Rotation: Intensive Care/Coronary Care Unit
Site:
- Surgical ICU, corner near room 222
Instructors:
- Drs Yalamanchili, Richey, and others.
Makeup of team (responsibility of each team member):
- One junior resident (intern)---Is paired with a senior resident. At the discretion of the senior resident (depending on patient severity), the intern will either perform the initial history and physical and establish a diagnostic/therapeutic plan, or work more in tandem with the senior resident on the more critically ill.. The intern will document with complete daily progress notes on his/her patients. The intern/resident team will admit patients for 24 consecutive hours.
- 3 senior residents---May be paired with an intern, a junior medical student, a senior medical student doing an elective, or may be alone. Residents will admit patients for 24 consecutive hours.. The resident is always accountable for overall patient care regardless of the presence of interns or students. The resident is accountable for the overall quality of the documented house staff progress notes, regardless which team member writes them.. The resident is responsible for communication with attendings, consultants, and the patient's family.. The resident should view themselves as THE physician in charge of the total patient.. When paired with junior caregivers, they will supervise, teach, and nurture the development of those team members.. It is the resident's responsibility to dictate discharge summaries/transfer notes as needed, and the accountability for a seamless transfer of information to the ward resident when patients leave the ICU setting.. The on call resident runs all medical codes in the hospital. The resident will make "night rounds" on the whole team's patients to look for opportunities to timely intervene.
- One attending---Supervises and ensures quality of care for the patients.. Fosters a sense of progressive responsibility among junior team members, brings evidence-based-medicine to bear on the clinical problem, establishes an environment where professionalism, humanism, scholarship, and teamwork are valued, and provides feedback to the team members.
- 3 rd year medical students---are primarily there to observe the process of a multidisciplinary critical care team at work.. He/she is paired with a senior resident. Is expected to work up and present at least 2 patients during a week's rotation. He/she is expected to take one night's call to appreciate the complexity of ICU patient's rapid change in status that requires constant reevaluation.
- 4 th year medical students---this should be viewed as a true "acting internship". He/she will be paired with a resident, will take night call with that resident, and should do the work of an intern.
- There are often pharmacists, pharmacy students, and others that will participate in rounds. We espouse the model put forth by the Society of Critical Care Medicine: that ICU patients are best served by a physician-led multidisciplinary team. The team includes, but is not limited to, nurses, respiratory therapists, pharmacist, and dietitians. All team members will be treated with the respect they deserve for the position they hold.
Days per week (night call):
- The team rounds seven days per week. Each resident will have 4 days off per month. On these days, the other residents will assume clinical responsibilities. Night call is every 4 th night. The patients that belong to the post-call team will be seen 1 st during morning rounds. The post-call team will then break off rounds to finish their work and be checked out by noon. The average number of admissions per day is 2 to 3.
Usual time of attending rounds (meeting place):
- 09:00 until 11:30 (or until all patients are seen). Rounds will start at 08:30 on days when there is no 0800 meeting.
Types of patients encountered:
The service includes a broad range of inpatients that are critically ill. Most patients are admitted with medical or primary cardiac problems. Often we are asked to consult or to assume care of patients that are admitted for a primary surgical problem, but have multiple medical co-morbidities. Occasionally we are asked to consult on obstetric patients with respiratory failure. It is unlikely we will be involved in pediatric patients (under 17). Genders are equally represented, as well as a wide variety of ethnicities. Geriatrics is always well represented in medical ICU's. We are usually consultants on oncologic admissions.
Educational goals/competencies:
Patient care:
Residents will learn how to quickly stabilize the patient while at the same time using the history, physical exam, and a few very basic tests (ECG's, emergency labs, and simple X-rays) to generate a limited number of diagnostic possibilities. Based on this list, the residents will learn to treat or develop a diagnostic strategy for the most life-threatening problems in a logical and efficient manner. Residents will choose therapy backed by evidence-based-medicine. When evidence is lacking, residents will choose a team-consistent approach to treatment. Residents will treat in a cost-effective manner, realizing that the most expensive therapy is the wrong therapy.
The resident will learn those procedures that are integral to the management of ICU patients. These would include CPR, intubations, central lines, pulmonary artery catheters, arterial lines, paracentesis, thoracentesis, and lumbar puncture.
Medical knowledge:
Residents will continue to develop the knowledge base from the ward rotations. In addition, the residents will develop a working knowledge of problems more specific to the ICU. These would include:
- acute coronary syndromes requiring intravenous infusions and emergency catheterizations
- respiratory failure management for severe COPD/asthma, acute lung injury/ARDS, coma patients with increased ICP, and routine post-op
- renal failure management and renal replacement therapies
- severe GI bleeding management
- liver failure management
- endocrine emergency management
- new onset of altered mental status
- fluid, electrolyte, and nutritional manipulation
- how to care for the terminally ill in a compassionate fashion, including the proper process for withdrawal of care
Residents will learn how to take a rapid but efficient history from the patient and/or the family to begin a treatment process in unstable patients. Residents will learn how to prioritize their history taking to get the critical information quickly. Residents will learn how to efficiently get information from other sources (old charts, doctor's records, etc) in order to better understand the total patient.
Residents will learn how to write efficient notes that will maximize appropriate billing processes. They will learn how to efficiently present complex patients to others, and learn how to make "hand-offs" (check outs at the end of the day, or transferring patients to the wards) as seamless as possible.
Residents will learn how to compassionately talk with families about their loved ones condition, learn how to effectively address code status, and how to deal with angry families.
Professionalism:
Residents will learn how to treat all patients the same regardless of insurance, social, incarceration, ethnic, or sexual background. All patients will be treated as if he/she were a member of the resident's family.
Residents will treat all team members with respect. This not only includes the other physicians on the team (other residents, interns, and faculty) but also includes students, nurses, clerks, therapists, pharmacists, and any other person participating in the care of the patient.
Practice-based learning and improvement:
Residents will learn to develop habits that make for optimal patient care. These would include:
- an efficient pre-rounding process to maximize information gathering in a short time frame
- the efficient presentation of patients to others
- the development of standardized protocols to reduce error rate
- How to recognize when they need to ask for help
- How to use current literature to deviate from, or completely change protocols
- How to learn from their own mistakes, but as important, to learn from other's mistakes
- How to see errors in medicine as system problems, not personnel problems
- How to be an effective team leader (how to engender others to want to follow)
Residents will learn how to use the network of systems to maximize the patient's ability to return to their premorbid state in a cost effective manner. These would include social workers, discharge planners, skilled nursing facilities, home health care agencies, etc. Residents will know the limitations of whatever payer source the patient has to reach the common goals. Residents will learn how to efficiently move the patient "through the system" (ICU to step-down to wards to appropriate discharge location) that will minimize costs while not affecting quality.
Text/references to be consulted:
The core text is the Oxford Textbook of Critical Care (most recent edition). Because critical care medicine is changing so rapidly, it is imperative to keep abreast of current literature. Residents are required to bring in at least one article per week pertinent to one of their patient's problems. Residents are required to read any article given to them by the attending.
Methods of evaluation:
Each faculty member will fill out the standard departmental evaluation form on each resident. The scale will be based on expectations relative to the timing of evaluation (early vs late intern year, 2 nd vs 3 rd year residents).
- Clinical judgment: Did the resident integrate all the information and truly understand what the underlying problem was, with an appropriate differential of other life-threatening issues that must be ruled out?
- Presentations: Can the resident present complex patients in an efficient manner?
- Medical records: Do the written notes reflect the complexity of the patient for billing purposes?
- Medical knowledge: Does the resident understand current treatment options for the patients problems?
- Procedural skills: Has the resident followed the standard protocol for sterile technique, insertion technique, etc?. The "success rate" is of minor influence on grade
- Leadership skills: Can the resident "take control" of the situation?. Will others want to follow?