The ICU Job

Consultant speciality interests

• The Royal London is a trauma centre, and as such a large number of patients have physical injuries which have landed them in ICU. Head injuries are common, with pre- and post-op neurosurgical intervention management making up a significant proportion of the workload in ICU. HEMS brings patients for emergency care so listen out for the helicopter…
• The unit has a good mix of anaesthetic and medical Consultants which leads to interesting discussions and a wide breadth of skills. Some have particular research interests in areas from fluid management, assessment of brain activity after head injury, post-ICU follow up and ventilator-weaning.
• Caring for critically ill, often young, patients on an intense rota for six months can take its’ toll so prepare for this and look after yourself. The Consultants are very approachable and supportive so if you’re struggling with the work, the emotional demands or the culture shock make sure you talk to someone. There is a a real sense of teamwork, support and camaraderie which shouldn’t be undervalued.

Meetings

• Frequent meetings with Radiologists
• Daily microbiology rounds
• Weekly attendance at clinical meeting/journal club
• Weekly attendance at M&M (yes, really weekly – you will present cases)
• Weekly Consultant-led teaching on ICU related topics
• Hospital Grand Round
• Other specialist meetings eg trauma, Ortho if interested

Lots of opportunities to learn! Very high quality teaching.

Bronchoscopy

• Adequate experience in Bronchoscopy – on ventilated patients, which has its own challenges!
• Variable supervision/learning environment dependant on trainees needs/confidence and the Consultants available on the unit/from the Respiratory team
• Opportunity to take initiative/volunteer skills if trainees feel confident/competent. Interesting pathology in critically ill patients.

Typical week

Variable dependant on which part of the rota you are on. You do the non-airway ICU/HDU rota (so there will always be someone on the unit who can intubate), just the same as the ACCS/anaesthetic trainees. It is as brutal as any ICU rota with lots of weekends, nights and unsociable hours. But you get compensatory days off which can be very useful for writing research grants, revising for the SCE, or even non-work! There are C days 8-8pm (when you lead the team and are the point of contact for the Consultant), L days 2-10pm (when you often do procedures and admit new patients) and S days 8-5pm.

The unit is split into HDU and ICU, and each of these is split into two halves. There are then teams which cover each of these sections, with a named Consultant doing the twice daily ward round and an allocation to staff to ensure an optimal still set. A typical day starts at 8am with handover. Each team goes through every patient at a board round, with particular attention paid to those who are most unstable, planned investigations and procedures, and infection risks. Every patient is seen by a trainee (you might review 4 patients), who then present their patients on the ward round. Jobs are allocated as you go round or in a quick debrief post ward round and the most urgent are completed before lunch (might not happen until 2pm when the afternoon shift starts). In the afternoon there are often patients to admit or review post-op, people to prepare for scans or procedures, new lines to do, and lots of liaising with specialties, as well as regularly reviewing the most unwell patients. Consultants do a further rapid ward round before the evening handover at 8pm.

Procedures (estimated in 6 months done by a Resp SpR)

• Chest drains: 5 – 10 (since most chest drains are ‘surgical’, inserted in the context of a trauma call).
• NIV initiation: 0 – 10 (since most patients on NIV are not initiated by you. Clearly you manage huge numbers of patients on NIV and other types of ventilation)
• Central line: 25+ (depending on how often you volunteer to do them. There are always central lines and vascaths that need doing)

Pleural USS

• The unit has a dedicated bedside ultrasound machine with a curvilinear probe, in addition to other machines with flat probes used for vascular access.
• There is no Level 2 trained Consultant in the department, but you can get a Radiologist to come up to observe.
• If you are already Level 1 competent your skills will be put to good use. This is not an ideal job in which to try to get signed off.

GIM

• N/A – on calls are in ICU, not on the acute take. Obviously lots of GIM experience in critically ill patients.

Teaching

• Weekly journal club – which you will contribute to at least once
• Observed undergraduate teaching
• Observed postgraduate teaching (eg FY2)
• There is plenty of formal and informal teaching in this job.

Management/leadership

• No obvious opportunities, but perhaps not your priority in this rotation. Of course there is always the opportunity for a quality improvement project (which would count as GIM).

Specialist training opportunities

• ICU/HDU

Research

• Research is ongoing in the department (both local studies, and multisite RCTs)

Stage of training best suited to this rotation

• ST4/5/6

 Recent trainee comments:

“ICU is always a challenging rotation, but the Royal London is a well-run, supportive department. Respiratory trainees are welcomed as part of the team, and the Consultants truly value the specialist skills we bring to the department (and make frequent use of them!) There are many educational opportunities, both formal and informal. There is good training in the principles and practice of invasive and non-invasive ventilation to easily meet ARCP requirements. Some may feel that there is too much SHO-like work, but this is compensated for by opportunities to care for critically ill patients with multi-system disorders, refine procedural skills, and reflect on effective team-working. The rota is gruelling but not as bad as some others. Six months is perhaps too long – 3-4 months would be optimal.”