MICU Top 10

Hi everyone,

I’m completing a week in the MICU today, and here are my top 10 takeaways:

1. Stop the sedation: If you want to drive me nuts, tell me your patient is on a fentanyl drip “because they’re intubated.” Not all intubated patients need sedation. Please, I beg you, stop the drip, wake the patient up, and remove the tube.
2. Critical illness is brutal: While you’re treating your patient’s sepsis and ARDS, don’t forget they’re enduring pain, hunger, anxiety, loneliness, immobility, and sleep disruption. If you want your patients to get better, let them sleep; order PT and OT; get them out of bed; D/C unnecessary meds, lines, and catheters; and listen to their concerns.
3. Get to know your patients: Every patient has a life outside the hospital. Just ask. Our team took care of a concert producer, a financier, a retired nurse, a painter, and a world traveler. It’s a joy to care for fellow humans.
4. Consultants are part of the team: This week, a palliative care APRN interjected on rounds so a patient’s husband could share his wife’s wishes. The APRN’s input was transformational. Throughout the week, cardiologists, nephrologists, hepatologists, infectious disease physicians, and hematologists came by the MICU to speak with us face-to-face, proving care is better together.
5. Nurses, pharmacists, and therapists are part of the team: Where would we be without our nurses, pharmacists, and respiratory therapists? If not for them, how would we know that the patient choked on his breakfast? How would we know that Unasyn would work just as well as Zosyn? How would we know how epoprostenol is nebulized? To take the best possible care of your patient, you need to welcome the nurses, pharmacists, and respiratory therapists into your circle.
6. Families are part of the team: We’re finally resuming our pre-COVID practice of inviting families to join rounds- filling in gaps in the history, sharing observations the team may have missed, and challenging us with crucial questions. Families are true partners in care.
7. Look for hazards: Did you know that anti-anaerobic antibiotics are associated with higher mortality? Did you need to be reminded that propofol exacerbates shock? Were you really surprised that the patient’s sodium rose after you made them NPO? So many hazards are visible to us when we open our eyes.
8. Focus on physiology: Just because a patient is septic and in shock doesn’t mean they’re in septic shock. Are you sure his heart is pumping normally? Are you certain she got enough fluids? Do a POCUS, check the central venous saturation (ScvO2), study the pulse pressure, and inspect the IVC. The physiology may surprise you.
9. Residents read your work: That was quite the moment on rounds when Johnathan quoted a letter to the editor from 13 years ago that I’d forgotten I’d written. Thank you, Johnathan, for reminding me that I’ve been repeating myself for decades!
10. Say yes: MICU nurses will teach you everything you need to know about life, death, and everything in between. So, if you see a bunch of nurses huddled outside a patient’s room, munching on Twizzlers, walk over and say hello. And if they ask if you want a Twizzler, say “yes.” Thank you, Tiffany Terni, for teaching me that strawberry Twizzlers make everything better.

Every MICU rotation is an opportunity to learn. Thank you, Derrick, Brian, Evi, Tamu, Justin, Johnathan, Marwah, and Alex for asking great questions, for teaching each other, and for inspiring us all to be the best doctors we can be.

Enjoy your Sunday, everyone. I’m headed in for one last day on MICU Blue.

Mark