Critical Care Medicine Rotation

Medicine

Rotation/Educational Purpose:

Critical Care Medicine encompasses the diagnosis and treatment of a wide range of clinical problems representing the extreme of human disease. These critically ill patients require coordinated care by a team that usually includes a general internist, sub-specialist, and allied health personnel. The general internist, at times, provides care and coordination with those trained in critical care medicine. However in some settings, the internist may be the primary provider of care and serve as a consultant for critically ill patients on surgical services. Care of these patients requires competency in end-of-life decisions, advance directives, estimating prognosis, and counseling of patients and their families.

Patient Care Goals and Objectives:

Goal:  Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.

Residents are expected to:

PGY 1

  1. To gain expertise in the diagnosis and management of critically ill patients in the Medicine Intensive Care Unit setting.

  2. To develop the procedural skills necessary to care for the critically ill patient.

PGY 2 and 3

  1. To gain expertise in the diagnosis and management of critically ill patients in the Medicine Intensive Care Unit setting.

  2. To develop the procedural skills necessary to care for the critically ill patient.

  3. Serve as first call on critically ill patients.

Medical Knowledge Goals and Objectives:

Goal:  Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, as well as the application of this knowledge to patient care. 

Residents are expected to:

PGY 1

  1. To understand the concepts of mechanical ventilator management.

  2. To learn the interpretation of telemetry, pulse oximetry, and hemodynamic monitoring.

PGY 2 and 3

  1. To understand the concepts of mechanical ventilator management.

  2. To learn the interpretation of telemetry, pulse oximetry, and hemodynamic monitoring.

Practice-Based Learning and Improvement Goals and Objectives:

Goal:  Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life long learning.

Residents are expected to develop skills and habits to be able to:

PGY 1

  1. To understand the principles of test ordering and interpretation.

PGY 2 and 3

  1. To understand the principles of test ordering and interpretation.

Systems Based Practice Goals and Objectives:

Goal:  Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care.

Residents are expected to:

PGY 1

PGY 2 and 3

  1. Supervise PGY-1 residents and senior medical students in all clinical aspects and procedural activities.

Professionalism Goals and Objectives:

Goal:  Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles.

Residents are expected to demonstrate:

PGY 1

PGY 2 and 3

Interpersonal and Communication Skills Goals and Objectives:

Goal:  Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and teaming with patients, their families, and professional associates.

Residents are expected to:

PGY 1

  1. To gain competency in end-of-life decision making and understand advanced directives.

PGY 2 and 3

  1. To gain competency in end-of-life decision making and understand advanced directives.

Teaching Methods:

The major teaching method in the MICU is teaching rounds with patient specific education by the MICU attending physician. Additionally, all MICU admissions are discussed with the Pulmonary/Critical Care fellow at the time of the admission. The patient’s diagnosis and treatment are discussed at length. Procedures are directly supervised. The attending physicians also conduct regular didactic sessions with the MICU team each month.

Mix of Diseases and Pathological Material:

The resident is expected to gain expertise in diagnosing and managing patients with acute respiratory failure, COPD, asthma, ARDS, septic and cardiogenic shock, abdominal pain, acute chest pain, acute intoxications, acute hepatic failure, acute renal failure, altered mental status of coma; hypotension, life-threatening arrhythmias, massive GI bleeding, massive hemoptysis, respiratory failure, severe hypertension, stroke, meningitis, encephalitis, and status epilepticus.

Patient Characteristics:

Patients are adult as defined by age 17 and older. The distribution of races reflects that of South Carolina with approximately 68% Caucasian persons, 28% African American persons, and 3.8% Hispanic persons with the remainder being Asian or other. There is a near equal distribution of male and female persons. There is on average of one pregnant person every 2 months.

Types of Clinical Encounters:

Patients are evaluated in the Emergency Room, on the general inpatient service, and in the intensive care unit. Patients are seen in a consultative role to determine their candidacy for intensive care as well as in the role of primary care giver. They are also direct ACLS resuscitation for the code team as PGY 2 and 3 residents.

Procedures and Services:

Procedural skills that need to be acquired include advanced cardiac life support, arterial puncture, mechanical ventilation, placement of arterial and central venous lines, paracentesis, thoracentesis, use of point of care ultrasound and placement of pulmonary artery catheters.

The resident will be able to interpret hemodynamic monitoring, pulse oximetry, and telemetry. The trainee needs to know when to order certain tests and have a working knowledge of the meaning of these tests. These include bronchoscopy, CT of the chest and abdomen, CT and MRI of the brain, coronary angiography, echocardiography, and electoencephalography.

Supervision:

Residents are directly supervised in their patient care duties by the Pulmonary fellow and the Pulmonary attending physician. The PGY 2 or 3 residents on the service supervise the PGY 1 residents and the senior medical student on service.

Educational Resources to be Used and Reading Lists:

The major resource is an online handbook that includes important articles related to critical care medicine. These articles have been selected by pulmonary critical care with some input from neurocritical care, and anesthesia critical care. They are also encouraged to complete a series of modules developed regarding pharmacotherapy in the ICU. In addition, they are given a link to educational modules developed by the Society of Critical Care Medicine. Finally, at the beginning of each month they are taken for additional ACLS training in the state of the art simulation center.  Additionally, the resident is expected to search the literature for journal articles regarding specific diagnoses or treatments when indicated. Other texts include The ICU Book, by Merino, Critical Care Pearls, by Drs. Sahn and Heffner, and Care of the Ventilated Patient.

Method of Evaluation of Resident Competence:

Residents are evaluated by the attending with the assistance of the fellow each month using the standard Departmental Evaluation form for each competency. Patient Care is assessed based on direct observation and chart review. Medical Knowledge is assessed through direct questioning on rounds. Professionalism is assessed based on observation of the resident’s demeanor and behavior in this stressful situation. Interpersonal and Communication Skills is assessed by observing the resident’s interactions with patients, families, and staff. Systems-Based Practice is evaluated based on the resident’s ability to function and excel in a critical care team setting. Practice-Based Learning is evaluated based on the resident’s ability to learn and improve his or her skills based on feedback, study, and literature review.