Tips for a MICU Rotation

Written by Elizabeth Yim, MD

The medical ICU, or MICU for short, is a daunting rotation for many in med school and residency. The sickest patients in the hospital are cared for here, and often patient care involves balancing the needs of all their organ systems. You’ll find that presenting a patient in the MICU is different from presenting a patient on another inpatient floor. For example, knowing whether or not your patient has a Foley isn’t enough; you’ll also have to know how much their input and output was over 24 hours. 

As you pre-round:

1. Receive sign-out from the night team for any overnight events that happened with your patients

2. Review what happened over the last 24 hours including changes in vitals, ins and outs (how much fluid they received and put out, net fluid balance), notes from consultants, major events, imaging performed, medications given, cultures grown, etc.

3. See the patient:

   1. Talk with the nurses about events overnight, what they noticed, what suggestions they have for patients’ care, etc

   2. Review their ventilator settings

   3. Rates at which their pressors and/or sedatives are running

   4. Do a head-to-toe exam! If your patient is on sedation, check their RASS score (I would look this up beforehand, you will likely be asked what their current and goal RASS scores are). Check for cough and gag reflexes when you suction your patients and note what the secretions look like. Aside from doing a typical full-body physical exam, remember to check for skin changes (like sacral ulcers!)

   5. Check for what lines and tubes patients have in (and how long they’ve been in)

4. Try to run the plan by your senior before rounding! They have your back and will often have an idea of what your attending may ask during rounds

As you round:

1. Stand as central as you can and speak loudly and clearly. I know this may seem intimidating at first, but there will be a large team consisting of an attending, senior residents, interns, ICU pharmacists, and nurses and everyone needs to hear updates to care

2. Have an organized template that you follow for every presentation consisting of

   1. Overnight events

   2. Major 24-hour events

   3. Subjective (if the patient is awake, what symptoms they report)

   4. Vital signs (over the last 24 hours, give a range of their BP, HR, RR, O2 sat, whether they were febrile, and their most recent vital signs if significantly different)

   5. Physical exam findings

   6. Significant labs (you don’t have to read the values for every electrolyte level)

   7. Micro studies that have come back

   8. New imaging performed

   9. MOST IMPORTANT PART: Assessment and Plan!

      1. For the assessment, don’t just repeat the patient’s entire past medical history. Instead, synthesize the patient’s PMH and why they were admitted to the MICU

      2. For the plan, talk about one organ system at a time. Generally, the categories are neuro, cardio, pulm, GI, renal, ID, endo, MSK

      3. Also don’t forget to consider whether the patient should undergo spontaneous awakening trials, spontaneous breathing trials, be mobilized out of the bed to the chair, have physical therapy sessions, talk to palliative care to clarify goals of care, etc.

      4. Miscellaneous: Know how many units of insulin the patient received and whether they have adequate glycemic control. Know what day of antibiotics the patients are on and when the end dates are

   10. Remember, it’s okay to be wrong about the plan, it’s important to show that you’re at least trying and thinking about how to optimize your patients’ care

After rounds:

1. Run the list with your team to ensure that everyone is on the same page about what tasks need to be performed and who will do what

2. Update and sign your notes

3. Prepare for and perform any procedures that need to be done (ie. central lines, arterial blood gas draws, ultrasound peripheral lines, etc)

4. Try to learn as much as you can from speaking to consultants, sitting in on family meetings, and gaining exposure on how to break bad news. These are skills that we don’t get much practice in during medical school and now is the best time to learn!

Common topics discussed during rounds:

1. Types of shock

2. ARDS and its management

3. Common ventilator settings

4. Antibiotics and what organisms they cover

5. Sepsis criteria

Overall, I learned a lot during my MICU month and gained confidence in my presentation skills. Even if you decide that crit care is not for you, you will undoubtedly become a stronger medical student by absorbing as much as possible from your residents, attendings, and consultants during this educational rotation. Have fun!