Block 2: The Dreaded MICU

Well, I can't put it off any longer. My month as a senior in the MICU is upon me; in fact I'm almost half way done! It is uniformly agreed upon among residents that the month as a senior resident in the MICU (medical intensive care unit) is the hardest, most stressful and most exhausting month of our 3 year residency program. Why? So many reasons I don't even know where to start.

But first, by way of explanation for the laypeople among you......

The MICU is where the sickest of the sick patients come. In order to come into our world on the 9th floor of Northwestern Memorial Hospital, a patient must be too sick to send home and too sick to go to a regular "general medicine" floor. So what kind of patients do we have? They generally fall into a few categories:

1. Sepsis or septic shock: These are people who have an infection somewhere that is serious enough that they are no longer hemodynamically stable- their blood pressure is dropping, or their heart beat is going way too fast- and we think they need more intensive support such as central lines (big IV's that go almost to the heart) and sometimes pressors (medicines that bring up blood pressure).

2. Respiratory distress or failure: These are folks who can no longer breathe for themselves for a variety of reasons such as pneumonia, extra fluid in their lungs from heart or kidney failure, drugs or infection causing confusion such that they can no longer "protect their aiway" to prevent themselves from aspirating their own saliva, or actual lung disease such as COPD (chronic obstructive pulmonary disease) or asthma. If they are sick enough to come to the ICU that usually means that they need to be intubated, i.e. a breathing tube is inserted into their throat so a ventilator can breathe for them.

3. Large GI (gastrointestinal) bleeds: These patients generally have lost a few liters of blood and their blood pressures are dropping as a result. We support them, give them blood products and fluids as needed until they either have a scope such as endoscopy or colonoscopy or they stop bleeding on their own.

4. Post-cardiac arrest: These are the scary calls that no one likes to get. Well, maybe some adrenaline junkies like to get them (ER peeps, I'm talking 'bout YOU!), but most of us internal medicine people are pretty cerebral thus emergencies are NOT our thing. Sometimes these patients had cardiac arrests (i.e. their heart stopped, or began to have a rhythm not compatible with life) out of the hospital, at home or on the street thus they come through the Emergency Room which is less stressful for me as the MICU resident, because they are intubated with central lines (nicely packaged w/ a bow) when they get to my floor. The scary ones are the cardiac arrests on the other floors of the hospital.

5. All around disasters: These are people with any number of problems from cirrhosis (liver disease) to overwhelming cancer to mutli-system organ failure from the disease of "my organs are telling me I'm not supposed to be alive anymore, but my brain or that of my loved one hasn't gotton the picture". We have a few of these tonight that I'm worried about. These are folks who wouldn't still be alive 10 years ago, but our advanced medicines and interventions are able to keep them alive. These interventions are miraculous when performed on relatively young, healthy people with only 1 major problem that is reversible but seem absurd to a lot of us when performed on older people with lots of medical problems or even younger people with some really bad medical problems that we are never going to cure. I believe in dying comfortably and going through a cardiac arrest with chest compressions (that are only done "right" if they are forceful enough to break bones) and shocks is NOT comfortable.

So, as you can imagine, being in charge of the management and treatment of any of the above patients can be terrifying. And as the senior resident, overnight you're it. You are the code (i.e. cardiac arrest) responder, and the person who evaluates patients in the ER and on the regular floors who aren't doing well. When I'm on call, I live in fear of the code alarms (if the code is in the MICU) or the code pager (if the code is out of the MICU) going off.

We are "on call" from 7am-7am, so a full 24 hrs, every 4th night. "We" consists of me and my two interns. One of the key benefits of doing the MICU rotation early in the year is that we all get 2 interns. After the full 24 hrs of call, we then have to round with the extended team. This includes our sister team (1 resident, two interns), our fellow (a person training to be an ICU doctor), our attending Pulmonary/Critical Care doctor, our pharmacist and the nurses for each patient. This, as you can imagine, takes f---o---r---e---v---e---r. Next to living in constant fear of an emergency, and being up all night, spending 4 hours standing on our feet post-call is a pretty miserable aspect of call. Imagine trying to explain critically ill patients to the team after getting absolutely no sleep. Not fun. Good thing that's the job of the interns;) I just sit back and make sure they don't leave out key pieces of information. Ah, to not be an intern anymore:)

I'm afraid I could go on and on about the MICU and then this blog would never get posted so I'll stop now. Tomorrow is call 4 out of 7 or "hump" call. Hopefully it will all be downhill from there!