MED VI MEDICAL INTENSIVE CARE (MICU) GOALS AND OBJECTIVES Internal Medicine University of Toledo

Transcription

1 MED VI MEDICAL INTENSIVE CARE (MICU) GOALS AND OBJECTIVES Internal Medicine University of Toledo Educational Goals and Objectives: The purpose of this rotation is to provide the residents with the knowledge and skill necessary to identify and manage common acute care problems. As PGY 1, PGY 2 and PGY 3, residents rotate through the University of Toledo Medical Center (UTMC), Medical Intensive Care Unit for four weeks. PGY 1 PGY 2 PGY 3 Obtain a detailed HPI emphasizing chronology of presentation and containing good descriptions of systems Patient Care obtain a detailed history of the illness, emphasizing chronology of the events with good review of systems. s presentation will include pertinent positive and negatives findings use nonpatient sources of data if cannot give a history for example calling the nursing home, the EMT, or the family. be able to tailor the physical examination to patient s complaints. be able to accurately identify and characterize the signs and stages of SHOCK (septic, cardiovascular, and hypovolemic). be able to identify and characterize cardiac murmurs and sounds be able to identify and characterized pulmonary auscultatory findings. s should be proficient identifying and interpreting the following elements of present without notes s presentation will include appropriate pertinent positive and negatives use appropriate nonpatient sources of data cannot give a history tailor the physical examination to patient s complaints be able to accurately identify and characterize the signs and stages of septic, cardiovascular, and hypovolemic shock obtain a detailed HPI emphasizing chronology of presentation and containing good descriptions of systems. present without notes. s presentation will include appropriate pertinent positive and negatives. use appropriate nonpatient sources of data cannot give a history. tailor the physical examination to patient s complaints. be able to accurately identify and characterize the signs and stages of septic, cardiovascular, and hypovolemic shock. be able to identify and characterize cardiac murmurs and sounds. be

2 the physical examination: blood pressure orthostatics, pulsus paradoxus; cardiopulmonary pulse examination venous pulsations JVD, hepatojugular reflux, v waves and arterial carotid, femoral, and pulse character; palpation and auscultation LV impulse (location and characterize) thrill, RV heave, regurgitant murmurs (AL, MR, TR), Stenotic murmurs (AS, MS), Pericardial Rub, S3 and S4, abnormal pulmonary findings crackles, wheezing, egophony, bronchophony, dullness to percussion, abdominal findings bowel sounds, fluid wave, shifting illness, neurologic coldcarlorics, asymmetric reflexes, strength and sensory Medical Knowledge Able to apply pathophysiology and perform focused, costeffective evaluations of the following complaints/ disorders: Approach to respiratory failure, acute and progressive dyspnea, pulmonary embolism, COPD, asthma, acute respiratory distress syndrome, Basic ventilator management. Approach to patient with shock (septic, Be proficient in the diagnosis and therapeutic management including monitoring for the adverse effects of specific therapuic management, including monitoring for the adverse effects of specific therapeutic interventions, for the following medical conditions/compla ints: Cardiology - able to identify and characterized pulmonary auscultatory findings. understands the epidemiology, pathophysiology, and pharmacology of common critical illness including ARDS, multiple organ system failure, pulmonary embolus, shock, vegetative state and brain death, ketoacidosis and hyperosmolar coma, asthma and COPD, and psychosis/delirium

3 cardiogenic, hypovlemic), chest pain, cardiopulmonary arrest, hypertensive emergency, aortic dissection Approach to GI bleed, acute liver failure, complications of liver failure Altered mental status, seizures, stroke, intracranial hemorrhage. Bleeding diathesis, DI, anticoagulation, VET treatment, HIT diagnosis and treatment, DVT prophylaxis in the ICU setting Diabetic ketoacidosis, hyper/hypo-kalemia, hyper/hypo-natremia, hypo/hyper-calcemia, renal insufficiency Nutrition fundamentals Fever in ICU setting, line infections, meningitis, complications from HIV, servers community and health care associated pneumonia, fungal diseases, severe sepsis. Drug overdose and poisoning Begin to develop interpretative skills of: Oximetry and blood gases, Serum electrolytes, Chest X- rays, Results from thoracentesis, paracentesis, spinal fluid, Pulmonary artery pressure reading, EKG s (see Shock (septic, cardiogenic, hypovolemic) shest pain, cardiopulmonary arrest, hypertensive emergency, artic dissection; Pulmonary - Respiatory failure, Acute and progressive dyspnea, pulmonary embolism, COPD, asthma, acute respiratory distress syndrome - Basic ventilator management; GI/hepatology - GI bleed, acute liver failure, complications of liver failure; Neurology - Altered mental status, seizures, stroke, intercranial hemorrhage; Hematology - Bleeding diathesis, DI, anticoagulation, VET treatment, HIT diagnosis and treatment, DVT prophylaxis in the ICU setting; Metabolic & Electrolyte disorders Diabetic ketoacidosis, hyper/hypokalemia, hyper/hyponatremia, hypo/hypercalcemia, renal insufficiency in the ICU setting. develop experience in the use of vasoactive drug. achieve or demonstrate competency in all ABIM required procedures as patient case mix allows. demonstrate developing competency in the use ventilatory support.

4 cardiology ward objectives) Know the indications, limitations, and complications associated with the following test/procedures: Mechanical Ventilation, Lung VQ scan, High-resolution CT, lower extremity Doppler, CT and MRI imaging of the head, chest and abdomen, Bronchoscopy and bronchoalveolar lavage, Endoscopy, Stress test-chemical or exercise stress testing, stress echo, stress thallium (also addressed in Cardiology ward), Transthoracic echocardiogram, transesophageal echocardiogram Develop proficiency in the interpretation of: Oximetry and blood gases, Serum electrolytes, Chest X-rays, Results from thoracentesis, paracentesis, spinal fluid, Pulmonary artery pressure readings EKG s (see cardiology ward objectives) Appropriately order and understand the indications and contraindications as well as complications associated with the following tests/procedures: Mechanical Ventilation, Gastrointestinal endoscopy, CT and MRI imaging of the head, chest, and abdomen, Bronchoscopy and bronchoalveolar lavage, Lung VQ scan, Highresolution CT, lower extremity Doppler Stress tests chemical or exercise stress testing, stress echo, stress thallium (also addressed in Cardiology ward) Practice-Based Attend all ICU

5 Learning and Improvement Interpersonal and Communication Skills conferences including morning report, topic review and presentation conference, and mortality conferences. present a minimum of one evidence based medicine review of a topic. Patient will develop clinical judgment in the strategies used to match treatment protocols with critical illness. Attend all autopsies preformed on patients expiring in the ICU. achieve enough score equal or above the benchmark for PGY1 regularly with patients and his/her family. is respectful to patient. is concerned about the patient s comfort. effectively with other members of the health care team. prioritizes diagnosis and treatment decisions based on patient s severity of illness Develop clinical judgment in the strategies used to match treatment protocols with critical illness Present a minimum of one EBM review at topic review and presentation conference. Attend all ICU conferences including morning report, topic review and presentation conference, and mortality conferences Attend all autopsies preformed on patients expiring in the ICU Achieve RIME specific criteria for PGY-2 resident regularly with patients and his/her family. is respectful to patient. is concerned about the patient s comfort. addresses patient care issues such as end of life prioritizes diagnosis and treatment decisions based on patient s severity of illness. develop clinical judgment in the strategies used to match treatment protocols with critical illness. present a minimum of one EBM review at topic review and presentation conference. regularly with patients and his/her family. is respectful to patient. is concerned about the patient s comfort. Effectively coordinates team to optimize patient

6 Professionalism completes the H&P/consultation within 24 hours of contact, and writes a daily progress note. follow through with scholarly assignments promptly. completes medical records on time. recognized and takes steps to correct his/her deficiencies. treats team members with respect, including nurses and other health care providers. acknowledges personal reaction to mortality associated with infectious disease Adheres to all ACGME mandated duty hour restrictions decisions with moderate faculty input. provides feedback to junior team members. functions as an effective team leader. effectively with other members of the health care team. completes the H&P/consultation within 24 hours of contact, and writes a daily progress note. follow through with scholarly assignments promptly. completes medical records on time. recognized and takes steps to correct his/her deficiencies. treats team members with respect, including nurses and other health care providers. Counsel s junior team members on issues of professionalism including personal reactions to the mortality associated with the care of patients care. Able to deal with challenging patients and families. Functions as an effective team leader. completes the H&P/consultation within 24 hours of contact, and writes a daily progress note. follow through with scholarly assignments promptly. completes medical records on time. recognized and takes steps to correct his/her deficiencies. treats team members with respect, including nurses and other health care providers. adheres to all ACGME mandated duty hour restrictions Counsel s junior team members on issues of professionalism including personal reactions to the

7 Systems-Based Practice can effectively initiate the appropriate clinical pathways. can effectively initiate the appropriate consultative services develops a multidisciplinary approach to medical intensive care requiring intensive medical management. adheres to all ACGME mandated duty hour restrictions. can effectively initiate the appropriate clinical pathways. can effectively initiate the appropriate consultative services develops a multidisciplinary approach to medical intensive care severs as a consultant to other services with moderate faculty input. mortality associated with the care of patients requiring intensive medical management Sets a tone of respect and collegiality for the team adheres to all ACGME mandated duty hour restrictions can effectively initiate the appropriate clinical pathways. can effectively initiate the appropriate consultative services develops a multidisciplinary approach to medical intensive care severs as a consultant to other services with moderate faculty input. critically evaluates all consultant evaluations including conflicting recommendation to develop an effective patient care plan. Teaching Methods: 1. Direct patient care 2. Directly supervised procedures 3. Faculty supervision 4. Core curriculum 5. Observed clinical examination skills

8 6. Reading materials and literature search Assessment Methods Competency Score Card: Medical Knowledge 1. Monthly test 2. New Innovation evaluations Patient Care 1. Procedures 2. Mini-CEX 3. New Innovation evaluations Practice-Based Learning 1. New Innovation evaluations 2. Consultation/Literature search (PGY 2/3) System-Based Learning 1. New Innovation evaluations 2. Care coordinator meetings (PGY 2/3) Professionalism 1. Medical record completion 2. New Innovation evaluations 3. Dictation completeness Communications evaluations 2. New Innovation evaluations 3. Transition of care (hand-off) Suggested Reading: Manual of the MICU-prepared by ICU division Available on MICU computer desktop Marini ICU book Revised 7/2010