When I last wrote about being in the intensive care unit, I was coming off a three-month research stint where my primary job was perfecting the art of appearing busy while actually doing nothing. I achieved true expertise in this area and earned commendations for my efforts, if not for my actual research.

Unfortunately, this meant I came into my medical ICU week pretty cold. For the week I was on service, I exhibited the presentation skills of a six-year-old describing his art class illustrations to his mom, and received some scathing reviews (i.e. “Nate Does Not Have a Career in Critical Care.”)

I have to admit, I had higher hopes for this month. Although I came into my “Acting Internship” at the VA medical intensive care unit just as icy, I had a month to get up to par! Also, I had the advantage of being a wise and worldly fourth-year student, which carries the primary benefit of not having to care about basically anything. This includes looking bad in front of my evaluators.

Once again, I had to present by systems, because people in the ICU pretty much never have only one thing wrong. There are many systems, including categories that are very definitely NOT systems such as “prophylaxis,” “access,” and “family concerns.”

This is cheating. Also, this is confusing to no one except, apparently, me.

During my first week in the ICU I (quite predictably) crashed and burned, mostly because I could not for the life of me remember systems like “fluids” or the all-elusive “butthole.” For systems where the patient had no problems, I tended to leave out the systems entirely, which is the style of emergency medicine. For instance, for a person who was sitting comfortably in bed and breathing on his own, finding something to say for “neuro” is a little challenging. If it ain’t broke, don’t fix it.

This is evidently a mistake.

I solved this problem of omission during Week 2 by writing all the systems out on a large index card. I am now quite facile at presenting by systems as long as I have this card. It is quite detailed:

-NEURO
-HEART STUFF
-LUNG STUFF
-KIDNEYS ARE A THING THAT NO ONE UNDERSTANDS
-GI, AND FOR SOME REASON FLUIDS
-INFECTIONS (I KNOW, NOT A SYSTEM)
-ENDOCRINE
-BLOOD STUFF
-PROPHYLAXIS

When it comes time to present my plan by system, I hold this card out in front of me like my parents with the dinner menu in a dimly-lit restaurant. My glasses even slide down my face a little, which makes me look smarter as I confidently proclaim, “INFECTIOUS DISEASE: We are following ID recommendations!”

This is a smart-sounding way of saying “My plan is to do what the smart infectious disease doctors said to do for this patient’s infection.” It is also an eminently reasonable plan, because no one understands antibiotics that well, least of all the idiot medical student flying by the seat of his pants for, amazingly, the fourth consecutive year.

Anyway.

My second week in the ICU, with my feet now wet and my sleep deficit nearing triple digits, I felt like I was finally settling in. I presented my patients in the morning, helped out with the usual tasks during the day, and even placed a few ultrasound-guided IVs. (My resident overseers, by and large, were internal medicine doctors, and thus less experienced with ultrasound – and consequently much more willing to let me use it!)

I felt pretty good about myself. At the end of the week, it was time for Midpoint Feedback With The Attending, which is required by the med school and the accrediting body that allows the med school to grant degrees.

My attending was a tremendously kind and profoundly nerdy man who got most excited reviewing the results of a clinical trial comparing various types of pneumonia treatments. For Midpoint Feedback, he sat me down in an empty ICU room (an unnerving experience by itself) and said, “I think you’ve been treading water, with Match Day in sight and everything.”

So much for settling in.

“Also,” he continued, “I think I’m going to stop requiring everyone to present by system. I find it just confuses everyone. I was only doing it because that’s how I was trained.”

The ceiling of the ICU room we were in parted and warm, glorious sunlight streamed in direct from Olympus. I saw Zeus in all his benevolent glory smiling down upon me from the heavens. I saw my future of presenting by problem again, free of the vagaries of “Neuro: nothing to do” and “Endo: on sliding scale insulin,” grow bright and luminous.

“…But I still want you to present by systems, for the rest of this week at least. You did make it a learning goal of yours, after all.”

Shit. Yes, I did. Shit shit shit.

Neuro: student made system-based presentation a learning goal. He is clearly an idiot.