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An on-call ICU registrar

A day in the life of an on-call ICU registrar

Alastair Hurry, ST6 ICM & Anaesthesia, at Queen Elizabeth University Hospital, Glasgow, shares a typical day with us. 

Identity crisis

The identity of a dual trainee in anaesthesia and intensive care can at times feel quite conflicted. How do you describe yourself when asked? Which role do you say first and in front of whom? Which conference should you attend with your limited budget (the Trainee Conference of course!)? And which e-Portfolio are you filling in today?

It can feel like trying to please two parents, who are sometimes not exactly experiencing marital bliss. However, through adversity comes strength. 

It all starts with the handover

The day of an ICU registrar begins not unlike those of many other registrars; the pain of exiting a warm bed, the infusion of caffeine and the donning of ill-fitting, and on occasion, paper-based scrubs. Work begins with the handover, a cathartic process for those on overnight and the time to plan the day's likely activities. I currently work in a relatively large unit, meaning this can take some time. By patient no. 20 some of us have started to nod off a little, or are lost when trying to remember if the patients are still on vasopressors, sedation or even ventilated. 

However, this is the point in the day when it can all go wrong… the worst thing that can happen to an ICU trainee's day is when at this precise moment the medical registrar decides the patient they have sat on all night has now reached the point of referral. That or the early morning stabbing has turned up in the ED, just to ruin the plans you'd started to make. 

Review 

Arriving on a medical ward to review a patient can go two ways. You can be greeted by an eager trainee keen to tell you all about the patient and show you every chart possible. Perhaps they have a secret desire to become an intensivist, that or they think I am taking away their nightmare patient. The other way is equivalent to discovering a castaway on an abandoned atoll, often starved, wearing rags and who has had little to no human contact for several days. Written notes are often particularly sparse, apart from the ubiquitous, 'or full active treatment' after the previous consultant review. 

After rescuing the castaway who has now had the requisite lines placed, latest bundles prescribed and the tome of admission paperwork completed, you can rightly reward yourself with a circular discussion on the ward round about the innermost workings of your long stay patient's bowel movements and debate the latest contradictory paper released on an intensive care topic.

For many non-ICU trainees, the removal of the ward round from their daily activity is one of the great joys of anaesthesia and the return to the wander round at the end of the bed is a chore. For those who feel like this, remember you can play games with those of us who specialise in the vague, throw away mentions of 'should we try some steroids?'. Or the simple one liner of 'levosimendan?' will simultaneously generate rage and inquisition and allow you to deflect any unwanted questions. 

The talking patient

Communication, as ever, is key, and as the day goes on you find you have communicated with relatives, colleagues, visiting specialties, a variety of surgeons, often a radiologist, and the daily update from microbiology on a new unpronounceable and highly resistant bacterium your patient has cultured. But one of the great oddities of intensive care is the one person we communicate with least is often the patient themselves. For some, the talking ICU patient is unfamiliar and the more difficult one to manage. 

It's with these discussions and endless variety, though, that intensive care is at its most rewarding. Having the expertise in communicating, discussing, re-reviewing and taking the time to properly assess and make the decisions the patient's need is where the skill in intensivism lies.

As the day draws on, prophetic discussions can continue. One such discussion I had with a fellow dual trainee one evening broached the topic of how ICU may have changed us as people. 

Yes, being a medical doctor is certainly, for most, quite a defining part of our psyche and how others see us, but how your choice in specialty has altered your personality wasn't something I'd thought about. The breath between life and death seen, discussed and decided upon daily in ICU does change one's perspective and thought processes as well as the emotional toll of being involved in these discussions. 

These aren't necessarily always negative experiences and making difficult decisions is what ICU is all about. But making these decisions, and increasingly becoming responsible for them, well, I had to agree with my colleague; yes, it has changed me, but undoubtedly for the better. 

Article was originally published in Anaesthesia News, June 2018.