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SURGICAL INTENSIVE CARE UNIT ROTATION

DIVISION OF CRITICAL CARE MEDICINE

DEPARTMENT OF ANESTHESIOLOGY

ORIENTATION MATERIALS

GOALS AND OBJECTIVES

The faculty of the Division welcomes you to the SICU.  As part of your training, it is important that you have a clear, concise understanding of the principles of Critical Care Medicine (CCM).  We will endeavor to assist you in gaining an appreciation for these during your rotation in the Surgical Intensive Care Unit (SICU).  By the time you have finished rotating with us, you should have a much clearer understanding of these principles and their interrelation in the critically ill patient.  This is also an opportunity to perfect your skills for various invasive procedures.

 

Our goal is to provide you with an understanding of CCM as well as new insights into the problems in the postoperative and trauma patient.  In addition to being where some of the sickest individuals in our institution reside as the recover, the ICU is also an outstanding physiology and pharmacology laboratory.  We want this experience to assist in your becoming a superiorly trained, technically expert, and compassionate physician.

 

RESPONSIBILITIES:

There are a series of issues you will be held responsible for; we encourage you to carefully read through this document to ensure there are no misunderstandings. 

  1. The resident on the SICU rotation has responsibilities for patients in the SICU, 94-IMC, Overnight Recovery Room, Burn Unit, Emergency Room, cardiac arrests around the hospital, various consults on the floors, and patients referred for hyperbaric oxygen (HBO) therapy.  All patients admitted to the SICU are seen, cared for, and followed by the members of the CCM team.  The resident is expected to be actively involved and a participant in the care of these patients.  This includes management, performance of procedures, decision-making, order writing, and entering progress notes in the patient’s hospital record.  Having said this, it is important to note that this Unit has very high acuity; thus, all major decisions / changes in plan are carried out only after discussion with the CCM Fellow / attending.
  2. The care we provide in the SICU is delivered via a collaborative care model.  This model assumes co-equal management with our surgical colleagues.  Thus, the duties you carry out are done so in conjunction with members of the surgical team, who also have responsibility for the patient.  This entails cooperation and communication on the part of both services.  You will find that, given the size and acuity of the SICU, appropriate communication will become a challenge at times.  This is an important issue in the management of the unit and will not be considered “secondary”.
  3. The line of responsibility for the SICU resident is through the CCM Fellow.  The Fellow is responsible for determining the amount of care to be administered by the resident, and the degree of autonomy exercised by the resident.  Before major interventional changes or invasive procedures are carried out, the Fellow should be notified.  Basic communication with the surgical services should be carried out at the appropriate level.  CCM Fellows are available for communication with Chief Residents and Attendings of the various surgical services; administrative responsibilities in the SICU are carried out by the CCM Fellows.
  4. There is coverage on 94-IMC 24 hours per day, 7 days per week.  On days when one of our mid-level providers (PA / ARNP) is absent, residents will also be responsible for patient care in the IMC.  Most often, you will be called to the IMC by a nurse or a mid-level provider for a problem they feel is of significance.  You are encouraged to go look at the patient, do not attempt to “triage” the IMC (or Burn Unit) over the phone.  DO NOT give telephone orders if you have not seen the patient.  After you have seen the IMC patient, make sure that you write a brief note explaining what you have done and why; if the issue is major, or one that the surgical service wishes to know about, call the surgical house officer on call and update them.
  5. Patients admitted to the PACU / Overnight Recovery Room are also the responsibility of the Critical Care Medicine resident.  These patients are evaluated and treated in an appropriate fashion.  The follow up responsibility is through the CCM Fellow and either the SICU Attending or Anesthesia OR Attending.  These patients must be evaluated at the time of their arrival in the PACU and require an admission note.
  6. The CCM Team manages the critical care aspects of the thermally injured patient, while the Trauma / Burn Team cares for the burn itself.  Our primary role in these patients is look after their mechanical ventilatory and cardiovascular needs.  However, any call by one of the nurses in the BICU will be responded to just as we do in the SICU and IMC.  These patients will not be “triaged” over the phone; you must evaluate the patient and leave a note as to what you did.  Make sure that you discuss your plan with the Fellow or Attending (either Critical Care or Burn / Trauma) if there are difficulties.
  7. The CCM resident is a member of the cardiac arrest team for the hospital.  As such, you and the Fellow will have Code Blue Pagers, which should be promptly answered.  The resident’s responsibility is to establish the airway.  If the medical resident has arrived on the scene, this individual has responsibility for conducting the code; however, in his absence, the CCM resident should step in and handle the situation.  Again, once the situation is stabilized and after the medical resident agrees, the CCM resident may leave the scene.  A brief note should be placed into the chart detailing what was done by you; if, upon arrival, there is no need for your services, place a brief note documenting your presence.  A code bag is maintained by the CCM residents.  This has a selection of endotracheal tubes as well as laryngoscopes to fit most situations. Some emergency drugs are also present.  It is the responsibility of the resident carrying the cardiac arrest pager that the bag be stocked with items that he / she wishes to use.  This includes drugs.
     

Occasionally, the medical resident / intern will ask you to allow them to access the airway.  In general, a code situation is not the best time for airway education.  The decision is yours; if you feel that an educational experience is inappropriate, you may so state and direct the resident to one of the CCM attendings for an airway experience.  If one of the Pulmonary / Critical Care Medicine attendings is present, wishes to access the airway, simply leave a brief note that your services were not needed.

 

  1. From time to time consults may arrive requesting central line placement or other procedures for patients on the main hospital floors.  At the discretion of the Fellow, these may be carried out, based upon time and work constraints.
  2. Patients requiring hyperbaric oxygen therapy are also cared for by members of the CCM team. As such, the resident may occasionally receive outside requests for consultation.  These should be immediately referred to the CCM Fellow.  During hyperbaric oxygen therapy, situations may develop which require the presence of the CCM resident in the hyperbaric oxygen therapy facility. They should promptly report to this location and render whatever services are necessary.  Again, the CCM Fellow is a primary backup for any of these problems.
  3. Patients in the SICU often require transport to other areas of the hospital.  When this is carried out the resident, along with the patient’s RN, should make a decision as to whether or not a physician is:
    • Needed to accompany the patient during transport, or
    • Required to be present during the procedure outside the intensive care unit.  If a physician is necessary for any of these steps, this will be the CCM resident.  If the work load is such that this is not possible, contact will be made with the operating room anesthesiology group to schedule sedation / anesthesia / physiologic support.
  4. Any difficulties / conflicts will be adjudicated by the CCM Fellow.

SCHEDULE: 

Your SICU day begins with pre-round evaluation of patients, followed by morning bedside rounds.  All members of the team are to be present for daily rounds.  SICU Core Lecture Conference is at noon in the SICU conference room, 2512 PSB.  Afternoon rounds are held between 4:30-6:30 pm, at the discretion of the SICU Attending.  Both the SICU residents on call that evening will be present for the afternoon rounds.  Weekend rounds are held once daily, at a time to be determined by the SICU Attending physician.

  1. The 80-hour work week rule is taken seriously by the Department and Division.  If you feel that there are work-hour violations, you are encouraged to discuss this with the Division Chief.
  2. Resident dismissal times will be discussed during the first conference of the rotation.

 

THE WORK DAY:

  1. Residents are expected to arrive in time each morning to be adequately prepared for rounds.  Since each resident is expected to be ready for Radiology Conference (2512 PSB) at 0900 hours sharp, please prepare accordingly.
  2. Each morning, except Wednesday, in Room 2512 we have Morning Report, in which we go over each new patient together.   The resident who admitted the patient will present the patient briefly, with emphasis on reason for admission, acute problems, treatment since admission, and plan for treatment.  The faculty, Fellows, and residents present will discuss the case with the presenting resident; emphasis will be on resident education and presentation skills.  Patients presented in Morning Report will not be represented, except as needed, on rounds.
  3. Rounds last from about 0800 to approximately 1030 hours.  Thereafter, the SICU Fellow will divide up work assignments for the day.  It is imperative that these tasks be carried out in a timely fashion, prior to the arrival of new patients.
  4. Our daily SICU Conference is at noon in the SICU Conference Room (2512 PSB).  If you eat in this room, please pick up after yourself.
  5. On each Wednesday, all of the residents will attend Surgical M&M (0700 to 0800) and Surgical Grand Rounds (0800 to 0900).  We will begin rounds precisely at 0900 in the SICU Conference Room.  On Wednesday, there is no noon lecture.
  6. Two or three times per month, lecture is replaced by a Radiology or Neuroradiology conference.  These begin at 1130 and the location will be announced.
  7. Again, the workday ends in a manner consistent with the 80-hour work week rule.  However, before he / she departs, the resident must check out with the SICU Fellow or Attending on that day.

 

CHART NOTES:

  1. Patient assignments will be equitably distributed among all the CCM residents.  If on-call admissions result in a lop-sided distribution, the CCM Fellow will redistribute the patients.
  2. Prior to rounds, talk to the RN caring for the patient and the resident on-call the previous night to rapidly determine if there were any overnight changes.
  3. Each resident is responsible for a daily note on his / her patient.  This should be a Problem-Oriented note.  This means that the problems are listed in numerical order (see attached example).  Each problem is followed by information documenting and establishing the current state of that problem.
  4. Notes will include physical examination.  If there is any question as to what is meant by physical examination, please ask.
  5. Notes will include plans for the treatment of the patient for the day; this portion of the note need not be finalized prior to rounds.  The specific format for daily progress notes is shown below.  All progress notes must follow this format - any other format is not acceptable and will result in an adverse action being taken.

    Daily Progress Note Template

    • History:
      • Description of problem bringing Patient to unit
      • If ROS UNOBTAINABLE….so note
      • Problem list including ACTIVE PROBLEMS and at least 3 chronic problems (if they exist) with status (active – inactive).  Make the last problem of the list whether or not there are allergies……i.e.:
        • Respiratory failure— weaning from ventilator
        • CAD—stable
        • Chronic renal insufficiency—stable
        • Type 2 DM—controlled
        • NKDA
      • If available: alcohol Hx, tobacco Hx (in pack years) , and Hx of drug use
    • Examination:….LAB DATA ARE NOT AN EXAM
        • Vitals
        • Neurologic— orientation, commands.  Sedatives / analgesics and sedation score
        • Eyes— icteric or not
        • Pulmonary—BSEBL, wheezing, labored respirations, etc
        • Cardiac—S1, S2, is there an S3, S4 or murmur.  Rhythm ?
        • Abdominal / GI—soft, non-tender, non-distended, BS
        • Skin—is there a pressure sore, rash
        • Any other element as indicated
    • Laboratory Studies:
        • X-rays:
        • Lab studies
        • Cultures / Antibiotics
    •  Lines / Feeds / Drugs
    •  Assessment
        • “As above”, and include any new deterioration or changes
    • Plan:
        • State that we will review and order labs and radiographs
        • List at least 4 things to be done based upon the problem list, i.e.:
          • “Attempt to de-escalate ventilatory support
          • Continue antibiotics as above
          • De-escalate antibiotics as appropriate
          • Continue to treat / follow CAD, CRF, DM
  6. All invasive procedures require a separate note labeled as the type of procedure performed. These should include the procedure, indication, findings, medications, complications, and follow-up.
  7. All notes should be signed, physician number legibly written, dated, and the time noted.  Notes covering more than one page should be signed on both pages.
  8. Chart notes by the students should be read, corrected (if necessary), and signed by the resident assigned to that patient.  Complete recapitulation, by the resident, of properly covered areas in the student’s daily note are not required.

ORDERS

  1. Verbal orders are, except in emergencies, not utilized.  Each resident must write his / her order.  Orders for recurrent labs expire at 10:00 am each day and must be reordered by that time.
  2. Hyperalimentation orders must be rewritten daily and sent to the pharmacy before 1:30 pm.
  3. Patients on amphotericin B or liposomal amphotericin B must have the order rewritten daily.
  4. The medication sheet indicates the initial day all medications were begun.  The flow sheet also lists all one time and prn drugs given each day.
  5. The flow sheet also lists the dosage rate for all drugs given on a continuous basis.

 

STUDENTS:

  1. The CCM residents are responsible for the senior medical students / Physician Assistant students assigned to the rotation.  They should determine the workday for the student.  Students are expected to take in house, over-night call and to carry pagers.
  2. The CCM resident / Fellow will determine when students may carry out various invasive procedures.  No student will perform an invasive procedure without the direct attendance of the CCM resident or Fellow.  In the case of central lines, both the resident and the student should be gowned and gloved for the procedure.

 

PROCEDURES— General:

  1. See the ICU Handbook (www.anest.ufl.edu, click on critical care) for detail on this.

 

RESIDENT PRESENTATIONS: 

  1. The resident or student assigned to a particular patient will be responsible for a presentation on daily rounds.
  2. Presentations should be in a problem-oriented fashion similar to the note entered as part of the patient’s daily record.  This means that the patient must be seen prior to 8:00 am.
  3. In addition to the ICU flow sheet, sources of information include the call team from the previous night, the bedside nurse, and chart notes, particularly those written by the surgical service.

 

SURGICAL SERVICES:

Since we jointly care for SICU patients with the surgical team, it is imperative that each resident maintain good communication with the surgical service.  This includes reading the notes written by the service and discussing the case when a member of the team appears in the SICU or when the team makes rounds.

 

CONSULTANTS:

Multiple consultants come to the ICU.  Be sure you not only read their notes, but also discuss your patient with them – they are a resource to be utilized.

 

EDUCATION

  1. SICU READING LIST:
    • (http://www.anest.ufl.edu/articles/sicu) The SICU Reading List is a compilation of journal articles, selected by Dr. Gallagher, to be used as required reading for all residents and medical students on the SICU rotation.  These articles can be found on the Department of Anesthesiology’s website at www.anest.ufl.edu, on the anesthesiology site list under Info & Schedules.
    • To access the SICU Reading List from outside the Department, you will be prompted to enter the following:

      Username:  sicu

      Password:   sicu1

 

If you have any questions about the reading list, please see Dr. Layon’s assistant, Poppy Meehan, in Room 2536-PSB, or contact her by phone at 265.0486.  You also can call Curtis Browne, in the Department of Anesthesiology’s computer support office, 265.1861.

 

  1. Books:
    • There are eight copies of the Murray, et al: Perioperative Care in the ICU.  You may check one of these out from Ms. Poppy Meehan in PSB 2536; they must be returned at the end of the rotation.
    • The ICU Handbook, available on line (www.anest.ufl.edu, click on critical care) and in bound paper form (from Ms. Meehan) is available.  This details the commonest problems and issues in the Unit; the on-line version is frequently updated.
  2. Doctor Gallagher’s on-line lectures are available, covering many basic topics.
  3. We are pleased to assist you with your education.  However, it is your responsibility to read, ask questions, and to be familiar with the ACGME Competencies (see attached CCM Rotation Goals and Objectives).  Your evaluation will be partially based upon how you do in an oral examination based upon the competencies.

    

CALL SCHEDULE: 

Dr. Lawrence Caruso prepares the resident call schedule.  After the schedule has been published, all changes are to be negotiated among the residents and then must be approved by either Dr. Caruso or Dr. Layon.

 

PAGERS:

  1. Please keep the pager on at all times.  Since we use digital pagers, it is imperative that all calls be answered immediately.  This is particularly so when calls are made from the SICU.  Calls from the SICU Pods will generally be from the following numbers:

    Pod I                   5.0428 or 4.2917 / 4.2918

    Pod II                  5.0442 or 4.2969 / 4.2970

    Pod III                 5.0491 or 4.3452 / 4.3453

    Pod IV                 5.0251 or 4.4549 / 4.3493

    Pod V                  5.0252 or 4.3394 / 4.7224

    BICU                   5.0200

    94-IMC                5.0094

     

  2. During the daytime, the resident not on call that day and not on call the previous evening should also carry the cardiac arrest pager.  At night the CCM resident on call will carry the cardiac arrest pager.  Batteries are available in Joanie Nyland’s office (room 2284).  Also, coordinate all pager repair work through Ms. Nyland’s office.

 

CALL ROOM: 

  1. A call room is available across from Pod III for the residents on the SICU rotation.  The room number is 2550. Since all share the room, please insure that you keep it relatively neat and clean.
  2. A second call room, when residents of the opposite gender are on call together, is available in the operating room call room area.

 

 

SICU M&M CONFERENCE:

  • The SICU Morbidity & Mortality conference is held on the last Thursday of each rotation, at noon, in the SICU conference room (2512).  Lunch is provided.
  • At this conference, we will review and discuss all deaths that have occurred in the SICU for the month.  The CCM Fellows will present the information for discussion by the entire group. 

 

DEBRIEFING:

  1. A debriefing session is held on the last Friday of each rotation, at noon, in the SICU conference room (2512). Lunch is provided.
  2. This session allows feedback from the resident in regard to his / her experience during the rotation.  At this session, you will receive an evaluation form for the SICU Rotation.
    1. PLEASE NOTE: As mandated by the ACGME, these evaluations must be completed by each resident on the rotation.
    2. Upon completion, evaluations should be returned to S. Poppy Meehan in PSB 2536.

CONTACTS:

Please feel free at any time during the rotation to bring any comments or questions to any of the SICU Attendings or Fellows.  We are here to help to you.

 

Contact Information for the SICU Attendings is as follows:

Lawrence J. Caruso, Jr., MD

Associate Professor of Anesthesiology and Surgery

Office: #2211-PSB

Phone: 4.4031

Pager: 413.7707

E-mail: LCaruso@anest.ufl.edu

Assistant: Iris Gassaway [phone: 265.0463, office: #2509-PSB]

E-mail: IGassaway@anest.ufl.edu

Andrea Gabrielli, MD

Associate Professor of Anesthesiology and Surgery

Clinical Unit Chief of Hyperbaric Medicine

Medical Director, Respiratory Therapy Services

Office: #2536-PSB

Phone: 4.4543

Pager: 413.7772

E-mail:  AGabrielli@anest.ufl.edu

Assistant: Poppy Meehan [phone: 265.0486, office: #2536-PSB]

E-mail: Psmith@anest.ufl.edu

 

T. James Gallagher, MD, FCCM

Professor of Anesthesiology and Surgery

Office: #2509-PSB

Phone: 265.0463

Pager: 413.0859

E-mail: Jgallagher@anest.ufl.edu

Assistant: Iris Gassaway [phone: 265.0463, office: #2507-PSB]

E-mail: IGassaway@anest.ufl.edu

 

 

A. Joseph Layon, MD, FACP

Professor of Anesthesiology, Surgery, and Medicine

Chief, Division of Critical Care Medicine

Medical Director, Gainesville Fire / Rescue Service

Office: #2536-PSB

Phone: 4.5198

Pager: 413.8020

E-mail: JLayon@anest.ufl.edu, layon@ufl.edu

Assistant: Poppy Meehan [phone: 265.0486, office: #2536-PSB]

E-mail: Psmith@anest.ufl.edu

 

Carl W. Peters, MD

Clinical Associate Professor of Anesthesiology

Office: #2213-PSB

Phone: 4.3727

Pager: 413.8101

E-mail: cpeters@anest.ufl.edu

Assistant: Iris Gassaway [phone: 265.0463, office: #2507-PSB]

E-mail: IGassaway@anest.ufl.edu

 

Murat Sungur, MD

Assistant Professor of Anesthesiology

Office: #2211-PSB

Phone: 4.5600

Pager: 413.7811

E-mail: MSungur@anest.ufl.edu

Assistant: Iris Gassaway [phone: 265.0463, office: #2507-PSB]

E-mail: IGassaway@anest.ufl.edu

 

University of Florida College of Medicine

Department of Anesthesiology

Division of Critical Care Medicine

Resident Goals and Objectives for the SICU Rotation

 

 

The resident will be evaluated on the six core competencies required by the ACGME (described below), as pertains to the care of the ICU patient and the above listed goals and objectives.  It is understood that the breadth of knowledge and experience gained will be proportional to the amount of time spent rotating in the ICU as well as the effort of the resident on rounds and in reviewing appropriate reading materials, including textbooks, the peer-reviewed literature, and web-based educational materials.  Please note that the oral examination topics are most often drawn from the ACGME competencies.

Training in the surgical ICU is accomplished during three (at least) separate ICU rotations which will generally occur during the CA-1 and CA-2 training years.  Clinical base interns may also choose to participate in the surgical ICU.  We expect that the full spectrum of the goals and objectives listed below will be accomplished by the time the third rotation is completed.  In addition, graduated levels of responsibility will be given during each ICU rotation.  Residents whose intern schedule requires completion of more than three ICU months will be given even more responsibility during later rotations and may be asked to function as acting SICU fellows.

Responsibility Guidelines:

Clinical base rotation:  Clinical base residents will be closely supervised in all areas of the rotation.  They will be expected to follow fewer patients than more advanced residents.  All orders will be discussed with and approved by more senior residents or fellows.  All procedures will be directly supervised by faculty, fellows, or more senior residents with proven competency in the involved procedure.  Clinical base residents will be expected to carry out the agreed upon patient care plans and monitor results in all patients assigned to him / her. 

CA-1 rotation:  The CA-1 resident will be given an increased patient load.  In addition, after documentation of sufficient experience and with attending approval, CA-1 residents may perform procedures independently and supervise clinical base residents in performing procedures.  CA-1 residents will not initiate procedures or therapies without previous discussion and approval from the SICU fellow or attending, but will be expected to be more active in developing patient care plans.

CA-2 rotation:  In addition to responsibilities of the CA-1 resident, the CA-2 resident will be given an increased patient load.   The CA-2 resident will be expected to be very proactive in developing both initial patient care plans and plans in response to changes in a patient's condition, discuss the plans with the fellow / attending, implement the plans, and closely follow the results.  They will be expected to be aware of and practice well-established Preventive / Proactive Medicine relevant to common critical care problems.

General Goals:

  • Understand the spectrum of critical surgical illness  Follow course of postoperative critically ill patients
    • Learn from observations of the postoperative course of critically ill surgical patients how to better care for critically ill patients intraoperatively 
    Assimilate and organize large amounts of information on critically ill patientsDevelop competence in the placement and use of invasive hemodynamic monitoring toolsRecognize the critically ill patient who needs intensive postoperative care from the patient who does not require such care concentrating on:
    • Physiologic instability
      • NeurologicRespiratory
      • Hemodynamic
    • Need for Close Monitoring
      • Neurologic statusHigh risk of continuing bleeding or postoperative bleeding
      • Free flap or graft viability
      • The patient with poor physiologic reserve
        • NeurologicRespiratory
        • Cardiovascular (Hemodynamic)

Specific Competencies - See also General Competencies

PATIENT CARE SKILLS AND MEDICAL KNOWLEDGE:

  • Efficiently obtain historical information from the patient or the chart relevant to acute critical care management
  • Elicit physical examination findings relevant to acute critical care management
  • The resident completing 3 rotations in the SICU should be able to demonstrate patient care skills and medical knowledge adequate to appropriately deal with the following general situations commonly seen in a surgical ICU
    • the postoperative patient with oliguria
    • the postoperative patient with hypotension
    • the febrile postoperative patient and the surgical patient with septic shock - includes appropriate use of antibiotics
    • the postoperative surgical patient requiring ventilatory support for either acute or chronic respiratory failure - including choice of ventilatory modes and weaning from mechanical ventilation
    • the postoperative patient requiring acute airway management - who also has a difficult airway
    • the postoperative surgical patient with myocardial ischemia
    • the postoperative surgical patient with a coagulopathy
    • the postoperative patient requiring either parenteral or enteral nutrition
    • the patient requiring resuscitation - demonstrate a working knowledge of BLS, ATLS, and ACLS
  • Able to synthesize an appropriate management plan from available history, physical findings, and laboratory information - specifically for the following system related problems:
    • Cardiovascular system - fluids (trauma / burn patients)
      • Fluid maintenance requirements
      • Replacement of blood loss
      • Assessment and replacement of 3rd space losses
      • Burn injury resuscitation
        • Resuscitation formulas (Parkland, Brook)
        • Titration of resuscitation
        • Indications for invasive monitoring
    • Neurologic system - Differential diagnosis and appropriate treatment of:
      • Postoperative confusion / agitation
      • Seizures
      • Hydrocephalus
      • Cerebral vasospasm
      • Increased ICP and Herniation syndromes
    • Cardiovascular system
      • Differential diagnosis and appropriate treatment of:
        • Hypotension
        • Hypertension
        • Arrhythmias
        • Cardiac arrest (ACLS)
        • Shock states
        • Pulmonary embolism
    • Respiratory system
      • Differential diagnosis and appropriate treatment of:
        • Hypoxemia
        • Hypercapnia
        • Acute Lung Injury / ARDS
        • Airway compromise - understand different methods for managing and securing the airway
          • Endotracheal intubation with and without drugs (via direct laryngoscopy)
          • Awake fiberoptic intubation
          • Laryngeal mask airway
          • Indications (not performance) for surgical airway
            • cricothyrotomy
            • formal surgical tracheostomy
      • Know available ventilatory support modes and be able to appropriately recognize when each mode is most effectively used
    • Renal system
      • Differential diagnosis and appropriate treatment of:
        • Oliguria
        • Azotemia
        • Common electrolyte abnormalities including but not limited to:
          • hyper / hyponatremia
          • hyper / hypokalemia
          • hyper / hypocalcemia
          • hyper / hypophosphatemia
          • hypomagnesemia
          • Acid-base disorders
      • Renal replacement therapy
    • Hepatic system
      • Differential diagosis and appropriate treatment of:
        • Jaundice
        • Coagulopathy
        • Shock liver
    • Hematologic system
      • Differential diagnosis and appropriate treatment of:
        • Anemia
        • Thrombocytopenia
        • Coagulopathy
    • Endocrine system
      • Differential diagnosis and appropriate treatment of:
        • Adrenal insufficiency
        • Thyroid disorders
        • Diabetes insipidus
        • Diabetes mellitus and glycemic control
        • SIADH
        • Cerebral salt-wasting syndrome
    • Reproductive system
      • Be aware of the diagnosis and critical care implications of:
        • Pre-eclampsia / eclampsia
        • Peripartum hemorrhage
        • Pulmonary and amniotic fluid embolism
        • Peripartum cardiomyopathy
  • Be aware of and competently manage Immune System / Infectious Disease issues, specifically:
    • Evaluation and workup of postoperative fever
    • Appropriate selection of antibiotics
      • Initial choice
      • Narrowing antibiotic focus based upon culture sensitivities
      • Drug level monitoring
      • Duration of therapy
    • Prevention, evaluation and treatment of common infections in the surgical patient
      • Ventilator associated pneumonia (VAP)
      • Catheter-related bloodstream infection
      • Urinary tract infections
      • Wound infections
      • Peritonitis / intraabdominal abscess
      • Meningitis
      • Sepsis / septic shock
    • Surgical antibiotic prophylaxis
  • Be aware of and competently manage nutrition related issues, specifically:
    • Evaluation of nutritional status and assessment of need for:
      • Enteral nutrition
      • Parenteral nutrition
  • Be aware indications for and appropriately utilize blood component therapy including:
    • Packed red blood cells
    • Platelets
    • Fresh frozen plasma
    • cryoprecipitate
    • Recombinant Factor VIIa
  • PROCEDURES and MONITORING TECHNIQUES - Over the course of 3 ICU rotations, the anesthesiology resident will learn indications and techniques for use / placement as well as appropriate interpretative skills (as applicable) for the following:
    • Capnography
    • Arterial catheterization
    • Central venous catheterization
    • Pulmonary artery catheterization
    • Cardiac output / function assessment:
      • Thermodilution
      • Lithium dilution (LiDCO)
      • Esophageal Doppler
      • Echocardiography
    • Transvenous cardiac pacemaker (may not actually see or do this procedure, but should have knowledge)
    • External (Zoll) cardiac pacemaker
    • Chest tube insertion
    • Diagnostic and therapeutic bronchoscopy
  • Be aware of and practice well-established Preventive / Proactive Medicine relevant to common critical care problems including:
    • DVT prophylaxis
    • Stress ulcer prophylaxis
    • Pulmonary toilet / bronchodilators / VAP prophylaxis
    • Perioperative heart rate and blood pressure control
    • Renal protection prior to use of dyes for diagnostic procedures
  • Appropriately provide sedation and analgesia to postoperative ICU patients
  • Appropriately utilize and monitor neuromuscular blockade as necessary in the ventilated postoperative patient
  • Anticipate problems associated with transport of critically ill patients
  • Trauma related issues:
  • Be able to perform primary, secondary and tertiary surveys in the trauma patient admitted to the surgical ICU, especially in patients with:
    • Traumatic Brain Injury
    • Head and neck injury
    • Thoracic Injuries
    • Abdominal and Pelvic injuries
    • Extremity Injuries
    • Pregnancy

MEDICAL KNOWLEDGE:    In addition to knowledge pertaining to the specific areas mentioned above, the anesthesiology resident will demonstrate knowledge in the following general areas relevant to critical care:

  • Pathophysiology of patients' preexisting and current surgical and medical illnesses, and the critical care implications of these illnesses.
  • Basic science knowledge (physiology, pharmacology, anatomy) as related to patients.
  • Pharmacology of drugs commonly used in the critical care setting, especially vasopressors, vasodilators, pain management drugs, sedative drugs, and antimicrobial therapy
  • Principles of mechanical ventilation; understands function of modern ventilators
  • Acid-Base Physiology

PROFESSIONALISM:   See General Competencies

  • Understand ethical principles of medicine and how these impact and influence the way patients are treated
  • Participates in rounds on time and promptly when called, responds to care requests promptly and courteously, provides dictations and char

INTERPERSONAL AND COMMUNICATION SKILLS:   See General Competencies, plus:

  • Provides optimum medical care assisted by professional and effective relationships and communication with attending physicians, surgical colleagues, medical and other consultants
  • Has effective and appropriate relationships and communication with nursing and ancillary staff
  • Demonstrates compassionate relationships and communication with patients and their families during the difficult intensive care setting.  Able to appropriately deal with issues surrounding death and the dying process both with patients and their families. 

PRACTICE-BASED LEARNING:  See General Competencies

  • Learn how to use evidence-based medicine to improve patient care
  • Become proficient at using the electronic medical record and the use of the Internet to look up medical information.
  • Assimilate concepts learned from medical rounds and daily conferences into the developing critical care practice skills.

SYSTEMS-BASED PRACTICE:   See General Competencies

  • Learn how to work with an interdisciplinary team in the care of the critically ill patient including arranging care from consultative teams
  • Learn how to approach patient care problems from a systems-based approach rather than the individual "band-aid" approach.
  • Learn to practice cost-effective medicine without compromising patient care.
  • Learn to appropriately utilize health care resources available to critically ill patients - both during their stay in the ICU and for planning for discharge from the ICU and hospital. 

Areas and Means of Evaluation to Determine Goal Achievement 

  • Area: Daily rounds; Means: Attending and fellows assigned to the SICU for that week 
  • Area: Clinical care; Means: Attending and fellows assigned to the SICU during that rotation 
  • Area: Presentation of case at clinical conference during the rotation;  Means: SICU faculty and fellows 
  • Area: Chart notes;  Means: Daily review by the attending assigned to the SICU that day
  • Area: Discussions related to daily care of patients;  Means: All attendings involved 
  • Area: Rotation debriefing session;  Means: T. James Gallagher, MD; A. Joseph Layon, MD; Lawrence Caruso, MD; Andrea Gabrielli, MD; Carl Peters, MD;  Murat Sungur, MD
  • Area: Overall evaluations at the end of the rotation:  SICU faculty who worked with you will complete a monthly online resident evaluation form.  These forms are reviewed quarterly by the clinical competence committee and continuously by the program director.  Your advisor will share with you promptly any problems identified and assist you with correction.  Departmental Online Rotation Evaluation Forms are completed by resident and regularly reviewed by rotation directors to ensure that rotation goals are being met 

Teaching Resources to Accomplish Objectives 

  • 2000+ patients per year requiring care in the following areas: 
    • General and plastic surgery 
    • Multiple trauma 
    • Neurosurgery 
      • Spinal operations and craniotomy (especially neurovascular patients)
      • Closed head trauma 
    • Orthopedic surgery
    • Urology 
    • Transplantation (renal, liver, and pancreas) 
    • Gynecology and gyn-oncology 
    • Vascular surgery (non-cardiothoracic) 
    • Otorhinolaryngology 
    • Plastic surgery - burn unit 
  • Daily SICU conference at 0830 
  • Reading lists from critical care texts, which are constantly updated 
  • VIDEO TEACHING RESOURCES 
  • Faculty
         A. Joseph Layon, MD (chief)

     Lawrence Caruso, MD
     Andrea Gabrielli, MD

     T. James Gallagher, MD

     Carl Peters, MD

     Murat Sungur, MD
    

Dr. Layon is the faculty member responsible for this rotation. 

RETURN TO INDEX FOR GOALS AND OBJECTIVES
Revised 9/2005