attendings and most of the nurses. Overall, it’s a good place to be. We get a pretty steady mix of patients with all kinds of stuff, so it’s a good learning environment.
I think we work together pretty well, although sometimes the nurses are kind of hostile. I can’t really blame them—they’re often short a nurse for a shift, then they have to cover 2-3 patients instead of 1 or 2. Still, they could try to be nicer to the residents, who are really only here for a little while, and there’s a lot for them to learn. I’ve been able to work on better relationships since I became a fellow and I’m here all the time.
We also just put in a new electronic record system for the ICU, and it hasn’t gone all that well. We have a hard time finding information that we used to be able to get easily, so we have to have the nurses with us on rounds so that we can get more information about what’s been going on with the patient.
I think we do a pretty good job on getting patients liberated from ventilators. A few patients sometimes fall through the cracks, but overall, we do okay. I’m not sure what our average ventilator days are for patients who need ventilation, but I’m sure we’re doing okay.
We did have a bit of a problem with a new nurse the other day, who tried to do a sedation interruption without planning for it. I got “talked to” by the nurse manager, who said that I should have worked with the nurse to figure out what he needed to do—I’m willing to try, but I have a lot of other responsibilities. The residents were in conference for a long time that day, and I think I got paged about 4 times to write more specific orders, which I did. I can’t help it if the nurse didn’t know he should have had RT there when he decreased the sedation.
I think the liberation campaign is a good thing, and yes, I know all about ABCDE. The evidence is pretty good, although I think that the fact that most of the trials get done in high acuity academic medical centers makes it a little unrealistic in smaller ICUs like ours. We don’t always have all the components, like PT—our PT resources are really limited, and we can’t get a physical therapist when we need one. We can certainly do all the other stuff, although frankly, I don’t know how much difference it makes. Patients coming off mechanical ventilation are always pretty sick, and it’s not really realistic to expect that they’ll be up walking soon. We aren’t really staffed for that.
I don’t think we need a protocol for this. I know what to do, and our attendings certainly do. We can all get this done, and all that protocols do is make a one-size-fits-all approach that isn’t realistic. Besides, we have some other really important priorities, like figuring out how to get pain management for our patients. Trying to take people off ventilators too soon can just make that worse.