My experience of working in ITU - as part of my placement as a ST4 Acute Medicine Registrar

This post is about my experience of working in ITU as part of my Acute Internal Medicine training. 
As an acute medical trainee registrar, I have to rotate in respiratory, cardiology, AMU, care of elderly and intensive care. 

I started my rotation in December,2020. As we were the worst hit hospital in the second wave of COVID-19, I was asked to continue my medical on calls by the management instead of ITU on calls . 

This is how it is for Acute Medicine Trainees rotating in ITU in my trust:
1. We are put on the ITU SHO rota 
2. We are supernumerary doctors 
3. We do on calls in ITU ( as a ITU SHO) with an ITU registrar 
4. We are not expected to make any decisions on our own as the ITU registrar and ITU consultant are always available to help. 

What was different for me:
I would be doing medical on calls rather than ITU on calls till the pandemic settled 

How a SHO post was different for me:
1. After working as a registrar for 1.5 years ( ST3 and 4 months in ST4), I initially found this a bit strange. However it is good as ITU is a completely different ball game and I am glad I am a supernumerary SHO there. 
2. I have excellent support 
3. The ITU nurses have more knowledge than I do - They have a lot of experience and help me with everything. 

ITUs in my trust :
There are 3 ITUs - one is non-COVID and 2 are COVID ITUs

A ward round on non COVID ITU:
Handover at 0800 sharp in all ITUs where patients from the night ITU consultant , registrar, SHO, ANPs are handed over to the day ITU team ( full team from SHOs to consultant are present in the handover). The handover is detailed and takes around 30 minutes. 
The ITU registrar then allocates beds to the SHOs, ANPs and (s)he also sees patients. We get 2 or 3 beds. 
We fill out the daily handover sheet which is a prefilled sheet with all the necessary details 
The ward round starts at 0900 and we present our cases to the consultant.
The whole team goes around together ( The consultant does not start the ward round till we have seen and assessed our patients)
The consultant usually documents his/her assessment and plan in the consultant ward round section. 
Some of the team members are allocated urgent jobs and break off from the ward round after presenting their patients. If necessary, the ITU reg and consultant help. 
One of the ITU team members keeps a detailed list of the ward jobs. 
The ward round finishes at around 1130 AM. 
We carry out the ward jobs and then go for lunch at 1200 PM ( before COVID, we would have lunch together but now everyone does their own thing). 
Then we carry out any left over jobs and then do our own thing.
The ITU registrar is physically available on ITU and the ITU consultant is in his office, happy to be called at any point 
The ITU consultant then does a second ward round at 1500 or1600. It is just like the first ward round with a full team but is faster, yet thorough. 
The team leaves once the jobs are done. We are supposed to stay till 1800 but we can leave early after letting the ITU registrar know- They actually ask us to leave as they do not want doctors sitting idle on ITU especially in the pandemic. 

INDUCTION DAY 
I came at 0800, attended the handover in the non COVID ITU and then one of the ITU nurses provided me with my home testing kit for COVID:
We are supposed to swab ourselves at least twice a week if we are asymptomatic, log the results on the trust database which we can access at home. 
If we are negative, we continue coming to work. If we are positive, we immediately self isolate and arrange a PCR test through the trust. 
This test prevents asymptomatic positive healthcare professionals coming to work and infecting others. 
We then had an ITU consultant go through the local policies with us and gave some excellent tips. 
We then went on the ward rounds. 

HOW ITU IS DIFFERENT FROM OTHER SPECIALTIES I HAVE WORKED IN 
1. The ITU registrar and consultant are always available for advice. It is very hands-on for them and they like to do everything themselves. They personally help to chase jobs if the juniors are struggling. 
2. The ITU nurses are very knowledgeable and experienced. Some have more than 20 years experience and sometimes even call the ITU registrar and consultant directly if they are concerned about anything. 
3. The handover is very thorough - it is not like ' oh this is the same patient who has been here since 4 days' - it is always in a SBAR manner with all relevant details even if the patient has been there for ages 
4. The daily progress notes and consultants ward round is very detailed. 
5. The nurses have already done the bloods early in the morning ( almost all patients have arterial lines from where nurses do bloods) and the results are available on the ward round at 0900. 

MEDICAL TRAINEES IN ITU 
We have Acute Medicine trainee registrars, respiratory registrars, IMT trainees who are all part of the supernumerary rota. This is for the sake of patient safety as ITU trainees know what to do if things go wrong which medical trainees may struggle with. 
They are still considered part of the team. They see ITU patients, document the daily progress notes and follow the consultants ward round plans. They also do procedures. 

PROCEDURES MEDICAL TRAINEES CAN LEARN 
This comes down to the trainee and how willing they are. 
However by the end of their placement, trainees are expected to be competent in:
1. Central lines 
2. Arterial lines 
3. USS guided cannulation 
4. Chest drains 
5. Any other procedures they want to learn as part of their personal development plan. 

CASES WE SEE ON ITU 
Medical:
DKA 
Severe respiratory failure 
Sepsis with multiorgan failure 
Cardiogenic shock 
COVID-19 

Surgical 
Post-op cases 
Road traffic accidents 
Neurosurgical cases 

This list is no way complete however this is what I remember - I will keep updating it as I go along. 

COVID-19 ITU 
This is a completely different ball game. We see unwell patients who continue to get more complicated. We are fighting a virus and throwing everything possible at it yet we have very few success stories, especially in the slightly elderly patients. However we see young people without any co-morbidities deteriorate as well. Hence, the morale on COVID ITUs is very low. Yet, we prod on. We try to stay positive yet we all know we will loose this battle. We see our own health care professional colleagues who were standing with us a few days ago, now on 15 liters of oxygen and we wonder when will it be our turn. No one is safe. 
For this reason, the ITU consultants are very supportive.
This is how a typical day on ITU is spent:
1. We come at 0800 AM and take a detailed handover from the night team. This is attended by the night registrar and day consultants. 
2. We then divide patients - we can have up to 5 patients per health care worker (which includes FY1, FY2, ACCS trainee, ACP, medical registrar rotating in ITU, ITU registrar). 
3. If the night team has not mentioned any urgent issues, we wait till 0900 AM and then put full PPE 3 on ( there is a healthcare worker whose sole responsibility is to ensure all colleagues entering ITU are adequately protected and to ensure there is enough PPE supply). 
4. We fill out daily review sheets - it is a typical story: 60 year old, otherwise fit and well, tested positive for COVID a few days ago, admitted with shortness of breath, requiring O2, O2 requirements increased, started on CPAP, SO2 worsened on day 2 and was tiring. Intubated and ventilated. Now day 7- to consider tracheostomy if remains stable. 
5. After seeing these patients, the consultant comes in at around 0930 and does a detailed ward round. 
6. The ward round can last anything between one hour to 2 hours depending on how complicated the patients are. 
7. We then divide jobs and once we have sorted out the urgent stuff, we go out. 
8. The ITU nurses have our numbers/bleeps and contact us whenever they need to. They have direct access to the registrar/consultants and usually contact them directly if they are concerned. 
9. We have a second ward round at around which lasts 30 minutes to an hour and then we do the jobs. 
10. The on call doctor stays in the doctors room and the rest of the team leave. 

HOW COVID ITU IS DIFFERENT FROM THE OTHER ITUs
1. As mentioned above, we have less success stories on COVID ITU
2. Staff morale from nursing staff to consultants is very low. The patients who were doing well on CPAP a week ago are now intubated on quad strength inotropic support. In 2 weeks time we may be considering palliating them if they continue to deteriorate. 
3. Working in full PPE 3 is extremely difficult. The hospital is heated and we need regular breaks while wearing full PPE 3 in 25 degrees. 
4. Limitations in treatment - we throw everything at these patients - we spare no expense. Yet we get very few good results. 

Regardless of this, the nursing staff, doctors and other healthcare professionals remain extremely thorough. They do not miss out on anything. The nursing staff meticulously document OBS like they would on a non covid ITU. The ward rounds are just as thorough. None of the patients are neglected and actually, receive the best care possible. The amazing nurses shave them, give them a wash, update families, hold their hands when they are on CPAP , scared and see other patients who were doing 'okay on CPAP' intubated and then going to the morgue in a body bag. Yet they keep at it. The doctors try to help as much as possible - especially proning patients ( with a ETT, central line, NGT we need upto 6 health care professionals with a airway trained person to prone a patient) 
Most of the health care professionals working on COVID ITU are rotated whenever possible for this very reason - it is depressing, stressful and it breaks us. 
I have been a registrar on the COVID wards in the first wave and now in the second wave. I am a very positive person but this has broken me as well. 
COVID ITU is completely different and you only realize it when you work there for a few days. 
However, we celebrate success stories, they are few but we still keep ourselves motivated. I tell everyone proudly how my 65 year old patient was successfully extubated and was discharged. This keeps us all going. This gives us hope. Yes, we keep breaking but we work together. We support each other and this kindness and determination is what keeps us going. 
I really hope this vaccine works. It has to! 

TIPS FOR MEDICAL TRAINEES ON ITU:
1. Try to learn as much as you can. As we are supernumerary, we are not expected to be as well trained as our ITU trainee colleagues but if you show an interest, they will teach you a lot. 
2. When you are a medical registrar on medical on calls, get to know your ITU SpR. As I work in a very busy teaching hospital, I have to refer a lot of patients to ITU who are unwell in ED RESUS and on the wards ( where appropriate) and knew most of the ITU trainees before I started. 
3. Work as if you are a trainee in ITU - learn everything. Even if it is regarding a surgical patient. You are looking after them that day, so learn and read everything you can about that case. 
4. Respect the ITU nurses - they are amazing and can be your best friend or worst enemy. They have a lot of knowledge. 
5. When you are free, learn whatever you can about ventilators. You will never rotate on ITU again and this is a very good opportunity to learn. You can clear your concepts about pharmacology, physiology and anatomy. 
6. Some specialties, like acute medicine offer specialist skills training in intensive care. So keep an open mind when you rotate here- you may never know that you enjoy it so much that you want to take this up as a specialist skill, or just train full time in ITU. 
7. Do not make any decisions on your own - the ITU registrar and ITU consultant are there to help. 
8. Do not shy away from working on the COVID-19 ITU, unless you are shielding. It is a good learning experience, albeit depressing. I have certainly learnt a lot and actually prefer it to the non-COVID ITU as this experience helps me make decisions when I am on call on the COVID wards as a medical registrar. 

WHY WORKING ON ITU IS NOT A GOOD IDEA AS YOUR FIRST JOB IN THE NHS AS A NON TRAINEE IMG IF YOU ARE NOT INTERESTED IN ANAESTHETIC TRAINING 
This is ONLY valid for those IMGs who are not interested in ITU as a specialty but have been offered a job as their first post in the NHS. 
Here are my reasons:
1. ITU is a highly specialized and supported environment where doctors other than ITU trainees are considered to be supernumerary 
2. You will NOT be able to meet the requirements to get your CREST form signed:
https://www.oriel.nhs.uk/Web/ResourceBank/Edit/MTA3NA%3D%3D unless you have a very supportive ITU consultant 
3. You will not learn the basics expected by foundation trainees like clerking on medicine, doing medical ward rounds, medical jobs, etc - ITU shifts are very different than medicine. Hence, if you plan to apply for a training post in medicine, you might struggle with understanding how everything works and may need time to settle.

Please note that this is my experience of ITU and other colleagues/ trusts may have a different way of working.