ICU WITH TARPS AND PLASTIC BAGS, TRIP 2, DAY 8

We spend most of the night shift making sure tasks get done and putting out fires. We’ve gotten a few transfer patients who needed blood transfusions or to be intubated on very short notice, but all in all night shift is a lot calmer than days. I’m an absolute fish out of water in this department. While I do know how to do most of the things here, I am only accomplishing perhaps ¼ or ⅓ of what one of their regular providers would. The charting system is one I’ve never used before and it’s taken me several days to really get used to it. Critical care medicine is not the same in an ICU as it is in an ED, though there are enough similarities that I can squeak by. I have a lot less autonomy here than I do in the ED, where I was basically running my own show. I’m frankly a lot more comfortable with less autonomy in this setting; I can manage emergencies well, but long-term planning is just not my wheelhouse and it’s going to take some time before I adjust to the thought process.

During day shift rounds, I’m expected to understand and be able to verbalize the entirety of the plan of care to date; the rationale behind that plan of care; all of the labs, previous medications, and other interventions; and then help synthesize plan changes. We don’t do a formal set of rounds on nights or make major changes to the plan, thankfully, but I still need to know those things to make good decisions when someone needs an abrupt change of plans (usually due to deterioration). Often those good decisions are absolutely contrasted with the previous plan of care, and that’s okay on a short-term basis. Many patients are being tapered off their paralytics on the day shift, for example, and are put right back on them on nights to keep the patients from straining their systems and wasting their bodies’ resources by fighting against and choking on the ventilator, particularly at night. It’s uncoordinated and ugly, but we’re getting things done anyway. Part of the disconnect is just the day/night perspective change. We endeavor to maintain a normal sleep/wake cycle, so during night shift, we try to keep the patients asleep as much as possible. Due to constant interruptions in the ICU and the fact that many patients spend their daylight hours weaning off sedatives, we often have to change previous care orders to promote nocturnal sleep. Additionally, many people sleep in the prone position (on their stomach), which they often can’t do without at least a low dose of a paralyzing medication.