Feature Christmas 2021: What a Wonderful World
Just a smidge, or a bridge too far? Slang use in the ICU
James M Hodgetts, Ayat Mohamed, Stephen Lewis
BMJ 2021; 375 doi: https://doi.org/10.1136/bmj-2021-067900 (Published 16 December 2021)Cite this as: BMJ 2021;375:e067900
A shared lingo can create cohesion in “the unit,” but James M Hodgetts and colleaguesask whether this is exclusionary and puts patient safety at risk
Towards the end of the second covid surge, the intensive care unit (ICU) at Frimley Park Hospital enjoyed a brief period when patient numbers were falling but enhanced staffing remained. During a relatively relaxed evening ward the authors got talking about medical language and slang used on our ICU. What was its role? How much of it did we use? Was it a hindrance or help to communication? To what extent might it include or exclude the people using and hearing it?
Thinking about slang
Slang can add colour, humour, and nuance to professional interactions and may reinforce group cohesion. It may sometimes seem dark or even callous to the external observer, but it can form part of the armour that doctors develop to protect them from continual exposure to human suffering.
However, where one party doesn’t understand its meaning, slang may create a sense of exclusion. From a patient safety perspective, it’s difficult to support the use of terminology that’s never been formally taught or codified when communicating potentially crucial clinical information. This situation would be unimaginable in the airline industry, whose safety culture anaesthesia and intensive care often attempt to emulate. But our colleagues, including those newer to our department, wish on the whole for it to remain, having worked hard to learn this unwritten code.
Creating a dictionary
We collected the slang terms used by others and ourselves in the ICU over six months and collated these terms and expressions (those that can be committed to print) in a mini-dictionary of ICU slang, and some are used in UK medicine more broadly. We were surprised by how often we communicated crucial information using speech that could not have been learnt in a classroom or from a textbook.
There was medical slang, British slang, and military slang (Frimley Park Hospital has a strong military connection). There was the British tendency to understatement (“The ICU is a little bit busy at the moment”). Some speech was related to medical superstition, such as referring to the Tangle Fairy or never daring to describe a shift as quiet. Perhaps the least accessible was phraseology with a subtext, such as a referral beginning, “Just to let you know . . .”
We hope that our dictionary may be of use and possibly a source of amusement—and that it causes ICU staff and other healthcare workers to reflect on the suitability and inclusivity of the language they use with colleagues.
a bridge too fareuph Escalating the level of organ support to a point where the burden on the patient outweighs the benefit. From the title of the 1974 book by Cornelius Ryan describing the events of Operation Market Garden in the second world war.
a little bitn1 A small amount: “He’s on a little bit of noradrenaline” (see smidge). 2 An understated large amount: “It’s been a little bit busy on the unit overnight.” Meaning: “I was run off my feet last night.”
albatrossn The on-call bleep. Named after the sea bird metaphor for a psychological burden that feels like a curse. Originates from The Rime of the Ancient Mariner (1798) by Samuel Taylor Coleridge.
anaemia of investigationn A fall in the patient’s haemoglobin caused by repeatedly testing for it.
bag squeezern Derogatory term for an anaesthetist.
bed and breakfasteuph When a surgical patient is admitted to the unit for observation in the postoperative period. They should aim to leave the unit the next morning unless they wobble.
believe nothing, trust no one, give oxygenphr Three golden rules for practising intensive care medicine. Occasionally, the third rule is incorrect.
boggyadj Wet, often when describing pulmonary oedema.
career laughn The polite chuckle from juniors that follows a lame joke by the boss.
chip awayeuph Gradually reduce the patient’s need for support. Commonly used regarding oxygen or vasoactive drugs.
closest crocodile to the canoeeuph The most urgent clinical problem. ICU patients frequently have multiple pathologies with conflicting treatments, such as gastrointestinal bleeding while anticoagulated for pulmonary embolism, in which case the only option is to whack the closest crocodile to the canoe.
crack onv To commence work, or an instruction to do so.
crispyadj Dehydrated. May also be a treatment target: “Run them crispy, we don’t want them developing pulmonary oedema again.”
Domestosn A cocktail of potent antibiotics, usually second or third line, named after the popular bleach. (Other brands are available).
don’t hesitate to copephr A parting plea from the on-call ICU consultant to the duty doctor before the former retires to bed. Meant to discourage frequent and unnecessary sleep disturbance. An outdated, unsupportive, and potentially unsafe request, now used only (semi) ironically with a wink and a smile.
EDabbrev Emergency department. Pronounced “ee-dee” and now so integrated into medical language that some people have been known to refer to the “emergency ED department” when attempting to use the full title.
end-of-the-bed-ogramn A hypothetical qualitative measurement of health that occurs in the brain of a doctor when eyeballing a patient. “The patient’s numbers are much worse than their end-of-the-bed-ogram.”
eyeballv To briefly assess a patient. “I’ll quickly eyeball the patient before we transfer them out of theunit.”
faffingv To waste time performing a useless task. “Stop faffing around trying to place an arterial line—his blood pressure is in his boots and we need to move him to the operating theatre!”
finger dislocatorn Pulse oximeter. Named for its propensity to be left attached to the patient’s finger during slides and turns.
fell in a heap/fell off their percheuph The patient’s condition has suddenly deteriorated.
flappingv Panicking. “When I got to resus, the ED registrar was flapping like a pigeon in a wheely bin.”
gas mann An anaesthetist who identifies as male.
gas girln An anaesthetist who identifies as female. (“Gas woman” may be preferable, but the alliteration sounds better.)
gas godn An anaesthetist who is the subject of hero worship, usually by a more junior anaesthetist.
going to my office to do some adminphr From the ICU consultant to the juniors before allowing them to get on with the work of the unit. Meaning: “I’m going to my office to drink coffee, gossip, and google my own name.”
have you had your Weetabix?phr Are you feeling strong? Usually asked before performing a manual handling manoeuvre on a particularly heavy patient. Derived from a 1990s advertising campaign for the popular breakfast cereal.
in their bootseuph Very low. “Their blood pressure was in their boots.”
iPhone positiveadj The patient’s health is good enough to allow them to continue to send text messages and update their Facebook status. (Other models of mobile phone are available.)
just to let you knowphr The first words spoken by another specialty doctor when making a pseudo-referral to the intensive care team. An underhand attempt to passively transfer responsibility for a clinical outcome, guaranteed to raise the ire of the intensivist. The other specialist hopes to record “ICU aware” in the medical notes without doing the work associated with a proper referral. “Just to let you know that I’m in resus seeing an acidotic, hypotensive, bedbound nursing home resident who has severe dementia.”
knob twiddlern Derogatory term for an intensivist.
line monkeyn The only ICU junior on duty who can competently insert central lines. Usually a bag squeezer. See transfer monkey.
masterful inactivity and cat-like attention to detailphr Carefully monitoring the patient and intervening only when there’s a compelling reason to do so. A philosophy of intensive care that probably yields the best results. Extension of the Hippocratic entreaty to “do no harm.”
metal inotropen The Macintosh laryngoscope. Instrumentation of a patient’s airway with this device is extremely stimulating and may produce a brief inotropic effect.
micro-roundn A discussion of each patient with a microbiologist to agree on their antibiotic management. The arrival of the microbiologist usually coincides with the first mouthful of sandwich taken by the intensivist after finishing their own rounds. Not to be confused with a very short ward round.
missed the boateuph When a clinical deterioration has advanced beyond the point of rescue. “You can give him antibiotics, but unfortunately I think we’ve missed the boat.”
Movibombn A large dose of the macrogol based laxative Movicol (up to 8 sachets), used by some intensivists to treat constipation in ventilated patients. (Other laxative brands are available.)
No heroicsphr An instruction not to escalate organ support inappropriately. See a bridge too far.
off-pisteadj Description of treatment that has deviated from clinical guidelines. Does not necessarily imply poor clinical judgment. Stems from a skiing term, when one skis off the mapped runs. “The management of DKA in bed 7 has been a little bit off-piste . . .”
O signn A clinical feature, elicited when eyeballing a patient, where they are seen to be unconscious with their mouth open. See Q sign.
Prolene deficiencyeuph Inadequate surgical haemostasis causing postoperative bleeding. Prolene is a synthetic non-absorbable suture. “I can give them more FFP and tranexamic acid, but I think the problem here is Prolene deficiency.”
put the unit to bedv To conduct the final ward round of the day, with the intention of dealing with any issues before night time. Creates the false impression that the intensivist will be tucking each patient in and reading them a story.
Q signn Same as the O sign, except that the patient’s tongue is now protruding from their mouth, and therefore an even more ominous feature.
quiescentadj In a state of inactivity or dormancy. “The chest drain has been quiescent.” An example of an unnecessarily obscure word being used to describe a simple situation, usually by a doctor trying to sound clever.
quietadj Superstition dictates that this word should never be spoken aloud, even if the shift has been blissful. Its use ensures that the rest of the shift will be excruciatingly busy. Sometimes used maliciously at handover to jinx the incoming team.
red herringn Something that draws attention away from the main issue. “I think the fact that he had his first covid jab last week is a red herring.”
retrospectoscopen An imaginary device that allows the past to be altered, with the advantage of knowing how events will unfold.
rinse and spinv To simultaneously give intravenous fluid (often albumin) while administering a diuretic. To some, a valid method of driving renal function; to others, a contradictory approach. Derived from a washing machine mode.
Royal College of Bag Squeezersn Derogatory term for the Royal College of Anaesthetists.
seminar roomn Commonly mispronounced as “coffee room,” this is the social place where ICU doctors hand over patients, discuss management plans, drink coffee, and generally hide. It is rare for an actual seminar to occur here.
SEPabbrev1 Somatosensory evoked potentials. 2 Someone else’s problem.
smash and grab extubationeuph Where the sedation is turned off and the endotracheal tube is removed as the patient wakes—usually a confused patient who is not expected to be compliant at any point in the process.
smidgen A small amount, commonly used to describe how much medication the patient is taking. “He’s on a smidge of noradrenaline for blood pressure.” Shortened form of smidgen.
snake’s weddingn The chaotic mass of wires and lines that seem to tie themselves around each other immediately on transferring an intensive care patient outside the unit. Usually blamed on the Tangle Fairy.
SODabbrev Single organ doctor. A derogatory term for a doctor specialising in a one organ system only, such as a cardiologist.
Tangle Fairyn A mythical invisible creature believed by some to accompany every patient transfer in intensive care. It ties knots in monitoring wires and lines when the staff are not looking, creating a snake’s wedding.
the expensive care unitn Colloquial term for the intensive care unit, acknowledging that it costs around £3000 per day per patient.
the intensive scare unitn Colloquial term for the intensive care unit, acknowledging that it can be a frightening place for all concerned.
the unitn Endearing term for the intensive care unit. Any hospital has several clinical “units,” but in the same way that the SAS is known as “the regiment,” only one is known as “the unit.”
transfer monkeyn The only ICU junior on duty who can competently move intubated patients outside the unit. Usually a bag squeezer. See line monkey.
trial separationn A careful attempt to move the bed of a ventilated patient away from its usual spot, before commencing an out-of-unit transfer. Usually reveals that the mattress is still plugged in.
TWOCabbrev, v1 Trial without catheter. 2 To remove a patient’s urinary catheter to see if it is still needed. Pronounced “twock.”
vein of shamen A tiny, delicate, but reliably visible vein on the anterior aspect of the wrist. “The patient needed a cannula so that we could discharge him to the ward. He was so puffy I had to put a 24 gauge in the vein of shame.”
warm, wake, and weanv Rewarm the patient, reduce their sedation, and slowly remove vasoactive drug support. An abbreviated handover of an intubated postoperative patient, from the anaesthetic team to the ICU team. Most commonly heard in cardiothoracic centres.
wobblev To become clinically unstable. “The patient in bed 3 had a wobble overnight.”
