Intensive Care Medicine (ICM) - a day in the life



In this teaching session, Dr. Jack and Dr. Navaran will give you an extensive look into the day-to-day life of delivering Intensive Care. Learn about the rewarding aspects of the job, pick up some of the unique skills required, and gain insider knowledge about application processes. Dr. Navaran, a current junior clinical fellow at a tertiary intensive care unit in Scotland, will be sharing his experiences as a fellow embedded in a unit for a full year, offering a unique glimpse into ICU work. Learn about valuable procedural skills, multidisciplinary team dynamics, and the various pathways into intensive care work. This session, which forms part two of our three-part series, is perfect for anyone interested in a career in intensive care.
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This is part 2 of 3 of the 'Day in the life' ACCS series. This talk is relevant to medical professionals interested in Intensive Care Medicine (ICM) via the ACCS pathway as well as tips on improving your ACCS application. Join Dr Navian Viknaswaran an ICM clinical fellow and current ACCS applicant to find out more about what it's like to work in a tertiary ICU, the benefits of an ICU fellowship and live insights into the current working of the ACCS application process.

Learning objectives

1. Understand the roles and responsibilities of an intensivist and the nature of work within an Intensive Care Unit (ICU). 2. Understand the processes involved in the admission, examination, treatment, and follow-up care of patients in an ICU. 3. Understand the process and procedures related to applying for an Acute Critical Care Services (ACCS) Training Program. 4. Understand how multidisciplinary teams work together in treatment planning and execution in an ICU setup. 5. Understand the key procedures performed by an intensivist or ICU doctor, including arterial lines, central lines, and ultrasound-guided cannulation.
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Computer generated transcript

The following transcript was generated automatically from the content and has not been checked or corrected manually.

OK, everyone, I think we'll make a start. Um Some people might join as we go on. Um Just to introduce myself. My name is Jack. I'm on a um a doctor working in intensive care medicine as a foundation year two doctor at the minute in Edinburgh. Um and I'm part of the er MTB Anesthetics and A CCS team. Um Today, this is a talk um as part of our day in the life series. This is part two of three where we bring you an insight into the workings of being in an intensive care unit. Um some of the benefits of, of being in there and the skills that you can pick up and then again, going over application processes into a CCS. Um Our speaker today is Dr Navaran. He is a current junior clinical fellow in a tertiary intensive care unit in Scotland. Um and he'll be talking about his experience. I think it's quite a unique one, being a fellow. So being there for a full year and really embedding into a unit and learning the skills and he's currently in the process of um an A CCS application. So um he can give us some real insight into that. So, um I'll hand over to a and um as always, this talk is recorded so you can look back at it and others can look at it again in the future. So I'll hand over to you. Thanks Jack for the introduction. So I'm just gonna bring up my slide here. Um Let's see. Let me know if you can see it, Jack. Yeah, I can see that. Perfect, good, excellent. So thanks everyone for uh attending this talk. It will last about 30 45 minutes. Um So this is just a topic on the day in the life of an ICU doctor. I'm Naan. I'm one of the ICU Clinical fellows in the Royal Infirmary in Edinburgh. And I uh will be there for the next year until August this year. So just a little bit about me, I graduated in 2018 from Galway, Ireland and then I returned to Malaysia to do two years of house compulsory housemanship. And subsequently I came back to the UK to Northern Ireland specifically to do an fy two stand alone, so that I will be eligible to apply for training, training programs. Subsequently, I decided to do a clinical fellow post in acute medicine in the Victoria Hospital in Scotland. And then uh since as of August last year, I have been a clinical fellow in ICU in the Royal Infirmary of Edinburgh, Scotland. So today I will be talking about a couple of things. So I will explain to you what a day in the life of an ICU doctor is like, um why did I decide to choose ACDF uh job in ICU, a clinical Developmental fellow in ICU? Um What it is like working in ICU specifically in the Royal Infirmary of Edinburgh. Um I will briefly touch on the different pathways to get into ICU. So there is a direct ICU path, There is a ICU pathway, anesthetics pathway and a CCS pathway which we will all touch on later. And then I will describe a little bit about the anesthetic application because that is what most people would um use to get into ICU. So the picture on your on the right is just a, a stop picture of a typical patient in ICU. It might look very intimidating with all the um gadgets around the patient and lines and all the other stuff. But uh this is what we see on day to day and we learn how to um assess each patient systematically from top to toe so that we don't miss anything. So just a little bit about our rota. Um we have a total of 40 hours a week. Roughly, this is an example of my rota for the month of March. Um We have mainly long day shifts and night shifts um which each would be about 12 hours um shifts, but we get the odd day shifts, which is an which is a half 8 to 5 pm shift. Um We also get four hours developmental time per week, which is um instituted into our rota, but we are given off time so that we can decide what we want to do with it every month. We also have um this protected trainee half day teaching session um as on the last Wednesday of each month and every week, we also have journal club teachings which are presented by the trainees supervised by a consultant. We also have grand rounds going through each and every patient in um ICU and also on Fridays early morning, we have uh mortality and morbidity meetings to go through the patients that have died um throughout the week and what what uh the cost of their stay in ICU was like. So I am going to talk a little bit about the Royal Infirmary of Edinburgh. Um So we are 40 bedded unit with mixed level two and level three units. Approximately 2000 admissions a year. Level two would be something like HD HD U care where it is um two patients to one nurse and level three is ICU care where it is 1 to 1 nursing care. Um The Royal Infirmary of Edinburgh is also the Scottish Liver Transplant Center and it is a tertiary care for neurosurgery HPV trauma. We have a major trauma ward. Uh We have a lot of upper gi surgeries and vascular surgery as well. So this is just a picture of one of the ports in the Royal Infirmary because the 40 beds are split up into four different pos essentially so typical day uh day shift in uh ICU. We come in at about 815. Uh we change into our scrubs and then at half eight, we gather for a handover from the night team in our individual pos um this lasts about half an hour and then we um divvy up the patients. Usually it's about 2 to 3 patients per uh training and we review them until about 11. Once everyone has seen their patients, we go for a short coffee break and then we start our consultant ward rounds usually about half 11 and will end by lunch time. Uh We will then have our lunch break and carry out the jobs that were generated from the morning ward round. This usually involves procedures such as putting in arterial lines, putting in central lines, um carrying out any jobs such as updating families, you know, whatever jobs that is generated, sorry generated from the morning. And then at about three o'clock, we have a microbiology ward round, which is um the microbiology team with the microbiology consultant will come to each of the part and we would go through each patient to um see if we have any queries with regards to micro and then if there is time, we might get another short coffee break before we head for our afternoon consultant work round, which is mainly just to make sure that the jobs that were generated in the morning were chased and were done. And then, um, throughout this time, we also get new admissions um to ICU or to HD U. And then, uh the evening would be spent completing whatever jobs and updating families. And then at half eight, we would have handover to the night team and we head home at about nine o'clock. So that is typically uh um a day in working in ICU as a trainee. So why did I choose a clinical fellow job in ICU, particularly in the Royal Infirmary? So there's two parts to this. Why did I choose an ICU clinical fellow job? And why did I choose Royal Infirmary? So ICU you have a lot of opportunities to develop, to develop procedural skills. Um There are a CCPS, there are registrars around to do dos with you if you need them done. Um You get to do a lot of arterial lines, central lines, you get to do a lot of uh ultrasound guided um cannulation, which is interesting and you can also do um any ultrasound related procedures with um the patients, you get to enjoy treating patients holistically. So it's not just um you know, cardiovascular, not just neurology, you deal with everything from top to toe, including their nutrition, including their um you know, their microbiology, their bloods, everything. Um I also wanted to see whether that my personality fit an acute or critical care setting. Um where would I be able to, would I freeze under pressure or would I be able to perform uh when it comes to patients who are very ill? Um I am also interested in pursuing anesthetics. So ICU closely relates to anesthetics which um has we get exposure to, you know, um the ventilators, we get exposure to post outpatients. Um And of course, it also having a year of year out doing ICU improves my CV four application. So the reason I chose Royal Infirmary is because I had a couple of colleagues who did this job that I'm doing the year before and they gave really good feedback. They said that they were very well supported with a lot of learning opportunities. And um I was also interested in learning about transplant medicine. Um as I mentioned earlier, um the Royal Infirmary of Edinburgh is a primary Scottish transplant facility. And there is also because it is a teaching hospital. There are opportunities for research for Q I projects and audits. So what is, what is it like working in ICU? So as mentioned earlier, there are plenty of learning opportunities. Every ward round that we have is a teaching ward round because once we see our individual patients, the consultant during the consultant ward round, we will go through each and every patient again, top to toe and you get to ask any questions that you are not sure about. You get to uh if, if time permits, you get teaching on the particular topic uh of why the patients in uh as mentioned earlier, get to treat patients holistically from top to toe. Um You also get, you're also able to be involved in multidisciplinary discussions um with dieticians with salt team with. Um there is also an in uh in inpatient ICU pharmacist that follows our ward rounds to provide any uh pharmaceutical uh or pharmacological expertise. Um We also get plenty of support from consultants and registrar. Um 24 7, there is at least one registrar in the unit and there is always a consultant that you can uh call for any um any queries we also get are given time to attend courses for procedural skill, mastery. Um So everyone that comes into ICU especially the clinical fellows, we get a day a day out in one of the peripheral hospitals where we get to have different stations where we get in depth teaching on inserting arterial lines, the complications, the indications uh of inserting arterial lines, central venous catheters. And also uh we get to practice ultrasound guided pvcs. As mentioned earlier in ICU. There is no distinct distinguishing feature between medical and surgical patients. We deal with um all patients that need um an organ support. So that's a good mixture of medical and surgical patients. So I'm gonna talk a little bit about the different pathways that um that uh you, you might need to know to get to, to if you plan to do ICU. So the first one which is the most common is to uh go through the anesthetics pathway. So after foundation training of two years, you apply to stage one training uh where you will need to do the M SRA exam, which is AMC Q exam, which we'll talk about later. And you also need to go through an interview to be accepted into stage one. Stage one is CT one to CT three. But if you go into the A CCS pathway, which I'll talk about in a short while it is four years. So if you go to call anesthetics three years, A CCS extra one year. And during this stage one, training in your first month or two of training, you will need to complete the I A CIA C is essentially the integrated um competency that um is the basic competencies that need to be signed off so that you can perform procedures with supervision. And then by the end of stage one, you are expected to complete your primary F RCA paper. Then subsequently, after stage one, you will need to reapply again for stage two and stage three. Um stage two is two years. And by the end of stage two, you are expected to finish your final F RCA paper. And stage three is ST six and seven where you get to explore special interests and uh it's a preparation stage for you for CCT for when you become a consultant. So um usually, I mean, some, some people they decide to do dual train in anesthetics and uh intensive care. So that would be an additional one year. So it will go up to ST eight, which can be integrated in this um in this pathway as well. And then there is this is the A CCS pathway which essentially is a mixture of anesthesia, emergency medicine, internal medicine and intensive care. So if you decide to go into the A CCS pathway, um it is six months of each of those four specialties in your first two years. And then you apply into stage two, which is C sorry, you then return to your parents specialty. Um So if you apply for A CCS anesthesia, you do two years of six months each and then you go back into anesthesia for CT three, CT four. And then you follow the earlier steps where you, where you apply again for stage two and stage three or you can do dual anesthesia. Uh ICM as discussed earlier, I won't talk about uh too much about emergency medicine and internal medicine because um that's out of the scope of this um to, if you decide to do intensive care by itself, you can go through the A CCS completion of any of the three programs there and just uh applying to ICM without the anesthesia part. OK. I'll let you have a couple of minutes to look back, look at this uh diagram again. OK. So then this is the ICM pathway which a lot of these overlap with what I've spoken about earlier. But I think this gives a clearer picture if you want to do ICM. So a CCS or call anesthetics training, which is the first um four years or call medical training. I MT training, you complete your primary papers and then you can go, you can join the um intensive care training here. And by the end of your fifth ST five, you will need to complete your final fum examination, right? So just a little bit about the anesthetics application timeline and the process because I'm, I'm, I'm applying for this so I can talk a little bit about it. So if you are completing, if you are in your F two year, uh if you're on your F two year, you can start applying in October usually. And then um you will be invited to the M SRA in January of the year you are applying into and then you would do your M SRA if you, if you achieve the threshold of the M Sra point, you get invited to interview uh which usually is about now this period. But um this year, it has been postponed slightly and then uh based on your interview and your M SRA scores, you would be given a, a post. So the M SRA exam is actually a GP exam that has been integrated into um into uh filtering out uh candidates for the anesthetic application. So there's two parts to today's M SRA exam. There is the professional dilemma section where it is very similar to the S GT. There are 50 scenarios um which can come in two forms so it can come in uh ranking 1 to 51 being the most likely action that you would do. Five being the least likely action that you would do or it could be choose three best actions um out of the eight options that were given. And this professional dilemma section um usually lasts about 95 minutes. You have to complete it within 95 minutes, this 50 scenarios. Um this is similar to the S GT that maybe you would have to do in medical school, maybe not anymore. But uh it's similar to the SS GT, but they expect your actions to be aligned with um your level as a fy two doctor. And then there is the clinical problem solving question which is similar to final year exam, but uh slightly higher level to af 0.2 standard. So there is 86 questions um which can be either single best answer. So choose one out of the five or extended matching questions where they give you, uh let's say eight options and you match it to three different questions. Um So this clinical problem solving. Part of the paper is 75 minutes and it includes a multitude of uh specialties which um might or might not be related to anesthesia. But uh it is a, it is an exam that we need to do to be granted an interview. So then once you have done your M sra they will give you a score if you reach the threshold to be invited to an interview. Um The interview is fairly straightforward. Um There's two stations, it used to be 15 minutes, but for this year, they have reduced it to 10 minutes each because the interview um diet was is uh is overlapping with uh industrial action. So they had to increase the number of interviews per day. So there is two stations, 10 minutes each and each station would have two interviewers. So station one is a clinical scenario where they will give you a clinical scenario, you have five minutes to read and then you will have five min, you have 10 minutes to answer any uh questions that they post. You will get 15 marks per assessor based on your um the clinical scenario. And they would, you would have an additional 10 marks per assessor for global rating, just of your impression and your confidence when you uh present your case. And then there is um a general interviews um station where essentially you talk about your CV, what make, what make you suitable to be an anesthetic trainee which is 10 minutes total and the the marks are the same. So if you can see from this actually, just from your impression and your confidence alone, it is 40 marks out of the 100 marks that can be given. So it is very important to um present yourself well. And then this is the, let me see if I can push this to the side. This is just um uh vacancies that are available for the anesthetics application. It is important to note that uh when you apply for anesthetics, you can only choose either the Scotland region, Northern Ireland region or England and England and Wales region. So you can't apply for, you can't put in your preference for all of it. You need to choose one of those three regions. OK. So that concludes my talk for today. Um It's a fairly short and straightforward talk. Um So I appreciate your time um listening to this and I would like to welcome any questions if you have any. Thanks, maybe. Yeah, I'll, I'll start off. That was really good. I think the insight into what is um a challenging environment in intensive care is, is good to see. I think um speaking from my own experience, it's a patient with a place with very complex patient demographic. And I think um do, do you feel like you're coming out of this year that you'll feel more prepared for a training post within anesthetics or, or A CCS. I think so. Definitely. Um I got to deal with a lot of very, very ill patients. Um And I also got some exposure to ventilators, how to adjust them, you know, how, how to um how to adjust the settings based on what the patient needs. Um I also got to talk to a lot of ICU consultants who most of them have uh some experience in anesthesia as well. So those are all really helpful, um helpful points for. And when you agree that that there aren't many other departments where you get those opportunities, especially with ventilators to get experiences and training. Yeah, exactly. Exactly. I think even, you know, those procedural skills such as um art line and central lines, you don't do it anywhere else outside ICU maybe in theaters. But um other than that, you won't really have the opportunity to do that. And in terms of um gaining a fellowship post at the Royal, did, did you have to apply? And if so was that a difficult application process? And did you need any prerequisites to, to gain that, that role? So it was uh I think this uh clinical fellow job is quite a competitive post. Um There was only nine posts available uh for this application for, for this post. And uh we had to go through an interview process. I think they were looking for anyone who is post a two with less than two years of experience. So I think if you can uh present yourself well, um it will be ok. So I think my interview stations that were the first part, there, there were three stations, essentially, the first station was about uh just about tell, tell me about yourself kind of question. And then the second one was a clinical scenario where they gave me five different uh five different uh patients that I had to deal with and I had to prioritize who I would see first and why explain to them my rationale for, for um prioritizing them. And then the third station was just a little bit about any audits or any um Q I projects that I've done. Yeah, that's great. Yeah. Um I'll just check the, the chat and to see whether there's anything I can't see anything at the minute, I think it was um very comprehensive. And yeah, like I said, a really good insight into um working in the department. And I think with people taking years out of training, becoming more of a common thing uh post for a full year in, in an, in an ICU environment is, is um really valuable. So, yeah, thank you very much for the talk. Um Good luck with the application process. Thank you very much. Thanks for inviting me for the talk. Pleasure. Ok, we'll finish it there. Thank you. All right. Thank you.