DIP Episode 416 - ICU Prep For Residents and Medical Students (Part 1-Foundation)

Okay, welcome. My name is Divine. This is episode 416 of the Divine Intervention Podcasts. And into this podcast, I'm going to be starting something I call an ICU series. So this is the ICU series for residents and medical students. So I'm going to make sure it cuts across all strata. So if you're a medical student, you definitely benefit from this. If you're a resident, you definitely benefit from this. And into this series, what I'm going to be discussing is the foundation, preparation. Like literally, what do you need to do to prepare for an ICU rotation? And I mean, you'll probably find this advice to be pretty useful as well for essentially any other rotation that you do. But again, my focus is going to be exclusively on the ICU. Now, one thing I want to say with all of this is please, the advice I'm giving here is not intended to guide your medical decision making. Again, this is solely for educational purposes. Just again, something you need to say, just to again, cover oneself. Okay, so how do you prepare for a ICU rotation? What's like a foundation? Because the thing is, if you have the wrong foundation, you can start building a house without having a good foundation. But when trouble comes, that house is going to fall over. And with that house falls over, you'll be like, wow, I wish I dealt with the foundation. So it's always good to deal with the foundation appropriately from the beginning so that you're not running health or shelter when problems come.

I mean, we're in buffet. It uses the school. It says that you only know who has been swimming naked when the tide goes out. So just be very careful. Build a good foundation. If you have a good foundation, then when trials and troubles and challenges come in an ICU, which they certainly will do, you'll be better able to deal with them. So what is so to them? I'm going to be discussing 17 principles, 17 basic things that I feel like you should have as a foundation or things you should be keeping in mind or attitudes you should be having as you prepare for a ICU rotation. So the first one is arrive early, arrive one time. The thing is a patient is in a ICU for a reason. A patient in a ICU is probably going through a lot of complex medical challenges. So it probably makes sense that you give yourself enough time to think. A ICU is not a place where you want to be in a hurry with evaluating patients and thinking through patients. Obviously, situations will arise where you have to do that. But the thing is again, if you build this foundation, based on what I'm saying, then you'll be very ready to deal with those kinds of patients very quickly. Over time, you get quicker and a lot faster at dealing with those presentations. But ICU requires a lot of thinking. You need a lot of thinking time. So that's why it's usually important to show up on time. Now, what's principle number two? Principle number two is B methodical.

This helps not just in the ICU, but in pretty much any other discipline of medicine, B methodical. B methodical. If you're a methodical, you will have certain benefits. One, you will not make too many mistakes. And two, you'll make you efficient. So you should literally have an approach for every single thing. You should have an approach for your notes. You should have an approach for your presentations. You should have an approach for rounding. You should have an approach for pre-rounding. You should have an approach for procedures. You should have an approach for common things. Basically, you don't have to have an approach for everything. We should have an approach for common things that you know constitute your day-to-day practice. And to be honest with you, as you design these approaches, one thing that may help is just observing a person that seems to be excelling at that thing. You want to design an approach too. And then literally, from the thing you observe in them, write it down and make it an algorithm. And these algorithms, after you've written them down, review them regularly so that it becomes baked into your brain. But I'm telling you, if you're a person that is methodical, if you're a person that has an approach, if you're a person that has an algorithm, if you're a person that has a checklist for many things, I'm telling you, be able to do so many great, great, great things at a high level, very quickly.

That is something that helped me significantly, as I went through residency, especially my intern year, where I had to do a lot of ICU rotations and award rotations. Now, the third principle for the ICU is become, become. I'm telling you, some of the greatest learning you get in an ICU comes from just being calm, quiet and observant. Like literally, you just watch. So, people think that, oh, until I do a thousand procedures, I won't get good at something. Don't get me wrong. You can get good from doing. That's one of the ways you get good. But you learn a lot. An ICU is like a very busy, nuanced environment. If you're very observant and you're calm, and you're not acting all crazy, you're going to learn a lot of stuff. Now, what is principle number four? Principle number four is to find out the presentation mode of your ICU and follow it. The thing is, the ICU is almost like its own hospital within a hospital. Everyone has ways they do things. The ICU in general, most people, the nurses, the physicians, the respiratory therapists, they all have an agreed upon, common approach to doing things because they know that they handle a lot of things that are error prone. So, most things in the ICU are very standardized. Learn the standard. What's the presentation mode? Sometimes, the way that cases, a patient is presented on the wards, is not the same way that same person will be presented in the ICU. So, find out. Many times, I see you have a printout for this.

Just ask you, attending or asking a senior, how do you do presentations? And then follow that method. You can't strike out on your own here because, again, you're pretty long the turun pool, even if you're a resident. So, most times, in my experience with a lot of ICU, most ICU's present by system. So, it's kind of different where, on the wards, most times, you know, it's like a problem list, you go by, by problem. No, most times, in the ICU is done by system. Just to make sure you cover everything and don't miss out on anything. Now, principle number five, this is probably one of the most important principles I'll discuss today. But in the ICU, you need to be a Y thinker. You need to be a Y thinker. The thing is, sometimes, in the ICU, you have to do things that are unusual that may not be common on the floor, but they may actually be the right thing to do. So, what I'm doing by being a Y thinker, you need to be able to prove to yourself why a diagnosis was made. Ask yourself, okay, this diagnosis that I'm opinion on this patient, why did I make that diagnosis? What was the data that helped me drive to making this diagnosis? That's a very smart thing to do. Just in general, question yourself when you're in the ICU. This diagnosis, why am I making this diagnosis? This treatment, why am I doing this treatment? Like, you shouldn't just say, oh, okay, I'm going to give LASIX. Why are you giving the LASIX?

In fact, I'm telling you this, many times, it's helpful to write down your Ys behind your actions. It's actually a very good learning experience. So, and the thing is, you're not always going to be sure of the diagnosis. If you're not sure of a diagnosis, create the safe approach to testing the hypothesis. Sometimes, in the ICU, to figure out what's going on with a patient, you have to test the hypothesis. That hypothesis can be you saying, okay, let me give a small amount of this drug and see how they respond to it. Or, let me withdraw this drug for a short period of time and see how they respond to it. Or, let me get this imaging study done and see what I find on imaging. I'm telling you, you're going to make very clean decisions when you know your wise. The ICU is a pathophysiological environment. So, again, you can just, I'm telling you, if you want to see a person do bad medicine, the ICU is a person that just does stuff without thinking, without knowing the wise. They just know, oh, this is the guideline. But, they don't even understand the guideline. They don't understand why the guideline was set up that way. You may do well with simple patients, but once you start dealing with complex patients, you start making some very life-threatening mistakes. And the thing is, in the ICU, keep learning, keep learning. I'm telling you, in the ICU, you're wrote management of patients. It may work for a while, but it's not a good long-term strategy.

You're going to do a lot of error-prone care if you follow that approach. Don't just follow work management. You need to think. You need to learn. You need to study. You need to read. You need to read. Again, bad medical practice is going by a work management. Good medical practice understanding the wise behind your actions and your thoughts, right? So think before doing really a good ICU physician is a thinking physician. Think before you're doing. Ask yourself, why? Why am I doing this? Why am I doing that? Why did I come up with this diagnosis? I'll write it down. Literally write it down. I'm telling you, even in the medical record, there's not even wrong about writing down your thinking. The thing is, if something bad happens from your actions, while you clearly documented your thinking in the medical record, you very likely not getting to trouble from a legal perspective. Because a person will see the reasoning behind what you did, especially if, again, your reasoning is in line with like accepted convention, right? And again, one thing I will say is make sure you think for yourself. Don't say, oh, this person has said this, I'm just going to accept you who client and think or no. People make mistakes. Even ICU heads make mistakes. Respiratory therapies make mistakes. You yourself will make mistakes, so it's just very important. When you see the decisions of others, just make sure you understand the reasoning behind their decision. Now, what is principle number six?

Principle number six is that contraindications matter. You need to think again. You need to think about contraindications when you're managing ICU patients. Again, this is why understanding helps. Because many times in the ICU, people get many different medications. They have many different comorbidities. A drug that may work for every other person that has a certain condition may be contraindicated in an ICU patient. Right? I remember there was a patient that, ooh, had like a skin problem. I'm like, hmm, and this person was being sedated and that sedation was with proper form. But I'm like, hmm, this person has this genetic issue. Proper form in a mobile good mix because proper form is prepared with a lot of triglycerides. Just that kind of thinking can help you again make very good quality safe decisions for your patients in the ICU. Obviously, it's not every patient that's going to have a genetic disease. But they are just certain times where like, ooh, a common drug that may be giving like an ACE inhibitor may not make sense in a particular ICU patient. And then principle number seven is as an ICU physician or an ICU trainee or medical student or whatever perform many rounds on your patients. It doesn't have to be like, wow, every five minutes. No. But every hour, every three hours or thereabouts is reasonable. You need to maintain surveillance on your patients. And again, the spacing out of the interval just depends on how sick or how complex the patient is.

If a patient is pretty stable, you don't probably do every four hours or something like that. But if a patient is really sick, you almost want to every hour make sure you want, checking on them. You want to, and the reason that you do these rounds is not just to, oh, so that you make sure your patients are doing well. But it actually helps you assess and see the trend of the decisions that you've made already. If you're making good decisions, you want to see that trend. Oh, like, wow. Okay, this patient came in with this EKG anomaly. Okay, check on the EKG regularly. Like, is this thing going in the right direction? Because sometimes it can cause you to say, hmm, okay, you know, this approach is not working out well. Or you begin to notice things or begin to, it's just helpful to have that fresh set of eyes every few hours on a patient. Right? So don't think of it as a mini round, like just surveillance. Obviously, you're not taking the team with you. You literally doing this on your own, right? But it's going to help you not get mini surprises because many times when surprises don't get me wrong, true surprises happen in medicine. But many times those surprises will not catch you on a wears if you're in constant surveillance mode. The US as a country is in constant surveillance mode to protect ourselves against terrorists. Right?

So again, if you're practicing medicine on patients that are very sick on patients that could blow up very quickly, then you want to make sure that you're surveilling them regularly. Now, what is principle number eight? Principle number eight is to confirm. I'm telling you errors in the ICU can be very costly. Confirm. After you've done something, if there is a way you can confirm that you did the right thing, confirm that you did the right thing. For example, if you've just placed a central line, there's nothing wrong with getting a chest x-ray. Just to make sure it was placed properly. If you've just placed an endotracheal tube, there's nothing wrong with confirming by chest x-ray. You did not put the endotracheal tube in the right means stem broncus. Again, verify. I'm telling you, it is one of the best ways to avoid errors as you practice medicine. Now, what is principle number nine? Respect everyone. Respect the patients, respect their families. Respect the nurses, respect the respiratory therapists. The thing is, especially if you're a new trainee, many of these people probably know more than you do, no offense. So, if you respect them, they will treat you well. Also, these people are at the bedside more often than you can be with a patient. If they notice something subtle that is changing, if they know that you're a respectful person, they will relay that information to you on time. They won't find out.

You won't have too many surprises because it's almost like you have in addition to your own personal surveillance, other people doing the surveillance for you. Now, what is principle number 10? In the ICU, documentation matters. Really, in any field of medicine, but in the ICU, especially documentation takes on a whole new level of importance. Because, again, patients in the ICU come there for test cases or circumstances. Sometimes people could come there because they had a drug overdose or whatever. Document, document, document. Document your actions, document your procedures, document your patient deaths, just document everything. Because, again, if someone comes down the line and says, okay, it's time to have you sued. If you have the medical record, if you have your thoughts, well written, it's sometimes it's better to document more than document less so that again, you can protect yourself from a legal perspective. Now, what is principle number 11? Principle number 11 is to pay attention to infection control. The thing is, many people in the ICU, they are immunocompromised. So, just exercise little extra wisdom, little extra caution in caring for those patients. Use your hands sanitizer, right? For infections where hands sanitizers are not going to work, wash your hands.

Put a proper protective gear because you're protecting yourself so you don't take stuff back home to your family, but you're also protecting them because they immunocompromised so that you don't add an extra problem on top of the problem that brought them into the ICU because you were careless. That's just a smart thing to do. Now, what is principle number 12? Principle number 12, call it confidential decompression, confidential decompression. Let me tell you this, the ICU is a tough environment. You're going to see a lot of patient death, a lot of stuff, right? So, you're not a robot, it's good to decompress with someone. And you notice I said confidential decompression again. Unfortunately, we live in a society where if people feel like, wow, this person is dealing with a lot of stuff emotionally, it can start creating a problem in residency program. So sometimes it may not be another resident, it may not be your program leadership that I good people to want to decompress with. You may have a buddy that is not even in medicine or a person that's a resident another program they can just sit down and chat with. You know, it's just helpful to sometimes just talking about certain things helps you deal with them better. Now, principle number 13 is restraint. Restraint is very important in an ICU. I feel like many times in the ICU, you see many people, they they act very antsy like, oh, I got to do something. Sometimes doing nothing is the right thing to do.

Like really in the ICU, it's very helpful to under-promise but over-deliver. That's a very good setting where this principle applies very strongly, right? Under-promise but over-deliver. You see some people, they get very exuberant. Whenever there's any minor improvement in a patient and they start telling the families, oh, he's improving dramatically. He's doing really well. He's going to come out. No, I'm telling you people, there are people in the ICU that, well, you're like, wow, this person has turned a corner. They're going to do well. And then an hour later, they're dead, right? They could throw off a PE, throw a stroke, get a heart attack out of the blue, right? So again, be guarded in your speech in an ICU, right? Literally wait until there's like, you're like, wow, the chance of this person like crashing from here is almost 0%. Like literally wait till a patient is just about to leave the ICU. Be stoned before you start offering your most optimistic prognostications to the families. I'm telling you like one thing that really helps in the ICU is just having this margin of safety, margin of safety reasoning concept, right? It's something that is very wise with investing, not talking about investing the future. But that margin of safety reasoning, where you're like, give yourself a wiggle room under promise, but over delivered. And then again, what is principle number 14? Principle number 14 is don't give up on a patient because you know they won't make it.

Still take good quality care of them. You see some people when they know that a patient is bringing it or whatever, like they kind of recuse themself from everything. They recuse themselves from family meetings, goes of care discussions with families and stuff. I'm telling you this, you're a trainee right now, wanting the future, you're going to have patients just like that. You're going to have to be the one running those meetings. You're going to have to be the one running those conversations. Again, I'm telling you, you can learn a lot from an ICU setting by just sitting down, being present and observing. Now, what is principle number 15? Principle number 15 deals with emergencies. Emergencies are a common in the ICU. I feel like the ICU in my experiences are placed where for extended stretches, it will be very quiet. And then out of the blue, like massive chaos just begins. The thing is, in emergency situations, I encourage you to have this principle of be focused and quick. In fact, let me call it this, be focused quick. This almost sounds like an anomaly, be focused quick. Divine, what do you mean by be focused quick? The thing is in the ICU, when an emergency is happening, try to make sure that you're shot out distractions. Shot out distractions. Shot out distractions. In fact, I think a statement that may encapsulate, sort of kind of what I'm saying is there's an ICU attending my hadry in my intern year. And you have this statement, be quick, but don't hurry.

It's a very useful principle, be quick, but don't hurry. Let me explain what that means. An emergency is happening. A patient is crashing right in front of you. But in that moment, become don't panic. I'm telling you, when you panic in an emergency situation, you're going to make a lot of mistakes. You're going to do a lot of things that are not smart. So while you're dealing with that emergency, be thinking as you're dealing with that emergency, focus on exactly what you need to do as you are acting. So be thinking and focusing. Make sure that what you're doing, like it's better to think and then act afterwards than act, make a mistake, and then have to start thinking and on doing those mistakes that you've made. So be quick, but don't hurry. Let me give you an example that may relate to regular life that many people receive. There's this show I love watching, the amazing race. You know, I watch it a lot. And you see people, you know, they're, by the time they get to the top three and it's the last pet stop or whatever, you see people start doing crazy things that they've not done all through the race. They start thinking about, oh, the other contestants where they are relative to them, they start thinking of doing all these on the hundred things to slow down other people instead of focusing on the race that is in front of them. Right.

The thing is when you start dealing with all those distractions, start panicking and doing all these things, you start making horrible mistakes. You see some people, it's a critical five minute period of distraction that makes them lose literally the whole race, one million dollars, they're out one million dollars. Right. So it's just very helpful in those emergency situations. Be rational. I'm telling you, it's hard to do what it's doable. Like I remember during my intern year, had patient codes and everything, you see people in the room just panicking, panicking, panicking massively. No. In those moments, think of yourself like a co-ion Leonard. Be quiet, become, be thinking, will be sharply focused. I'm telling you, when you do that, even if you're in a chaotic situation, life will seem to slow down for you in those circumstances, even if you're getting a lot of really good stuff done very quickly. That's probably the second most important principle I think I'm discussing in this podcast. Now, what is principle number 16? Principle number 16 is procedures, procedures, procedures, procedures. The thing is, I'm telling you to be good at a procedure, first, make a checklist of every step in that procedure. Second, break that procedure into discrete bits and learn each discrete bit very well. Like breaking it up into a set of tasks, even an intuition, you can break it up into like 10 or 15 parts and then ask yourself, okay, part one, what is it? Okay, how do I do it?

I'm doing it well, learn each thing and then mask it all together. If you do that well, you'll be excellent at procedures and you'll get very similar outcomes from all your procedures because you're doing it in that standardized way. And then principle number 17, which is our final principle is, what are some key topics you should try to make sure you learn? If you understand the topics that I'm going to discuss now, again, I'm not going to go into depth on any of these topics. There's going to be separate podcasts, God willing, on each and every one of these topics, at least most of them. But what are some things you want to make sure that you know and understand? If you know these things, especially for a resident, you know, maybe a little less so a medical student, you'll be able to deal with like 80 to 90% of what may arise in a ICU, right? So one, you want to know about feeding in the ICU. Like when do you do entero feeds? When do you do perintero feeds? That's a very helpful scale to master. Just knowing the having that knowledge, right? And then two, you need to make sure you know about AC based problems. Patients that come to the ICU many times to have AC based issues, you need to understand them, you need to know how to diagnose them, you need to know how to manage them, you need to know when to call an apology. And then I'm definitely that's also helpful to know about is ARDS. ARDS has a lot of physiology and pathophysed victim to it.

You want to make sure that you understand these things, how to again, manage it and stuff like that. You also want to make sure you understand ventilators. Ventilators are very useful to understand. Like ventilators, and I guess I can maybe throw in respiratory failure, right? Many people come to the ICU because they are going into respiratory failure. You also want to make sure you know everything you kind of all sepsis about shock, the different kinds of shock, the cardiogenic, the neurogenic, the septic, the um, about phylactic, you want to know those shocks, how they are assessed, and you want to keep yourself abreast of the chronic clinical guidelines, right? And then fluids, fluids, fluids, your imputes and outs, you need to know about fluids. When do you give up your men? When do you give normal saline? When those lactated rangers make the most sense? When should I do blood transfusions? It's not every patient that you with still seven, uh, hemoglobin of seven before you start transfusing, you need to know those indications, right? You also need to know as much as you physically can about sedation. Sedation is going to be a big part of your practice and ICU physician. When do you use fentanyl? When do you use dexmedia tomidine? That's a prosthetics. When do you use, um, proper form, right? When do you use those things? What are contraindications to those things? How do you titrate those medications? That's very useful to know.

And then delirium, delirium, delirium, you're going to have a lot of patients with delirium, right? A lot of patients with delirium. And they also want to make sure you know how to manage things like DKA and HHS. That's a very common reason for people to be admitted to many community IC Us. And then you also want to make sure you know about palliative care. At least the basic things, right? Like, ooh, if a patient is not, is not going to make it all, um, how do I assess for brain death? Or how do I get a person into the hospice pipeline? How do I get a person to a facility? That's a very smart thing to do. You also want to make sure you know about AKI, acute kidney injury. There are many people in the ICU that get renal replacement therapy literally at the bedside. You got to know those things, right? And then you need to know some basic neurology about strokes, especially strokes as a complication of procedures. So, people come from the OR to the ICU. You need to understand those complications, especially when people have gone to the OR for like joint procedures, or they've had like a triple A repaired, those things tend to have cabages like a coronary adrived bypass graft. Those procedures are fraught with a lot of risks and a lot of neurologic complications. And then you want to make sure you understand the ICU. You want to know the labs, you want to be able to recognize it, and you want to know how to treat it.

And again, you also want to know your overdoses and toxic drones. Right? Now, overdoses, your toxic drones, you want to know how to deal with those. If a person goes into cardiac arrest, ECLS, that's something you want to be familiar with. If a person has a GI bleed or they have like liver problems, you want to make sure that you can manage those things. Okay? So again, if you know these things in general, I suspect that you've been very good shape. And then just honestly in terms of procedures, procedures, you want to make sure that you're good at central lines. You want to make sure that you're good at innovations. And you want to make sure you're good at parsing T Cs, right? And also using an ultrasound instrument like wisely. If you can master those four things, you again, you can probably do a lot of things very successfully in an ICU. So I'm going to go ahead and stop here. Again, as I do at the end of every podcast, I do offer one of one tutoring for many exams, step one, step two, CK, step three, complex level one, two and three. The only thing I don't tutor for is women, but I actually tutor to even the CCS cases of step three. So that's something I'm interested in. Shoot me an email through the website. I'll give you some more information. And in addition to that, I offer review courses, offer a 20-hour review course for step two, CK and step three. It's also useful for a person that is like, I'm getting into my third year, I'm studying my shelf exams.

I want to get a broad overview to give myself a very solid review of most of the high-level things I'll see on my shelf exams. The 20-hour course is very helpful for that. I also have an MBME test ticket strategy course that's very useful. There's many people that have taken that course, they've done extremely well on the exams. I've literally had people have 30, 40, 50 point improvements just from the test ticket strategy course. And then I also have a biostatistics bootcamp. It's four hours long, but it's going to teach you how to re-sign through bio stats. Many people just know the formulas, but most of the MBME questions that are written these days do not depend on you memorizing some formula. Most of it is just processing on the standing and integrating. You'll see that most MBME biostat questions these days don't depend on math, don't depend on formulas. It's just more reasoning. If you want to get your reasoning concerned by your statistics right, that's a class you want to attend. And that class is attuned to step one, step two CK step three, complex level one to three. The MBME testing in strategy class is more for step two, step three, and people taking shelf exams. And then the 20-hour review again is for step two, step three, complex two, and three. And people taking shelf exams. So if you're interested in any of these, just shoot me an email. And these podcasts are an Apple podcast, Google podcasts on Spotify, the most recent 150.

If you want everything from episode one to this episode, episode four, 16, then you have to go on the website. Very easy to find, find these podcasts. So you can even go Google search or divine intervention podcasts, episode 25. Blah blah blah blah. And if you want to know exactly what podcasts you're listening to, go on the website, divineinterventionpodcast.com. And then click on the exam topics list header. And it will take you to a Google Sheets document that breaks things down by, oh, for step one, these are the different subjects, these are the suggested podcasts. For step two, these are the different subjects, these are the suggested podcasts, same thing for step three. So that's something that can really help you. And then I have a You Tube channel called Divine Intervention, USMLE Podcasts and Videos. That's where I post the videos that I make. And again, changes are coming to that You Tube channel. And then finally, I have a website called divineinterventionlifelessens.com. It's a website, it's Bible based, many of you that listen to this podcast on a Christian. And I use, because I got a lot of very positive feedback from the life lessons that have been putting at the end of my podcasts. And I'm still going to be doing that. But again, I decided you know what, I'm going to start a separate website just for this purpose. It's called divineinterventionlifelessens.com.

In fact, there is an associated podcast on Apple Podcasts called The Divine Intervention Life Lessens Podcasts. And I post two podcasts a week. And you know, they have about 10 to 20 minutes long. And they address a common life problem. That's faced by many people from a biblical perspective. I try to give very practical strategies for countering those problems. So thank you for listening to me today. I will be continuing the ICU series here shortly. Thank you for listening. God bless you. Have a wonderful rest of your day. Bye for now.

Being methodical; having an approach/algorithm for common day-to-day tasks (notes, rounding, procedures).

Write down their process and create an algorithm or checklist based on that observation.

Being a "Y thinker"—always asking yourself why a diagnosis or treatment was chosen, and what data supports it.

Find out the standard presentation mode of that specific unit (e.g., system-based vs. problem list) and follow it diligently.

Good practice involves understanding the why (the pathophysiology/wisdom behind actions), while bad practice is simply following work management without comprehension.

Under-promise but over-deliver; maintain a margin of safety and wait until the patient is nearly leaving the ICU before being overly optimistic.

Constantly questioning the rationale behind every diagnosis or treatment plan by asking, "Why?" (What data supports this?).

Acid-base problems, ARDS physiology/pathophysiology, and different types of shock (cardiogenic, septic, neurogenic, etc.).

Not just to check if the patient is doing well, but to assess trends in decisions made and catch subtle changes that might otherwise be missed.

Contraindications (e.g., a drug safe for one condition may be contraindicated due to another genetic or systemic issue).

Create a checklist, break the procedure into discrete tasks, and master each small step before assembling them all together.

Respecting nurses and respiratory therapists, as they are often at the bedside and notice subtle changes that can save lives.

Constantly questioning the rationale behind every diagnosis or treatment plan by asking, "Why?" (What data supports this?).

Acid-base problems, ARDS physiology/pathophysiology, and different types of shock (cardiogenic, septic, neurogenic, etc.).

Not just to check if the patient is doing well, but to assess trends in decisions made and catch subtle changes that might otherwise be missed.

Contraindications (e.g., a drug safe for one condition may be contraindicated due to another genetic or systemic issue).

Create a checklist, break the procedure into discrete tasks, and master each small step before assembling them all together.

Respecting nurses and respiratory therapists, as they are often at the bedside and notice subtle changes that can save lives.