I was asked to write this article to shed some light on the day-to-day of working as an ICU Registrar in order to help JMOs perhaps interested in pursuing a career in intensive care make an informed decision about how to go about it and what they are getting themselves into. I have found that ICU presents a fairly large day-to-day variation in terms of the volume and nature of work, particularly in smaller regional ICUs such as the one I currently work in. Then there are the differences between working day or night, which aren’t insignificant. This variability is one of the aspects of ICU that I find appealing, however doesn’t lend itself well to distilling all of the aspects of the job into an account of one day. I think it would be more appropriate to do a “year in the life of”, but I’d probably violate my word limit. So how do I make this post useful for you, dear reader, the JMO staring into the abyss of having to commit to a career choice? For starters, I think it is important to give things some context and tell you a bit about myself and how I ended up here. I’ll then discuss the things I enjoy about the job as well as things that I didn’t expect and some of the harder aspects. Finally, having only recently been in the position where I had to make a decision on my career path, I’ll give you advice I would have given myself three years ago.
When I graduated in 2013 I was keen on surgery, or at least I thought I was. I always liked scrubbing in on big cases as a student and holding a retractor or two. I told all of my friends and colleagues I was keen on it. I kept telling myself I really was keen on it! I went overseas and presented at conferences, and got in the good books of the right people. I had a surgical SRMO job lined up, but as my 2nd postgraduate year progressed I realised that my heart wasn’t really in it. During this time, I was doing an ICU term in a regional hospital as an RMO and thrown into the deep end, manning the unit overnight and looking after ventilated patients and patients on dialysis. I felt like I had learned more during that term than any I had done to that point. I got along really well with the consultants and the nursing staff, and was sad that the end of the term was nearing. Unfortunately, by that point, the PGY3 recruitment had finished in NSW and I was left wondering how I would go about getting an ICU job the following year. Fortunately, a newly minted consultant from Victoria, who would later become an important mentor for me, was doing a locum in the ICU where I was posted. She encouraged me to apply for a registrar job at her home hospital, and the rest is history. I had to move away from my friends and family, convince my girlfriend (now fiancée) to come with me, and contend with the daunting prospect of stepping into a registrar job in my third postgraduate year. It was all worth it in the end, and I consider myself very lucky that this opportunity presented itself when it did. I’m well aware of others facing the stressful prospect of not finding a job in their desired field. The take away message from this is to go into any junior doctor rotation with an open mind, and to be receptive to and take advantage of opportunities when they arise.
Working in ICU is satisfying on a number of different levels. I enjoy the immediacy of it. If there is a problem with a critically ill patient, you have the resources at your disposal to change their management and assess their response all in a short timeframe. Last week at the end of a night shift I admitted a gentleman in his 70’s who was still working on his farm in the 40 degree heat. He kept taking all of his antihypertensives and metformin and wound up with an anuric kidney injury. He was very acidaemic and quite confused and drowsy, with the thousand-yard stare of critical illness and a respiratory rate of about 35. I took him up to the unit, put a dialysis catheter in and started dialysing him just before my shift ended. I returned that night to find a different man, awake and chatting about how relieved he was that he didn’t feel so sick anymore. You get feedback on your actions almost immediately! This continues with the procedural aspect. It’s a good feeling when you see the tip of the central line you inserted projected perfectly above the cavo-atrial junction on a chest x-ray. It’s an even better feeling, however, seeing the smile on my resident’s face when they successfully get their first CVC in despite trembling hands and a fogged-up face shield. I also enjoy the culture, which I think is quite progressive compared to some other areas of medicine which remain quite hierarchical and old-fashioned.
It’s not all a nirvana of saving lives, machines that go ping and down-trending lactates, however. ICU is often the final destination of a tragic journey for many patients. One case that did keep me up at night was that of a young man who had unintentionally overdosed on long-acting opioids and was found the next day by his parents in respiratory arrest. He was resuscitated and did make it to our ICU, however with such a prolonged period of hypoxia he had no chance of a meaningful neurological recovery. Difficult conversations are plentiful, and although you become well-equipped to have them, some are still very hard. The working hours and rosters can be very tough; a recent audit by the AMA placed ICU registrars in one of the highest-risk professional groups for fatigue and burnout. I have definitely spent a few hours sitting on the lounge at home after my 7th night shift just staring at the wall, having a mini existential crisis. I’m lucky to have a supportive partner, caring bosses, and colleagues I am comfortable to debrief with. I’ve quickly learned that to last in this specialty, you need to be self-aware and willing to seek help from others when the going gets tough.
I’d like to finish by offering some advice I wish I had given myself in my first two years out of uni, which isn’t all that long ago. The tumultuous JMO years are fresh in my mind, and I’ve got a different perspective on things now that I’m past them. There are a lot of very driven and ambitious people coming out of medical schools these days; people enrolling in Masters degrees earlier and earlier, scoping out referees on their first day on the job, arranging meetings with directors of training. Whenever the topic of careers came up in conversations with my fellow interns, the theme would inevitably gravitate towards how hard it is to get into said specialty. I often felt like it was a bit of a mad rush to get a foot in the door and get started down a certain career path. This is all fine if you’re that type of personality, but I found it daunting as all hell. Ignore all of the noise. I think it’s important not to worry too much about what your colleagues are doing in terms of career development, and to run your own race.