Critical Care Curriculum for Two-Month Rotation as Part of an Anesthesiology Residency

Transcription

1 DEPARTMENT OF ANESTHESIA Critical Care Curriculum for Two-Month Rotation as Part of an Anesthesiology Residency 1. An anesthesiology resident, during a two month rotation should gain exposure to the scope of critical care problems and the types of patients who are typically seen in an intensive care unit. While it is recognized that an in-depth knowledge of every aspect of critical care is not possible in a rotation of this duration, the basic principles of pathophysiology, diagnosis, and treatment should be induced. 2. The resident should leant to manage all aspects of a critically ill patient, mot just the hemodynamic and respiratory systems, total care involves the management of the patient s renal, nutritional, neurological, endocrine and infectious disease problems, as well. 3. a) Residents should lean the process and criteria for admitting an discharging patients from an intensive care unit and principles of triage. b) Residents should be introduced to principles of ethics, such as withdrawal of therapy or whether or not to resuscitate, and social and financial aspects of patient care which are seen in an intensive care unit. c) Residents should become familiar with the various technical aspects of critical care including monitors, (insertion of monitoring lines) ventilators and mechanical support of the circulation (pacemakers, intra-aortic balloon pumps, ventricular assist devices). d) The following topics should become familiar while on this rotation: 1) Mechanical ventilator and airway management in the critically ill. Basic elements of respiratory physiology and mechanics will be taught. 2) Diagnosis and therapy of cardiac disease including Dysrhthmias, ischemia, and valvular heart disease. Pharmacologic treatment of the circulation. 3) Renal management, including indications and management of patients undergoing dialysis, CAVH, CAVHD, and peritoneal dialysis.

2 4) Antibiotic management and prophylaxis in critically ill patients, management of immunologically compromised patients. 5) Neurological intensive care, including management of increased intracranial pressure. Central nervous system physiology, pathology, pathophysiology, and therapy. 6) Use of sedatives and neuromuscular blocking agents in the intensive care unit. 7) Prevention of gastrointestinal bleeding. 8) Acid base balance. 9) Metabolic and endocrine effects of critical illness. 10) Trauma, including burns 11) Diagnosis and treatment of sepsis. 12) Nutrition, including enteral and total parenteral nutrition. 13) Transport of the critically ill patient. 14) Cardiopulmonary resuscitation 15) Obstetric disorders. 4. The resident must learn to work as part of a multi-disciplinary team and to learn to coordinate the care of a critically ill patient. This includes dealing with families of critically ill patients, as well as interacting with nurses and other staff. 5. Emphasis should be placed on synthesizing and editorializing from the base amounts of data generated in an intensive care unit. Daily note taking to emphasize history and differential diagnosis as well as data analysis is expected. 6. The curriculum must include presentations on daily rounds and formulating a diagnostic and treatment plan. The resident must take overnight ICU call, must be able to teach other housestaff, support personnel, and medical students. 7. The optimal way to teach these objectives is primary patient care. This means that the resident must have the ability to formulate diagnostic and therapeutic plans, and then be able to write orders and perform the necessary procedures to carry these plans through. This includes all aspects of the care of the critically ill patient. The resident must be part of a team which is given the ability to make decisions and then apply them.

3 Faculty must be available on a 24-hour basis. This would include being in the hospital during the day and available by consultation or at the bedside at night. 8. The faculty should be supportive a available to the resident. The faculty should take an active role in teaching on rounds, discussing issues at hand, and giving appropriate lectures. The faulty must meet with the resident to give him/her feedback about management decisions and interactions with their peers. The ideal faculty role model is an anesthesiologist trained in critical care. However, the resident must also come in contact with critical care physicians trained in other specialties. 9. Residents are evaluated daily and in formal sit-down conferences at the conclusion of the rotation.

4 ICU House Office Responsibilities Goals: To learn to care for critically ill patients with multiple organ system derangements. Each patient in the ICH is generally covered by an ICU team and a surgical team. Neuro SICU: Two Surgical resident / Anesthesia residents. Trauma / CTIC: a surgical resident. The House office team is made up of two anesthesia residents, and The house officer share responsibility and duties for the care of patients on an every third night rotation. Additionally, there will generally be an ICU fellow available to cover both units. A typical ICU call schedule for a house officer is: Day 1- Day 2 - Day 3 - ICU Off Consult Conference: On Mondays, Tuesdays, Thursdays and Fridays there is generally a teaching conference beginning at 7:00 a.m. in the 5 th floor SICU conference room. On Wednesday, Anesthesia Grand Rounds begin at 7:00 a.m. in the Sherman Auditorium. Surgical M&M form 7:00 8:00 a.m., Kennedy Auditorium. On Tuesday afternoons at 5:00 p.m. in the Anesthesia Mortality / Morbidity Conference. Daily Work Schedule: Rounds generally being on the ICU following the end of the morning lecture or x-ray rounds. Rounds will then follow in the ICU. On Wednesday mornings, rounds will begin in the ICU at 9:30 a.m., if the conference schedule allows. At the conclusion of rounds, the triage of patient in and out of the units for that day is discussed. Following this, the house officers will begin work in their respective units. The fellow and the attending oncall for the day are available to the house officers at all times for advice, supervision and help with procedures. House Officer On-Call Are Responsible for the Following Items: a) An admission and daily note on each patient b) Scheduling diagnostic and x-ray examinations. It is suggested that all x-ray examinations and laboratory investigations be ordered prior to morning rounds in each unit.

5 c) Ordering appropriate laboratory investigations. d) Performing diagnostic and therapeutic procedures on their patients such as insertion of hemodynamic monitoring lines, etc. e) Orders: House Officers may with orders on all aspects of patient care. All major management decisions should be discussed with the surgical team caring for the patient. All orders are t written by the ICU team. An ICU fellow or attending should be present for the insertion of all central monitoring lines and intra-arterial liens. All procedures, as usual, require a note in the history section of the patient s green chart. The on-call house officer is expected to be present during morning work rounds with the surgical teams caring for patients. This usually begins at approximately 6:00 a.m. The on-call house officer is responsible for arranging the time of these rounds the night before with the respective teams. Notes on the patients in each ICU will be written by the house officer assigned to the unit during the day. Calls to the ICU Attending and Fellow on Duty: The house officer on-call in each unit should contact the fellow or attending on duty when medical or administrative problems arise. A call schedule is posted in each unit. The fellow on-call should be notified of any admission, discharge, dramatic change in patient status, cardiac arrest, or unexpected death. For an admission request, a call to the attending on-call is mandatory. This holds whether the unit is full or not and whether the request seems appropriate or not. The fellow is expect to discuss these decisions with the attending on-call. Consult Responsibilities: During the week, the ICU consult officer is responsible for daytime consultation for admission to the ICUs. This house officer is also responsible for pre-operative evaluation of all scheduled admission to the ICU as wee as evaluation of patients who may require an ICU admission pre-operatively. The consult house officer is responsible for assisting at diagnostic tests and to assist the on-cal house officer as needed. At night, the responsibly as consult for the ICU is undertaken by the ICU house officer on-call. This generally will begin at 5 p.m. On week-ends the ICU house officer is the consult house officer; this house officer will see all pre-operative consultations at the request of the surgical teams and anesthesia staff. Care of ICU Patients Remote from the Unit: When a patient leaves the ICU, other than for final discharge, it is understood that house officer will either accompany the patient or, after discussion with the nurse caring

6 for the patient, will decide that physician escort is not necessary. Physician escort is necessary for all intubated patients. During nights or week-ends, the house officer who accompanies the patients may be a member of the surgical team. Rounds: Afternoon rounds are generally held with the attending and fellow on-call between 4:30 and 5:30 p.m. Rounds will be held with the fellow and the attending and house officer of each respective unit in their respective units. The timing of rounds in each ICU on the week-ends will be left to the discretion of the attending and the ICU fellow on-call. Cardioversions: Then anesthesia house office in the ICU is responsible for the performance of elective Cardioversions with the ICU anesthesia attending. These will generally be held at 1:00 p.m. General: House officers should sign-in with the page operator every day. Each house officer must check with the attending or fellow on-call prior to leaving for the day. Boarders in the MUCU or SDRU are managed as patients in the SICUs. House Officer Evaluation: Daily feedback and in a formal sit-down conference with Dr. Lisbon at the conclusion of the rotation.