Welcome
to your SICU rotation! As part of your training as an Anesthesiologist,
it is important that you have a clear, concise understanding of the principles
of Critical Care Medicine (CCM). We will endeavor to impart these to you
during your rotations in the Surgical Intensive Care Unit (SICU). This is an outstanding physiology and pharmacology
laboratory. At the end of
this rotation you should have a much clearer understanding of these principles
and how they interrelate 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. We hope
that these will enhance your training in Anesthesiology.
RESONSIBILITIES: The resident on the SICU rotation has responsibilities for patients in the SICU, Intermediate Care Unit, Overnight Recovery Room, Burn Unit, Emergency Room, cardiac arrests around the hospital, various consults on the floors, and patients referred for hyperbaric oxygen 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 of care, performance of procedures, decision making, order writing, and entering progress notes in the patient's hospital record. These duties are carried out 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. 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.
Patients admitted to the Overnight Recovery Room are also the responsibility of the SICU Anesthesia/Critical Care 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.
Patients in the Burn Unit requiring mechanical ventilator support or who have cardiovascular instability are followed and consulted on by the CCM team. However, we are expected to primarily carry out the mechanical ventilation and cardiovascular support of these patients.
The SICU Anesthesia/Critical Care resident will often be called to the Emergency
Room. The policy in place states that, "...the resident will evaluate all intubated patients in the Emergency Room." If a patient comes in already intubated, the SICU/Anesthesia resident will evaluate for correct placement of the endotracheal tube. The resident may further be called upon to stabilize an airway in a patient. Once these have been accomplished, the resident should clear the situation with the Emergency Room Attending before departing the scene. A note should be entered into the patient's record in each of these instances.
The SICU Anesthesia/Critical Care resident is a member of the cardiac arrest team for the hospital. As such, this person should promptly answer all code situations. 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 SICU Anesthesia/Critical Care resident should step in and handle the situation. Again, once the situation is stabilized and after the medical resident agrees, the SICU Anesthesia/Critical Care resident may leave the scene. A code box is maintained by the SICU Anesthesia/Critical Care 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 residents to ensure that this box is kept adequately stocked.
From time to time consults may arrive requesting cnetral line placement or other procedures for patients on the main hospital floors. At the discretion of the resident, these may be carried out. If one does not have time, or feel confident to do these procedures, please refer them to the CCM Fellow immediately.
Patients requiringhyperbaric 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 SICU Anesthesia/Critical Care 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.
Patients in the SICU often require transport to other areas of the hospital. When this is carried out, the resident should make a decision as to whether or not a physician is, a) needed to accompany the patient during transport, or b) required to be present during the procedure outside the intensive care unit. If a physician is necessary for any of these steps, this may be either the SICU Anesthesia/Critical Care resident or the resident of the primary surgical team responsible for the care of the patient. If either of these individuals is not available, then the patient should not be transported. In some situations, a member of the OR Anesthesia team may be available to help. These matters should be discussed with both the surgical service as well as the CCM Fellow.
Schedule: Your SICU day begins with evaluation of patients after the daily Anesthesia morning conference/bed control. This bed prioritization process occurs between 7:30-8:00 a.m. in the SICU. A daily SICU Core Lecture conference is held in the SICU conference room, 2512 PSB, at 8:00 a.m. Immediately following the conference morning bedside rounds generally begin, between 9:00-9:30 a.m. There are 2 separate ICU teams - each covering roughly 50% of all the ICU bed locations. Each team will have its own call schedule and will consist of a faculty member, 1 fellow, 3 residents and students. All members of the team are to be present for both the morning conference and daily rounds. Afternoon rounds are held between 4:30-6:30 p.m., at the discretion of the SICU Attending. Both the SICU resident on call that evening as well as the individual not on call the previous evening should be present for the afternoon rounds.
Weekend rounds are held once daily, at a time to be determined by the SICU Attending physician. Other conferences include the weekly ICU Conference. On the fourth Thursday of each month the CCM M&M conference is held in the SICU conference room. Copies of all conference and rotation schedules are posted in the SICU office, room 2507 PSB.
CHART NOTES: Patient assignments are to be equitably distributed among all the SICU residents. Each resident is responsible for a daily note on his or her patient. This should be a problem-oriented note. This means that the problems are listed in numerical order. Each problem is followed by information documenting and establishing the current state of that problem. This area should also include plans for the treatment of the patient that day. 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. All notes should be signed, dated, and the time noted. Notes covering more than one page should be signed on both pages. Chart notes by the students do not preclude the daily note by the SICU Anesthesia/Critical Care resident.
STUDENTS: The SICU Anesthesia/Critical Care residents are responsible for the Senior surgical students also assigned to the rotation. They should determine the work day for the Senior student. This includes determination of when students may carry out various invasive procedures. No student should perform an invasive procedure without the direct attendance of an SICU Anesthesia/Critical Care resident or CCM Fellow. In the case of central lines, both the resident and the student should be gowned and gloved for the procedure.
PROCEDURES: When invasive procedures are to be carried out, or there are any other major changes in the patient's care plan, the following people should be notified: CCM Fellow; a representative of the surgical team.
RESIDENT PRESENTATIONS: The resident or student assigned to a particular patient will be responsible for a presentation on daily rounds. These presentations should be in a problem- oriented fashion similar to the note entered as part of the patient's daily record. During the course of the rotation each resident will be expected to prepare a twenty-minute presentation for the morning conference. This presentation should include, when appropriate, the use of audio and visual aids as well as handouts. The presentation should be approximately twenty minutes in length and should encompass some area of CCM. The resident is also expected to provide breakfast the morning of his/her presentation.
SICU READING LIST: The SICU Reading List can now be found on the Department of Anesthesiology’s website. Go to http://www.anest.ufl.edu/articles/sicu(Please note that as of March 2000, some of the articles are still being added to the website.) You will receive a hard copy of the articles along with the other handout materials on day #1 of the rotation. If you have any questions about the reading list, please see Dr. Layon’s secretary, Poppy Meehan, in Room 2536-PSB, or contact her by phone at 265-0486. There is also an ICU article of the week that will appear on the website. This article may be a classical article of historical interest or a new, important article.
CALL SCHEDULE : Dr.
PAGERS: Each resident is assigned to a pager for the duration of the SICU rotation. Please keep the pager on at all times. Since these are digital pagers, it is imperative that all calls be answered. This is particularly so when calls are made from the SICU. The Pod I calls will generally be on numbers 5-0173 or 5-8926. Pod II calls will be on numbers 5-0251 or 4-4550. Pod III calls will be on 5-0252 or 4-4552. Pod IV calls will be on 5-1926. During 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 SICU resident on call will carry the cardiac arrest pager. Batteries are available in the residency office (room 2036). Also, coordinate all pager repair work through the residency office (Room 2036).
CALL
ROOM: A
ORDERS: Medications are ordered for patients on a daily basis. All medications, procedures, fluids and the like require a written order in the chart. Please minimize the amount of verbal orders since you will ultimately be required to sign these orders anyway. Ensure that daily chest films are ordered on all patients deemed necessary. The resident should review the daily 4:00 am chest film prior to the onset of morning bedside rounds. Chest films are to be done in the upright position when at all possible. Only unstable patients should not be placed in the upright position.
DEBRIEFING: A debriefing session is held on the last Friday of each rotation. This luncheon, at noon in the SICU conference room, allows feedback from the resident in regard to their experience during their rotation. Please feel free at any time during the rotation, to bring any comments or questions to any of the SICU Attendings. The Attendings may be reached in the following way:
ATTENDINGS:
A. Joseph Layon, MD, Professor of Anesthesiology and Surgery; Chief, Division of Critical Care Medicine: