Laveena Munshi, MD Jenna Spring, MD
Institution: Mount Sinai Hospital, Sinai Health System, and Princess Margaret Cancer Center, University Health Network; University of Toronto
Specialty: Critical Care Medicine
Years Practicing: 10 and 5, respectively
We work in a 27-bed medical/surgical intensive care unit (ICU) that serves Mount Sinai Hospital and Princess Margaret Cancer Center (one of Canada’s largest clinical and research cancer centers). In addition to oncology, these hospital systems have specialized programs for thrombosis, red blood cell disorders, and apheresis. Although a subset of our patients includes common critical care conditions (e.g., community-acquired pneumonia/acute respiratory distress syndrome), we care for a high proportion of patients with complex hematologic disorders (oncologic and classical). Relatively frequent diagnoses in our ICU include leukostasis for the patient with newly diagnosed acute myeloid leukemia, chimeric antigen receptor T-cell-associated cytokine release syndrome, acute respiratory failure or sepsis post-allogeneic or autologous hematopoietic cell transplant, thrombotic thrombocytopenic purpura, severe hemophagocytic lymphohistiocytosis, sickle cell crises, severe autoimmune hemolytic anemia, and new diffuse large B-cell lymphoma presenting as a mediastinal mass with respiratory and/or hemodynamic compromise (which becomes particularly stress inducing in an obstetric patient).
Given the volume of complex hematology/oncology cases, we have developed an Oncologic Critical Care fellowship for trained intensivists seeking more experience in this area. Improving care and developing evidence for critically ill patients with cancer is one of the major academic focuses in our ICU. Dr. Spring’s interests include quality improvement and education, and she is the program director for the University of Toronto’s Critical Care Medicine training program. Dr. Munshi is a clinician-scientist with a research program concentrated on oncologic critical care with an early focus on hematologic malignancies. None of these programs and clinical care would be possible without the close collaboration with our hematology and oncology colleagues, whom we communicate with several times a day.
Our ICU has two attending physicians on service each week, each taking care of 12 to 14 ICU patients. The two attending physicians alternate nights on call. Given that we are a teaching hospital, we have four to six residents (PGY 1-3) and three to four critical care fellows on service. When on call, we also serve as the rapid response physician. Those responsibilities include responding to deteriorating patients on the wards, providing telephone advice for community hospitals (and potentially accepting their patients in transfer if they require a specialized service), and overseeing the cardiac arrest team. We are on service for 12 to 18 weeks (about four months) a year. The weeks in between are dedicated to our academic responsibilities.
Here is an outline of a typical day when we are both on service:
6:00 a.m.: Clinical weeks are typically quite busy with long days, and we both have a commute into the city. Given this, the first challenge of our day is attempting to get ready and leave the house without waking up the children or furry creatures in our respective households.
7:00 a.m.: After arriving at the hospital, we briefly check in with the overnight team and charge nurse to ensure there are no acutely unstable patients before grabbing a coffee and skimming the morning labs. This is followed by a quick unit walk-through to see any new or sick patients before stepping away for sign-over.
7:45 a.m.: Morning sign-over is conducted with the residents and fellows, the charge nurse, and ICU pharmacists. During these rounds, the overnight resident and fellow provide a summary of the events for each patient and present any new admissions and consults they saw. Following this, we have dedicated teaching for the fellows twice weekly, often covering oncologic/hematologic critical care topics.
8:45 a.m.: The attending physicians review the distribution of patients, flag any patients who can be discharged from the ICU that day, and take note of any elective ICU admissions (i.e., planned transfers from other centers or elective ORs). The on-call physician may briefly see the consults that didn’t require ICU admission overnight to confirm their stability and disposition. During this time, the residents divide up the patients and preround. If there are any unstable patients, they notify the attending or fellow right away.
Dr. Jenna Spring demonstrates how to insert a central line
during a critical care simulation.
9:00 a.m.: ICU rounds begin. Rounds are led by the attending physician and ICU fellow. The team reviews each patient at their bedside in detail. The resident provides an introduction, the ICU nurse provides a detailed clinical overview, the ICU respiratory therapist reports on the ventilator settings or respiratory support, the ICU pharmacist reviews the current medications, the dietician outlines the nutrition plan and goals, and finally, the resident presents their daily plan. This plan is then reviewed and finessed by the fellow and attending. There are often bedside teaching moments on rounds (e.g., how to evaluate fluid responsiveness, how to determine if a patient should be extubated, and what really is HLH?). In an ideal world, rounds commence and are completed between 9 a.m. and noon; however, the physician team may be interrupted by a rapid response call, code blue, consultant request for an opinion, or a deteriorating patient in the unit who needs resuscitation. Definitely no two days are alike!
Noon: After rounds are complete, the team steps away for lunch and to review outstanding tasks. On Tuesdays, we have “Attending Rounds,” where all patients admitted to the ICU are briefly presented and reviewed with the entire attending group. This is a fantastic opportunity to obtain input from colleagues, but it also assists with continuity from week to week and occasionally leads to a lively debate on certain critical care topics. Other types of rounds that may occur include antimicrobial stewardship, morbidity and mortality, critical care oncology visiting professor, and bullet rounds with the allied health team (social worker, physiotherapist, dietician, speech-language pathologist, bioethicist, psychiatrist, palliative care clinician, and spiritual care practitioner).
1:00 p.m.: Afternoons in the ICU tend to be quite unpredictable. Some days there are multiple consults, admissions, family meetings, procedures, and in-hospital emergencies. Procedures may include intubation, central line insertions, pigtails, chest tubes, bronchoscopy, paracentesis, and lumbar punctures. On other days, we have time to complete any outstanding tasks from rounds (e.g., reviewing imaging, touching base with consulting services) and spend some extra time on resident bedside teaching. At the very least, we also aim to provide a brief update to patients or their families every day (and families are invited to listen in on morning rounds). The on-call physician also meets with the rapid response nurse and fellow and then rounds on the rapid response list (which could be anywhere from one to 10 or 12 patients). In addition to seeing emergencies, the rapid response nurse also sees the patients discharged from ICU for continuity of care.
Dr. Laveena Munshi performs an intubation simulation in the
ICU with her clinical team.
3:00 p.m.: Irrespective of unit activities, one attending or fellow takes the residents for dedicated ICU teaching for an hour.
4:30 p.m.: We aim to hand over to the on-call team at the same time every day. Ideally, tasks are wrapped up; however, it’s not uncommon that we have simultaneous sign-over and ongoing procedures or resuscitations. By 5:30 p.m., everyone who isn’t on call heads home.
6:00-10:00 p.m.: It’s not uncommon to have a wave of postsurgical cases admitted around 4 or 5 p.m. The on-call physician often sticks around to complete any outstanding tasks and procedures, communicate with consultants, and familiarize themselves with the opposing team’s patients — particularly any who have the potential to be unstable. When they leave the hospital depends on the activity in the unit. Before leaving, they touch base with the charge nurse about bed flow and anticipated admissions. We are fortunate to have 24-hour in-house fellow coverage with experienced critical care fellows, so we don’t need to stay in-house unless things are particularly busy. Evening rounds (“tuck-in rounds”) occur around 10 p.m. and are completed by the resident and fellow. The on-call attending touches base with the fellow on call to ensure there are no questions or issues. Overnight, the fellow and attending are in communication about any unstable patients and new admissions. If the unit becomes busy, the attending returns to assist.
Our ICU weeks are completely unpredictable. Our outstanding team is the key to maintaining the momentum needed to complete the week, and we have excellent consultants who assist us in the ICU. Our passion for our patients and working with the residents and fellows makes the weeks very fulfilling. We are also fortunate to have a highly skilled nursing group, allied health professional team, and respiratory therapy group. Our co-attendings are considered family and are individuals we admire and respect. We laugh together, cry together, and celebrate the great work we can accomplish as a cohesive team.
