My life as an Intensive Care Registrar
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 âfirefightingâ massive numbers of patients very dispiriting. I wanted to be able to focus, and feel like I wasnât 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. Itâs 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?
âHi, itâs the vascular FY1. Iâve just been asked to insert a cannulaâŚâ when youâre in the middle of a patient whoâs 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 itâs 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 didnât need an ICU bed for his patient and should⌠I think the suggested term was âman upâ, but perhaps thereâs 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 â when I realised they had taken bloods from a drip arm and the patient wasnât nearly so unwell as first thought!
The second wasnât 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 couldnât 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 â to withdraw on him. Iâve 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 Iâve ever had to do. I still donât really understand why â but itâs something I still remind myself about at the end of peoplesâ lives, to make sure Iâm 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?
Itâs difficult â though we try not to let capacity issues affect our judgment of whether a patient needs a bed. Itâs often said that as doctors we do things to our patients that weâd never subject ourselves to â and often when you speak to patients/family you find theyâre much more âon boardâ 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 â quoting the survival rates from that particular condition without accepting the patientâs multiple other comorbidities. But in the end weâre all trying to do the best for our patients; itâs just that some of us havenât seen that a peaceful death on the ward isnât 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 itâs not always the best one). An ability to recognise when a decision wasnât the best, and to change tack if needed. Finally, a recognition of your own limitations; we deal with complicated patients and thereâs a team for a reason! Always listen to the ICU nurses!
Itâs 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. Iâm a medic originally myself. Medics bring a refreshing viewpoint, even if they have to be reminded sometimes that they might have to skip âdiagnosisâ and move straight to âtreatmentâ so that the patient doesnât expire while theyâre diagnosing the abstruse rash theyâve 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 Iâd identified, he cut me off: âYouâre on ICU now â is there air going in and out or isnât there?â
I understand that anaesthetic attitude now, but thereâs 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, itâs a 24hr service but thereâs robust handover and itâs rare not to go home on time. When Iâm not in the building I really donât have to worry about whatâs going on. Itâs also very well supported â as a medic I was terrified of phoning consultants but on ICU the boss would really rather know whatâs going on. And youâre also part of a large team â the ICU nurses are great for banter overnight, or you can wander up to theatres to find the Anaesthetic Registrar and finish their crossword. Iâve even clerked patients for the Medical Registrar on a particularly boring night!
So you arenât 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 thatâs what weâre doing. But thatâs 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: donât eat the food until youâre on the way back â most Ambos seem to be ex-professional rally drivers, or at least think they are).
Finally, whatâs 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 everyoneâs 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!
Find locum work on your terms
The best locum agencies together in one place, competing to find you the best locum shifts. Managed for free through your Messly account.