Two months in the ICU have given me about all the procedural practice I can handle. (As opposed to OR practice, that is.) I’ve gotten to do – or attempt – several intubations. I tried to explain to the attending today that I have a 50/50 record: half the ones I’ve done have been when he wasn’t there, and they all went fine. Half of them were with him around, and they all failed. He opted to reiterate the pharyngeal anatomy and technique of laryngoscopy again.

Also central lines. I got a subclavian line today, in an intubated patient with no access, and thus no sedation and no drips. First stick, right in. The attending (same one; I don’t think he has 100% confidence in my procedures, for some reason!) was setting up to do a femoral line, as being quicker and more reliable,┬ábut I got the subclavian in before he could do more than prep his site. (I wanted the subclavian for central venous pressure monitoring, plus you’re allowed to leave them in longer, so conservation of effort.)

On the other hand, I proceeded to struggle with femoral a-lines for the rest of the morning (for the nonmedical folks, these should be the easiest of all lines, whereas a subclavian in an unstable patient should be the most difficult). Something about putting them into patients with VADs (ventricular assist devices), and thus non-pulsatile flow, and thus no pulse at all, seemed to complicate matters. Invariably, as soon as the nurse gave up on me getting the line any time in the next 5-10 minutes, and went out of the room for a quick errand, I got the line (you need the nurse to attached the pressure tubing in a semi-sterile fashion, otherwise you risk contaminating the field and losing your brand-new line by reaching for wherever the nurse tucked it).

Overall today was the worst possible of all my days in the cardiac ICU so far, except that I was with an attending I like and trust, which helps a lot. Without really verbalizing it, we split the unit in half: he took the most unstable patient, and the most hopelessly stable (no progress except in a steady downward direction), and I took all the others. It felt as though I was competing to see how many other procedural specialties I could involve in my patients’ care. By the end of the day I had a pretty full tally: general surgery, vascular surgery, GI, interventional radiology, plus some noninterventionalists: neurology, endocrinology, nephrology. At the same time, I managed to have fairly decent conversations with the families of four different patients, which is better than my usual ICU record. (Especially cardiac ICU: I usually feel as though I don’t know enough, or control enough, of the patients’ course, to be able to explain fairly.)

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