This week The Intensive Care Registrar from Facebook is giving us an insight into training in ICM. With the introduction of single-specialty ICM training, entry into the specialty can now be made from both anaesthetists and medicine after core training. Junior doctors often have little exposure to Intensive Care Medicine before applying, so we hope this interview will shed some light on life in the Intensive Care unit and answer some commonly asked questions and concerns.
Can you tell us what motivated you to become an Intensivist?
I wanted to be a medic originally; but I found ‘firefighting’ massive numbers of patients very dispiriting. I wanted to be able to focus, and feel like I wasn’t missing things; I also discovered a geeky interest in physiology and a taste for looking after really sick people without getting too stressed.
What are the best and worst aspects of training as an ICU reg?
The best bit is when things are going rapidly downhill, and everyone looks at you, and you step in and save the day. The worst bit is when things are going rapidly downhill, and everyone looks at you, and you have no idea at all. It’s also very hard dealing with people (relatives as well as other doctors) who have unrealistic expectations about what ICU can offer.
Anything else you particularly dislike?
“Hi, it’s the vascular FY1. I’ve just been asked to insert a cannula…” when you’re in the middle of a patient who’s trying to arrest.
Could you share with us your most challenging moment?
Challenges occur all the time; you deal with them in the moment as best you can and it’s usually only thinking through it afterwards that you realise how close everything came to going very badly wrong. That said, I can think of two moments that were challenging for very different reasons.
One was being set the task (by the ICU Consultant) of persuading a very senior Anaesthetic Consultant that he didn’t need an ICU bed for his patient and should… I think the suggested term was ‘man up’, but perhaps there’s a less sexist alternative. After much angst trying to work out how to turn down someone so senior, the day was bizarrely saved by the Surgical House Officer – when I realised they had taken bloods from a drip arm and the patient wasn’t nearly so unwell as first thought!
The second wasn’t so much challenging in terms of a dilemma, but it challenged my beliefs about ICU and withdrawing on patients. A man was on our unit with a terrible heart, and more-or-less stuck on the ventilator. He was fully awake but couldn’t speak due to the tracheostomy. He was a firm believer in living life to the full and I was amazed at how much he had done with the cardiac function he had.
We all knew the chances of him ever getting off the ventilator were vanishing; every time we tried to take it off he looked so grey and awful. He eventually asked us to take it off and leave it off – to withdraw on him. I’ve withdrawn treatment on so many people at the end of their lives, but bizarrely withdrawing on someone who was fully awake, and literally asking me to do it was the one of hardest things I’ve ever had to do. I still don’t really understand why – but it’s something I still remind myself about at the end of peoples’ lives, to make sure I’m treating them as people and not machines.
How do you find dealing with so much demand for your precious beds? It must be hard to push sick patients away?
It’s difficult – though we try not to let capacity issues affect our judgment of whether a patient needs a bed. It’s often said that as doctors we do things to our patients that we’d never subject ourselves to – and often when you speak to patients/family you find they’re much more ‘on board’ with limitations to treatment than the parent team seem to realise (Why do they put nails in coffins? To keep the haematologists from giving more chemo).
Single organ specialists can be particularly bad for this – quoting the survival rates from that particular condition without accepting the patient’s multiple other comorbidities. But in the end we’re all trying to do the best for our patients; it’s just that some of us haven’t seen that a peaceful death on the ward isn’t necessarily the worst possible outcome.
What do you think are the most critical personality traits that a doctor should possess for a career in ICU?
There are many. Calm under pressure. An ability to rapidly make a decision (even if it’s not always the best one). An ability to recognise when a decision wasn’t the best, and to change tack if needed. Finally, a recognition of your own limitations; we deal with complicated patients and there’s a team for a reason! Always listen to the ICU nurses!
It’s now possible for medics to apply for ICU. Is there a role for non-airway trained medics in the ICU?
Absolutely. There needs to be some kind of urgent airway availability but we can always use the Anaesthetic Registrar as a tube-monkey. I’m a medic originally myself. Medics bring a refreshing viewpoint, even if they have to be reminded sometimes that they might have to skip ‘diagnosis’ and move straight to ‘treatment’ so that the patient doesn’t expire while they’re diagnosing the abstruse rash they’ve noticed on the left little finger.
I particularly remember one of my first ICU ward rounds as an SHO. I examined the chest, and turned to the ICU Registrar to announce my findings in a thorough PACES style. About half way through my description of the small area of bronchial breathing I’d identified, he cut me off: “You’re on ICU now – is there air going in and out or isn’t there?”
I understand that anaesthetic attitude now, but there’s definitely room for more medical (and surgical) types on ICU to keep things fresh.
A concern of many trainees applying for ICU is the work-life balance; how do you cope with so many nights and weekends?
By laughing at the A&E Registrar! Yes, it’s a 24hr service but there’s robust handover and it’s rare not to go home on time. When I’m not in the building I really don’t have to worry about what’s going on. It’s also very well supported – as a medic I was terrified of phoning consultants but on ICU the boss would really rather know what’s going on. And you’re also part of a large team – the ICU nurses are great for banter overnight, or you can wander up to theatres to find the Anaesthetic Registrar and finish their crossword. I’ve even clerked patients for the Medical Registrar on a particularly boring night!
So you aren’t life-saving all the time? Is there enough downtime?
It varies massively, which is one of the delights and downsides of the job. The other specialties probably think we sit around drinking coffee all day, as when they see us that’s what we’re doing. But that’s balanced by an equal amount of time stuck in A&E with no food (Top tip: always take a snack down to A&E resus) or shuttling patients around the region in the back of an ambulance (Top tip: don’t eat the food until you’re on the way back – most Ambos seem to be ex-professional rally drivers, or at least think they are).
Finally, what’s your number one piece of advice to junior doctors who are considering applying for ICU?
Do it! If you want one of the few general specialties left (I think the only other one is Geriatrics), the ability to see people improve (or deteriorate) in front of your eyes, plenty of procedures, and to be the one everyone’s always pleased to see at cardiac arrests/in A&E (before they all bugger off and leave you bagging the 84-year-old on your own), then ICU is the one for you!