Hey guys, I'm Eli and in this particular video I'm going to be teaching you how to present your patients on rounds when you're in the ICU. Now this information will pertain to all types of ICU since I think that all intensivists at the end of the day, we think alike. We're all detail oriented people.
The reason why I decided to do this video is because I teach medical students, medical residents, interns, nurse practitioners, as well as physicians assistants who are both in training as well as practicing. There's a lot of variation, a lot of confusion as to how a patient should be presented and ultimately everybody has a different style. The way that I particularly like to work is in a low stress kind of environment because there's a lot of stress inside the patient's room. So if you keep your team nice and happy then your work day is going to be better and more productive.
But at the end of the day... Attendings are different and expectations are different and so while this might seem a lot what I'm teaching you I think that at the end of the day it's more important that you understand why we do it as opposed to just Speaking out numbers, which is what a lot of people who do not have experience actually do during rounds They just read their piece of paper and read out vital signs to me Ultimately, I know what the vital signs usually are at the beginning of rounds and I just want you to understand it and try to make the patient better take that information to make the patient better. I went through all this myself I mean I hit a number of brick walls when I was presenting patients there was a lot of hand holding that certain attendings who I'm very grateful for did with me in order to get me to the point where I am now and hopefully you will be at this point too okay. Going through things this as I said before this may seem overwhelming to you and like going to the gym you need a get a lot of repetitions in in order to get good at this and once you start getting better at this your comfort level will improve and as you keep on working with the same team of folks you will become more comfortable with your team with your environment and you will do a lot of this subconsciously this particular information that i'm going to be teaching you is tailored for united states icus i've practiced at a number of places i've also practiced in other countries and um Every country is different so for those viewers who are abroad and are looking to come to the United States I wish you a lot of luck in getting over here and putting your skills to great use and taking care of people and ultimately this is how we do it here. When we start presenting patients well when you all start presenting patients to the ICU attending such as myself You need to keep in the back of your mind that most of us, by the time that we start rounds at 8.30 or 9 o'clock in the morning or whatever time is designated, we've already seen all the patients quickly and we've already gone through all the patients'information.
I know that I could see 16 patients in the course of an hour and a half, as well as go through all their data and all that stuff. It's just quick, boom, boom, boom, boom, boom, take care of everybody, take care of what needs to be done immediately, and move on. So most of the stuff that you're going to be telling us during rounds, we're already aware of it.
But this is for teaching purposes. And in academic institutions, we want to teach. So we want to make you better. So that's just something to keep in the back of your mind.
When I dissect people's charts to see what their labs are and all that, remember, everything that we do is to try to help the patient out. Okay? So that's the reason why we... go through every little piece of data to try to improve the care of the patient.
I am a details kind of guy and I like all the little nuances. One of the things that I'm not going to do in this video is break down how to do the assessment and plan because I think that that's something that you need to work on yourself and it's something that's kind of lengthy to go through and for the sake of time I'm going to avoid going over how to do an assessment and plan because some places like a problem-based assessment and plan and some people like an assist excuse me a systems-based assessment plan so I'm not going to go through all that maybe in a later video if you think I should do it okay so this is what I'm going to teach you and I apologize for the glare behind me but I will go through this in detail so couple steps that I'm going to go through to present the patient well. Some people say how long should I be presenting the patient for?
Well you should get through all this data and once you become comfortable with it, it will occur fairly quickly. I know it seems like a lot but once you get the hang of it, it's really not that bad. Trust me.
So we'll start off with the one-liner. The one-liner is not an official term, but it's something that I think is important because it orients the whole group as to what's going on and I'll go over that in a second. Then we're going to talk about the overnight events, vital signs, and the overnight events. Eyes and nose, the ventilator if your patient is on the ventilator, the lab data, the imaging, basically all those tests that we ordered for our patient, we need to talk about it, the patient's tube, how many days, the life. how many days, catheters, etc.
The medications because at the end of the day we're doctors, we practice medicine so we need to know our patients medications inside out. In addition to that we're going to talk a little bit about the physical exam as well as what I already mentioned that I'm not going to talk about. not going to teach about which is the assessment plan okay so the one-liner what is it well when you come and present a patient I want you to just smack me in the face and tell me what's going on with the patient so you can say here in bed six we have Jane Doe she's a 68 year old female hospital day X number and the reason why I want you to tell me what hospital day the patient is in is because if the patient's on the bed and they've been on for a prolonged hospitalization i'm already thinking about treating the patient i'm thinking about goals of care which i'm already thinking about from day one but nevertheless it just triggers me to take into consideration how long the patient has been there and what progress should we have made by now okay so once again jane doe that's a made up name by the way jane doe 68 year old female hospital day six here for acopd exacerbation boom i know what's going on with the patient okay So right there my mind is channeled into knowing that I'm going to be treating Jane Doe for a COPD exacerbation and she's on the vent.
Good. Okay. Now the next step is the overnight events.
I want you to be able to tell me what happened during the 12 hours or so that I was not in the hospital. And this information could be obtained pretty darn well from either the person who is checking out from the overnight shift or from speaking to the nurses. Because the nurses are...
fantastic fantastic resource for two fantastic resource to get information with regards to what happened to your patient if the patient self-extubated if the patient dropped their blood pressure if the patient stopped making urine overnight these are things that your nurse will be able to tell you right away so these overnight events are things that you should definitely bring up during rounds immediately after you give me the one-liner you go ahead and you give me a job and then you give me an uppercut okay you let me know Boom boom what's going on with the patient? So the next step is the vital signs and so don't be that person who reads down the vital signs with regards to a range. Oh the temperature was between 98.5 and 100.1. That really doesn't, that shows me you can read off of a piece of paper, off of a computer screen, but it doesn't show me you're thinking about it. So if the patient, for example, had a fever, or if they received received any Tylenol or NSAIDs or any type of antipyretic to combat fever and you know the person was normal thermic but they did receive Tylenol during the course of the night or the patient was febrile and they received Tylenol for that fever okay so the other thing is that comes up in the vital signs is the temperature their oxygenation so you might say oh their stats were Between 95 and 100% the whole night.
That's great, but were they getting oxygen with it? Were they on acucannula? Were they on the vent?
Was the liters of oxygen turned up sometime during the night? Or was the... Were the settings on the vent changed at a certain time of the night?
These are things that I want to hear that you thought about, okay? So you could say, oh, their saps were great during the whole night. They're on two liters of canula. Boom, that showed me that you were smart enough to...
to identify that the patient was okay with regards to the oxygen, but they did require some assistance from two liters nasal cannula. So then you should tell me about their respiratory rate. That could be a range as well with regards to respiratory rate.
You could tell me if they're breathing 16 times a minute, but are they breathing 16 times a minute because there are a vent that's set at 16 or are they spontaneously breathing 16 times a minute? or is the vent set at 16 times a minute and they're breathing 34 times a minute over the vent? These are things that you should be able to interpret and give me that information. So the next thing in the vital sign, and once again, all these different parameters, respiratory rate, temperature, etc., could be in different orders. It's all, you know, basically what you want to do as long as you get that information out of there.
The next piece of information is the blood pressure. And in patients who are critically ill, those who have an arterial line, and those patients who are our oppressors I would rather prefer for to hear the mean arterial pressures as opposed to systolic and diastolic because we know about The problems with the blood pressure cuffs that are computerized and sent up to the monitor, that they're not really that accurate, okay? So I prefer to know the mean arterial pressure.
So if you could tell me, oh, the patient was normal tested the whole night, that's fantastic. intensive but were they on pressers were they on epi were they on phenylephrine were they on vasopressin with levophed these are things that I need to know and if they were on pressers I need to know if it was titrated upward or downward during the course of the night so you could say say yeah this person was normal tested the whole night but their levophed requirements went up from 2 mics to 30 mics. Well then they weren't really stable they were actually getting sicker.
So you kind of see what I mean by that? I hope that I'm elaborating all this perfectly and if for example somebody has an intracranial hemorrhage you really should keep their systolic blood pressure less than 140 per the guidelines. Now You can say, oh, this person was under 140 the whole night.
Yes, but did they get any PRN blood pressure medications? Did they get any labetalol? Did they get any hydralazine? These are things that you should be able to tell me during the course of rounds, okay?
What they got to treat their blood pressure. So, part of, that might seem like a lot so far, but we have a lot more to go. And I understand how this might be overwhelming, but trust me, trust me, trust me. And once you get the hang of doing this, it'll be pretty, pretty darn easy.
Okay? So I went over the one liner, overnight events, we covered the vital signs. Next thing is I's and O's.
And when you start saying the I's and O's, you should say, oh, this person, and this is usually obtained through the EMR somewhere in the software, or you could obtain this by a printer. you know basically everything that the nurses chart you should tell me how much the patient is net negative or net positive over the last 24 hours as well as how much they are net negative or net positive during the course of the hospitalization. And of course, insensible losses are something that you should keep in the back of your mind and, you know, use that in your assessment and plan.
The other thing that's extremely important in critically ill patients is measuring their urinary output on an hour-to-hour basis, okay? And sometimes you can find that on your EMR. Because I need to know whether the patient's urine output dropped off. and then they got a 500cc bolus at some point or the urine is picked up spontaneously.
Because that could lead us into clues as to things that could be going wrong with the kidneys. So, the other thing with regards to the I's and O's on the I's component of it, we need to know what the patient is getting with regards to IV fluids. Like, are they net positive because they received X amount of boluses?
Do they get normal saline maintenance fluid at 125? We need to keep that in the back of our minds because these are things that we could potentially cut back on. If the patient is net negative, we need to know is it because they're having a post-ATM diuresis or is it because we're actually trying to diuresis them using furosemide or some other agent? Are they having a lot of drainage from their JP drains in the case of people who are, um, in the case of the people who have had abdominal surgery, did they put out a lot from their chest tube, are they having a lot of diarrhea, vomiting, we need to know all these things.
And we also need to know if the patient's having bowel movements because that's important. One of the things about eyes and nose, as I said, you have to take insensible losses into account so they're not 100% accurate. And we're aware of this.
So, you know, that's just some more information from the presentation that we should go over. The next thing I'm going to talk about now is the ventilator. Now, I don't expect you to know absolutely everything about the ventilator because there's a reason why there's a fellowship for critical care and pulmonary critical care. It's to be the expert on the ventilator.
Also, there's a reason why there's respiratory therapists because the ventilator ultimately belongs to them. But I do need you to understand basic principles with regards to the ventilator because I need you to give me that information during rounds. So it's just going to be the basics.
I want you to be able to tell me what the mode of ventilation is. And usually the mode of ventilation, which I plan on making an independent video talking about ventilators, but you got to tell me if they're on pressure support, if they're on pressure control, if they're on volume control, if they're on SIMV, if they're on PRBC, are they on APRB. These particular components are important.
Okay. I need you to tell me what their driving pressure is. If there are some sort of pressure support mode, excuse me, some sort of pressure control mode, yeah, or pressure control mode, I would like for you to tell me what the FiO2 and PEEP is and the respiratory rate and the tidal volume.
And when you tell me the respiratory rate, you might go ahead and take a look and see that the rate is set to, for example, 16 as I use. earlier during this talk but the patient might actually be breathing spontaneously over over this particular rate so you might actually go over look at the patient might see that they're breathing faster than 16 times per minute and if you look on the vent there's usually an F somewhere in there depending on the brand name and that'll be able to indicate what the actual respiratory rate is for the patient okay so that's basically it for the for the ventilator also talk to your RTs they might be helpful in telling you you if there are any issues overnight with regards to the ventilator. So now we get to lab data and lab data tends to bog down people because they just go to the piece of paper and they say oh CBC hemoglobin, excuse me, let's go with normal order how it is in the United States. CBC 15.3, hemoglobin 9.6.
Do you think, do you really think that anybody's listening to you when you're saying that? I might be throwing over a bunch of, I might be like kicking myself under the table on a bunch of intestines, but that's just mundane data that most of us who are hyperactive people don't have the attention span to listen to. And like I said, we already went through that data. So when you actually go through your CBC, I want to know about trends.
I want to know about their white count trends, their hemoglobin trends, platelet counts. Things of that nature, okay, and the differential is always important, okay? So don't forget when you're saying the white count trends, keep in mind also, you know, somewhere in there, whether they're on antibiotics or not, or whether they are on some medication that's going to push their white count up. For example, steroids, they kick up your white cell count.
So keep that in mind. With regards to the hemoglobin trends... you know this is also important in patients who you suspect of bleeding patients who are on anticoagulants things like that so you might say oh the hemoglobin is 7.1 and you know it's different if it's 7.1 and it was 9.6 yesterday versus 7.1 and it was 7.3 yesterday so the trends are very important because clinically they tell us what to do and um we need to No, what's it do? That's the whole point of getting all this information. Platelet count trends are also important with regards to platelets being something reactive, so it could be something that's extremely elevated in patients who have some sort of intra-abdominal abscess, or you could think of thrombocytopenia because of a critical illness, sepsis, or the big scary three-letter acronym that we are not supposed to say during rounds, which is HIT.
Okay, always keep that in mind. And don't forget that hemodilution and hemoconcentration plays into your white count, not to your white count, but to your CBC. So that's why I kind of want you to know what your I's and O's are when you present the patients to me. Because you can say, oh, the patient's net negative over the last 24 hours, 2 liters, right?
And then you can correlate that into your CBC and say, oh, but the white count went up, and the hemoglobin went up, and the platelet count went up. Well, that's because you got rid of 2 liters somewhere, so there is some component of hemo concentration in that particular patient. So keep that in mind.
Remember, you're here to analyze data, not just to regurgitate it to me. And now with regards to the basic metabolic panel or the comprehensive metabolic panel, once again, knowing the trends is sometimes better than knowing the absolute number. So if you read to me, sodium-1- 37. Potassium 3.8. No, that's just not going to work for me. And yeah, here's how you should do it.
The sodium is 145 yesterday. Today it's 152. And you might think to yourself, oh man this patient is getting a bunch of sodium chloride which is 154 mEq per liter. Hmm, maybe I should change the IV fluids to something like plasmolyte or LR so that this patient doesn't become hypernatremic and hypochloremic because of some miscarriage. mistake that we're overlooking.
Okay, so you can, I hope that I'm portraying, you know, the common sense approach to presenting a patient rather than just getting through presenting a patient and going to go eat lunch, okay? So, other things that could affect the sodium, always remember the medications, the IV fluids, diuretics, whether they be thiazides making you hyponatremic or... Furosemide, which can make you hypernatremic, because you're excreting more free water.
These are things that you should keep in the back of your mind, because you could go ahead and show off in your assessment and plan and say, oh, this patient's hypernatremic because, amongst other things, they're getting a bunch of normal saline, which has 150 formula equivalents. Present that to me during rounds. I'm going to be impressed by you because that shows me you're thinking about things.
More so than you saying numbers over to me. So, when it comes down to the other electrolytes that we could replace, whether they be potassium, magnesium, phosphorus. Remember, phosphorus is very important for the respiratory muscles, so you got to keep that within normal limits, especially for ventilated patients and critically ill patients. You should be able to tell me whether those numbers are high or low during your presentation.
You could say, oh, the K is 3.2, which is low, or oh, the magnesium is 0. Hey, that's pretty darn low. We need to fix these. And you go ahead and you show off in your assessment and plan to say hypomagnesemia, which we will repeat, hypokalemia, etc. Okay. Excuse me as I clear my throat.
Also on your CMP and BMP, you're also going to get the glucose. My camera had just cut out. So getting back to what I was saying about glucose, the glucose trend is very important.
That's usually charted by your nursing staff. And so you should. report during your presentation that the patient has a glucose range between, let's say, 120 and 350, and then in your assessment and plan, you have to come up with a reason or way to bring that blood glucose down from 350 to a level that's more acceptable. Another thing that's very important to look at with regards to trends is the BUN and creatinine. Okay, because there are certain parameters which you should know, differential diagnosis for elevated BUNs, and it's not only the patient is dry, but something like a GI bleed could cause an elevated BUN.
So take that into account. And the creatinine is also super important. Even though it's ultimately not the best test for renal function, it is the best that we have right now. and basically it's an international test that you don't need to be at a fancy institution to be able to use.
And so you might say that the creatinine is 1.1 and it doesn't show up on red on the computer or on the printout and so therefore it's normal. Well that's not true. You have a person who had a creatinine of 0.5 the day before and the next day is 1.1 and this patient's creatinine has doubled in the last 24 hours. They're basically in renal failure right now. Okay, so that's why trends are important to just analyze these before and what the numbers have been and which general direction that Their their renal function is going so it's not only seeing the numbers but interpreting it Okay, LFTs also important think about what drugs and which medications You're giving the patient in order to alter those numbers.
Okay So as we move along the next step is the culture data which is here in the labs. My camera has overheated twice now so we're going to continue on talking about the culture data and this is the part you have to say what the results of the blood cultures are and keep in mind when they were drawn. Okay, because that helps me decide whether I need to redraw blood cultures if they're still sick, if they're still fevering, if they're still requiring escalating pressors or if I'm thinking I'm not getting the right blood with the right antibiotics.
So blood cultures, if they're negative, when were they drawn? Respiratory, Quan, urine culture, things of that nature should come out here. Cultures of any other thing you might have cultured.
That was redundant. Anyway, let's move on. So after we go over the lab data which includes the culture data, next up is the imaging. And the one thing I recommend for trainees as well as nurse practitioners and PA's is to review the images you're Don't just look at what the radiologist said and you know present that on rounds take a look at the picture yourself and interpret it During medical school, and I'm sure that this also applies to a nurse practitioner school and physician's assistant school They don't dedicate that much time to radiology It's very important and so if you look at a lot of pictures you're able to pick up on some trends and kind of be able to identify things that you weren't able to identify one.
So look at the picture, look at the read from the radiologist, then look at the picture again and use all that information to present your chest x-rays, KUVs, CT scans of the chest, head, whatever you need, learn to basically read it yourself. You also should keep in mind the nuances of echocardiograms because that's also a part of the imaging. In critical care medicine, The left heart is very important but the right heart is as well.
So keep that in mind if your patients take on the event that they're not a right heart failure. That's a conversation for another day. But look at the whole entire report for an echocardiogram and don't just focus on on the ejection fraction.
Okay, and next step is to look at tubes, lines, and catheters. Because if the patient's been tubed for three weeks now, well, you should have been thinking about a tracheostomy a while ago. has central lines, you should always be thinking about alternatives to central lines.
If the central line isn't needed anymore, you should definitely talk to your nursing staff about obtaining peripherals. The other thing is that you should always take a look at the foley, not look at the foley itself. Well, you should look at the foley yourself, but could the foley come out? These things, you need to try to get them out and talk about that during your assessment.
Now, we're all medicine doctors. Even if you might be a surgeon, you're still a medicine doctor. So you should know every medication that the patient is on and whether something needs to be escalated or de-escalated.
And you should tell me when you say, oh, this patient's been on vancomycin as an example. You should tell me. How long the patient's been on vancomycin for? You already told me what they're being treated for in the culture data, if something grew out.
But you should tell me how long the patient has been on vancomycin as well as any antibiotic for. Here you should also tell me what fluids they're on, what's the rate of the fluids. You should also be really analyzing how much insulin the patient got in case that they're hyperglycemic and how much sliding scale the patient got because that sliding scale could be converted to a long-acting insulin if that's available in your country.
Now, here's a time for the physical exam. And... Please, please, please, on this particular part, talk to your attending and find out what they prefer for you to present during the physical exam. In my particular case, we already talked about the vital signs, so you really should not tell me the vital signs again.
And when you go into the patient to examine the patient, you should always take a look at all the drips that the patient is on. The reason for that is because your physical exam could be altered based on the patient's sedation. So if the patient is on fentanyl and propofol, your mental status exam is not going to be kind of where you want it to be. They're not going to be as brisk in it.
as happy and as awake as you would think. Okay, so first when you're with the patient on the physical examination, you just say whether the patient is sedated and intubated, if they're awake, following commands. A neurologic exam is extremely important on a critically ill patient because a lot of times they get a stroke and if you don't turn off the sedation and try to get an exam on them, you're not going to be able to find out whether they have a stroke or not and then you're going to miss it and then they're going to be... Sicker because you missed something and that that's pretty bad So when you do your neurologic exam on the patient, I don't really expect you to be doing reflexes and things of that nature but make sure you turn off sedation and Try to get the patient to wake up open their eyes follow commands follow two-step commands see what they can do if they're not quite doing that, pinch them, try to elicit painful reflexes, see if they localize to pain.
Other components like that, which I'm not going to go over on this video, which are important for a neurologic exam, OK? Make sure that the tubes and the lines look good. Make sure that their heart sounds are good, that their breath sounds are OK, that the patient does not have a distended belly or absent bowel sounds. Make sure they don't have anything going on with their skin. Other components of the physical exam, which I'm not going into too much in depth because your physical exam should be pretty concise in critical care, but at the same time pretty thorough to what you're looking for in a particular patient.
You don't want to miss anything. Okay, so last but not least is the assessment and plan, and like I said, I'm not going to discuss this during this talk because... The assessment plan depends on the institution and the assessment plan is basically your opportunity to shine and your opportunity to say what the problem is with the patient and how you're going to fix it. Okay, whether you go by systems or by problem base, that's up to you, but what's up to your institution, excuse me, but ultimately that's your time to shine.
The whole point of doing all this is to be able to talk about your assessment plan. So this video is I guess it will be like 20 something minutes long now and I basically went through the whole entire the whole entire presentation of a patient so yours should be less than that because I ran my mouth quite a bit. So, lastly, thank you very much for watching this video.
I plan on growing my channel substantially now in 2017 it's been one of my new year's resolutions and I want to get 10,000 subscribers before the year is up right now. I only have about 47 subscribers, but hey, please give me a thumbs up, a like. If you think about giving me a thumbs down, please tell me why in the comments below. Thank you so much for watching and I hope you have a great 2017 as well. Thanks guys.