Today’s inane image/video of the day:
Introduction
As a premedical and medical student, I always wondered what an attending’s schedule the really looked like. Individuals that embark on this journey to becoming a physician are often reminded at each stage that “it gets better.” When I was a medical student starting on rotations, I frequently wondered when I would have an opportunity to really influence patient care. As an intern, I felt like I was making a difference in patient care, but lacked the experience and knowledge base to feel confident in my decisions. There were numerous moments of self-doubt when I started the anesthesiology part of my residency; after all, most medical students do not get real exposure to the complexities surrounding anesthetic care of a surgical patient.
Anyway, I digress. Long story short, at every stage of training, I wondered what the next one would look like and feel like. Now that I’m finally an attending, I can share my schedule and overall experience as an intensivist with all of you! Look out for a separate video/blog post on the anesthesiologist part of my job.
Super-detailed schedule breakdown
If you’re curious about an hourly look at my schedule, here’s an overview [in military time]:
0430 | Wake up. I rely on my wake-up alarm clock to rise at this hour consistently. Also, it has ensured that I’ve never accidentally slept in [I’m also a very light sleeper, so maybe that’s why light in the room guarantees that I get out of bed].
0530 | Sip on espresso [I used to have a Keurig but didn’t love the taste of the coffee… so I decided to try Nespresso and have been loving my Breville machine combined with Starbucks Blonde roast pods in these adorable little espresso cups] while reviewing my patient list in the unit. As a junior attending [and fresh out of fellowship], I feel better about starting my week off when I do some pre-reading on my patients.
0600 | Quick Peloton workout on my knock off spinning bike [I use the Peloton app and this bike – which was the best $399 I’ve ever spent for my sanity during the pandemic. If you’d like to put together a similar setup to my knock-off Peloton, all of the equipment is listed here.] Just so you know, “quick” means I literally a 10-15 minute workout. Seriously… every minute counts.
0615 | Shower [ain’t nobody want to round with a smelly attending 💁🏻♀️].
0630 | Walk to work [I don’t have a car in Boston and I’m happy about it]. Once at work, I’ll change from street clothes into hospital scrubs [I typically wear the hospital scrubs since… it’s less laundry to do!]
0700 | Get sign out from the overnight intensivist.
0715 | Pre-round on patients. Usually I like to catch our nurses during their sign out to ensure I hear first-hand what happened overnight. I hate interrupting handoff, but on patients that had significant overnight events, it’s important to gather additional information.
0730-0830 | Draft notes. These notes are nowhere near as painful to write as when I was a resident, but… they still take a lot of time and cognitive energy. Notes are important to communicate my thought process for patient care plans and to document the current status of the patient. In the ICU, notes are often outdated the moment they are written; many of our patients are constantly changing because of their illness process. I usually offer to grab coffee for the team at this time, too.
0830 | Rounds. We used to start at 0800, but in the last year due to feedback from our trainees, we’ve instituted a daily AM lecture series from 0800-0830. During rounds, we gather as a team [i.e. attending, fellow, resident/NP, bedside RN and sometimes, pharmacist and respiratory therapist] in front of the patient’s room to review the events of the night and create a care plan for the day. This is a time to review orders and medications; ICU patients frequently have many, many, many orders and as a result, it’s important to take time to review them to ensure they are still relevant/appropriate for the patient’s current status. When family members are at the bedside, I invite them to join in for rounds.
1100ish | It usually takes a few hours to get through rounds. There are often interruptions, involved discussions, or education that prolong rounding time. My philosophy as an attending is that it’s important to have succinct but thorough rounds in order to allow for time to follow-up on consults, procedures, and family meetings. Sometimes succinct rounds aren’t possible… but it’s good to try!
ALL DAY [0700-1700] | In my video, I mention the fact that in my institution, our division of critical care anesthesiologists offer a special consultant service called “RICU.” What this means is that anytime a patient needs an intubation [i.e. placement of a breathing tube] or evaluation for respiratory failure, we get paged. The only other specialty that does intubations in our hospital is emergency medicine. At any time during the day, the pager can go off; most of the time, the pages we get are emergencies, so we usually stop what we’re doing and head over to assess the patient.
1100 – 1600 | After rounds, I am usually famished so I run downstairs to grab food. If I didn’t finish all of my notes during rounds [that’s usually the case…], then I’ll head to my office to eat and work on finishing my notes. I’ll typically get updates on patients from the fellow and am present for procedures. If there are any communications I can help facilitate, I’ll work on making calls or meeting with patient family members during this time. Sometimes, if it’s a calm day, I’ll spend this time catching up with my friends working in the unit or try to go over an educational topic with the residents on service. Each day is a little different.
1600 | PM walk rounds. This is an opportunity for our team to walk around and for me to get last-minute updates on patients before signing out. The attending sign out is at 1700, so this hour gives us time to ensure there is a plan in place for the patient between all the sign outs and formal PM rounds [which generally start at 2000].
1700 | Sign out.
1715 | Change back into regular clothes [I wear “athleisure” under my scrubs every day – helps with feeling cold and adds another layer between me and the hospital detergent used to clean scrubs; I usually buy the cheapest stuff I can find like these Old Navy tops and leggings] and start my walk back home.
1730 | Shower [again]. This is why my skin gets so dry in the winter… I find that I need to shower after a clinical day since it’s helps with collecting my thoughts and processing any challenges faced during the day.
1800 | Dinner. Netflix. Wonder how my patients are doing.
2000 – 2200 | Crawl into bed. Really, I am proud of my granny bedtime because I need sleep. Plus, I’ve learned now that if I’m sleep-deprived, every single task just takes longer. My secret to success? Getting adequate sleep.
What kinds of patients do you care for in the SICU?
Most critical care anesthesiologists are trained in a surgical ICU [SICU] setting. Generally, SICUs care for patients that have had surgery of some sort. We accept patients from every surgical service except cardiac surgery [at our hospital, these patients go to a different cardiac surgery unit]. We see patients from every surgical service, but most frequently we care for thoracic, vascular, and trauma surgery patients. Different institutions have different styles for how their SICUs work; in many institutions the surgical team dictates the care plan… for our institution, the ICU has full control of orders, but we recognize the importance of the input of our surgical colleagues and respect their requests as well. I personally love working with our surgical colleagues, so this setting is perfect for me!
What about other critically ill patients [MICU]?
I trained at the same institution that I currently practice at and am proud of the time I spent rounding with the pulmonary/critical care colleagues. I learned so much about management of primary respiratory conditions and other primary medical conditions. What many people do not realize is that as anesthesiologists and surgical intensivists, we care for patients that have medical co-morbid disease, and thus, need to understand the pathophysiology in order to care for them. As an anesthesiologist, I use ventilators all day in the operating room, and thus am able to translate this knowledge to my patients in the ICU on ventilators.
With the pandemic, I don’t think many people realized that critical care anesthesiologists are well-suited to care for COVID ARDS. The management of ARDS has always been consistent – low tidal volume ventilation, application of PEEP, proning [as needed], and paralysis [as needed]. The rest of management is supportive. Furthermore, as anesthesiologists, we are very well-versed in the use of sedatives, making it easy for us to titrate these medications.
Why did you decide to do critical care?
There are a lot of reasons… I mention a big one in my video, but I’m going to more details on my specialty choice for a future video/blog entry!
Final thoughts
I hope this blog post and video helped to de-mystify what my day looks like in the ICU as an attending! Remember that every unit has a different setup for scheduling and process for patient care, so what I share may not be applicable to another unit [even within my own hospital!] or institution. If you have questions about this post or want to know more, feel free to reach out to me!