DEPARTMENT OF CRITICAL CARE MEDICINE RESIDENT ROTATION HANDOUT

- 1 - Faculty of Medicine Critical Care Medicine DEPARTMENT OF CRITICAL CARE MEDICINE RESIDENT ROTATION HANDOUT INDEX: General Principles.. 2 Prerequisites 2 Members of the Healthcare Team.... 3 Daily Activities... 4 ICU Clinical Duties... 5 Teaching Activities. 9 Evaluation Process. 10 Clinical Trials.. 10 Clinical Practice Guidelines.. 10 Organization of Resident Call.. 10 Resources. 11 Level of Care... 12 Appendix 1: Nursing Presentation Format........ 13 Appendix 2: Respiratory Therapy Overview. 14 Appendix 3: Suggested Format for Transfer Summary and Discharge Note.16 Appendix 4: Checklist for Notification of Medical Examiner.. 17 Appendix 5: Learning Objectives for ICU Curriculum. 18

A. General Principles - 2 - The intensive care unit provides you with an opportunity to care for patients with many concurrent illnesses in a closely supervised setting. You should hone the following skills, knowledge and behaviors during your rotation. Your evaluation will be based on them. Ability to make decisions and direct the care of patients whose status may be changing on a minute to minute basis. Ability to organize information and establish goals and priorities for the care of individual patients and, if necessary, for groups of patients. Ability to separate important from trivial information. Ability to work effectively with all members of a multi-disciplinary team. Ability to identify personal limits and consult appropriately. Ability to interact with patients and families. Ability to maintain a succinct, useful medical record. Transfer summaries should be brief and capture information important to ensure continuity of care upon transfer. Ability to critically appraise medical literature, preceptors, and consultants. This means reading around patient problems and actively participating in morning rounds by asking questions and challenging others. You are expected to assume responsibility commensurate with your specialty and level of training. Ensure there is continuity of care at all times. B. Prerequisites 1) ACLS training that is current. 2) SCM training - the hospital ordering system. 3) PACS training - the diagnostic imaging review system 4) IMPAX training the diagnostic imaging review system (ICU specific) 5) N95 Mask fitting is current. If you have not been trained in #2, #3 or #4 of the above, arrangements will be made during your first week of the rotation.

C. Members of the Healthcare Team - 3 - Intensivists: An Attending physician is available 24 hours a day, seven days a week either in person or over the telephone to answer questions and provide guidance. If they are not inhouse, they are within 15 minutes of the hospital in case of emergencies. Unit Director: Ann Kirby CCM/Internal Medicine Resident Coordinator: George Alvarez CCM/Internal Medicine Consultants: George Alvarez CCM/Internal Medicine Terry Hulme CCM/Pulmonary Carla Chrusch CCM/Internal Medicine Mike Dunham CCM/Surgery Frank Warshawski - CCM/Pulmonary Critical Care Fellows: When a Fellow is on service, they will essentially take the role of the attending physician. Therefore, if possible, address all issues and plans with the Critical Care Resident first, then proceed to involve the attending. Registered Nurses: The RN s can be an invaluable resource to you during your rotation. Patient Care Manager: Laurie Harding Assistant Patient Care Supervisor: Melissa Redlich Nurse Clinicians Bedside nurses: Typically responsible for one critically ill patient at a time. Respiratory Therapists: Two RT s are assigned to the ICU 24 hrs/day. They are responsible for the daily management of the ventilators and patient s respiratory issues. Unit Clerks: The unit clerks are excellent resources that can help make your life easier. From adding blood work on to previously collected samples, to tracking down old reports, to having other physicians paged, the unit clerks are there to help you. Multidisciplinary team: Infection Prevention and Control, Nutrition, Occupational Therapy, Pharmacy, Physiotherapy, Social Work, Speech Language Pathologists, Spiritual Services

D. Daily Activities - 4-1. Sign over: It is expected that important events from overnight be signed over from the post-call resident to the resident responsible for those patients during the day. This should only take a few minutes. 2. Review Patients: In preparation for morning rounds, examine your patients, review lab work and most importantly, develop a comprehensive problem list and plan for each of your patients. 3. Didactic Sessions: Lectures are held every day of the week starting at 08:00, except Wednesdays when they start at 08:30. See below under Educational Activities for more details. 4. Patient Rounds Start at 09:30 with the following format: (a) (b) (c) (d) (e) (f) Review Code Blues from past 24 hours and homework assignments Start with patients who were admitted in the past 24 hours, or the most critically ill patients. For new patients: Resident - presents brief synopsis Nurse - presents assessment (see Appendix 1: RN format) RT - presents assessment (see Appendix 2: RT format) Resident - presents a problem based plan of management Don't "lose" the problems Don't repeat RN's presentation unless you disagree For existing patients: - as above, but initial resident synopsis is limited to any changes overnight. To optimize patient care and time management, orders must be entered during rounds. Daily goals are utilized to identify the plan of care. Please summarize these goals at the end of the patient care discussion so all members of the healthcare team are aware of the management plan for the next 24 hours. 5. Afternoon: Complete tasks left over from rounds (procedures, notes, etc) and see new consults 6. Evening Sign-out Rounds Monday Friday at 17:00. Variable start time on the weekend. (a) Sign-out to on-call resident and Attending. (b) Review new developments of that day. (c) Review goals for the evening. (d) Order any blood work or investigations for the morning.

- 5 - E. ICU Clinical Duties 1. Consults Consults must be seen immediately, except preoperative consults for elective surgery, which must be seen on the same day. If you are busy and unable to see the patient immediately, ask another resident (or Fellow or Attending). Once you have had the opportunity to assess the patient, contact the Attending or Fellow so that the patient can be reviewed, and a disposition decision can be made. If the patient is unstable, call within 5 minutes of your arrival. If a patient is deemed an ICU candidate, he/she should be transferred promptly and should be accompanied by a physician. 2. Admissions (a) (b) (c) (d) (e) ICU Attending must be notified within ONE hour of all ICU referrals or admissions. Once the decision has been made to admit the patient, it is necessary to contact the Nurse Clinician to allow for preparation of a bed and adequate nursing coverage. Unless prior arrangements have been made, patients who may require ICU admission from the OR should generally be assessed in the Recovery Room. Any patient, either going to or coming from the OR, requires sign over between the anesthestist/surgeon and the ICU resident. Requests for patient transfer from another hospital should be directed immediately to the ICU attending physician. Declined admissions: Call Attending to discuss. Then speak with consulting physician or designate. If he/she disagrees with decision not to admit to ICU, speak with ICU Attending again or have the referring physician speak to with the ICU Attending. 3. Daily responsibilities (a) Notes An ICU admission note is required on all new patients. Daily notes are compulsory and should be brief (1-1½ pages) and outline active problems and plans. (b) Role in patient management: You are expected to assume the role of the physician primarily responsible for each of the patients assigned to you during your rotation. You will be expected to: obtain the relevant history perform a physical examination daily before rounds

- 6 - review laboratory and diagnostic imaging results daily develop a management plan for each patient (which may be modified depending on discussions held during rounds.) write cogent, legible, complete notes every day on each patient ensure orders are entered on each of the patients perform all necessary procedures order tomorrow s appropriate lab work and investigations prior to leaving today If you feel that you are not being adequately involved in the decision-making process, please speak to your Attending physician or Fellow. (c) Post-call resident: If you are post-call, ensure that you transfer responsibility (ie verbal sign-over including plan for the day) to another resident prior to going home. The resident(s) accepting responsibility will be expected to act as that patient s primary resident for the rest of the day. If you are the only resident on service during the block, ensure that you sign over to the Attending. (d) Nursing expectations: When paged by staff in the ICU, a response is required promptly When paged STAT, immediate response to the unit is required After placing a call or paging someone, inform the unit clerk and let them know where you will be Communicating where you will be and checking with the Nurse Clinician for outstanding issues before you leave the unit will help avoid numerous nuisance calls 4. Procedures The ICU Fellow or Attending should supervise any procedure done your first time in our ICU. Discuss all invasive procedures with Fellow or Attending prior to doing procedure, if not already discussed on rounds. Never hesitate to ask for help regardless of time of day. Please enter the procedure into the QS system so that an accurate record of the number and type of your procedures will be available at the end of your rotation for your records. 5. Discharge (a) Accepting Physician (Discharge planning) Prior to transfer, contact the accepting physician or his/her designate and speak with him/her directly.

(b) Orders - 7 - Enter transfer orders early (ideally before rounds). This includes reviewing all of the current orders, renewing those orders that will be continued on the ward and discontinuing all old orders. The order to transfer responsibility should be entered at the time of transfer out of the ICU. Ask the unit clerk to page the accepting service when the patient is leaving the ICU. (c) ICU Transfer/Discharge Summary Write a transfer/discharge summary in the chart as well as dictate the summary. This must be done before the patient leaves the ICU. Discharge summaries are for those patients who die, are discharged directly home from the ICU or who are transferred to another hospital. Please record the job ID # given at the end of dictations in the chart. Send copies to the physicians involved i.e. the accepting and referring physicians, intensivists and any other consultants involved. (d) Deaths In every patient that dies, consider approaching the family regarding tissue donation. Call Medical Examiner where required. See Appendix 4. Request permission for autopsy where appropriate (even if the patient is a medical examiners case). Complete authorization and history form for autopsy. Dictate a Hospital Discharge Summary and record the number in the chart. Notify other services that have been involved with the patients care and the family MD of the patients death. 6. Acute Physiological Collapse/ Cardiac Arrest ("Code Blue") The ICU provides the Code Blue/Resuscitation Team for all areas of the hospital excluding the Operating Room and the Emergency Room. For the Rockyview Hospital the code team consists of: ICU resident: acts as the code team leader. 2 RN s: responsible for medications, defibrillation, cardiac monitor, etc 2 RT s: responsible for assisting with intubation and collection of ABG's. 1 Nursing Assistant: performs CPR Additional assistance: call ICU Attending first; then Anesthesia or ER. If there is a code in a locked area (ie psychiatry) you will have to go with/meet the code team. It is important that clear direction be given during a code. The ICU resident should act as Code Team leader and direct the resuscitation. Delegate tasks (ie procedures) to other residents on the code team. More discussion on code blues will occur at the Orientation Course.

7. ICU Outreach Team Code 66-8 - The ICU Outreach Team was developed to assist in the timely management of patients at risk of developing critical illness. Any staff member in the hospital has the ability to call a Code 66 for patients they are concerned about or that meet specific physiologic criteria. The intent is to intervene before the patient becomes so unstable that a Code Blue must be called. Once a Code 66 has been activated, it is expected that the team (ICU resident or Attending, ICU RN and RT) will arrive within 5 15 minutes. Once there, you will treat the patient as you would any ICU consult; if they require ICU admission, discuss the case with the ICU attending physician. If after discussion with the ICU attending it is felt that the patient can be managed on the ward, return care to the admitting service with the appropriate recommendations regarding work-up and management. The Outreach RN and RT will follow-up with the patient to assess response to interventions. 8. QS (Quantitative Sentinel) System QS is a clinical database which records nursing notes, clinical information, vital signs, laboratory data, and procedures and can be accessed from all computers in the ICU. Orders must still be entered in the traditional format. You will be given an access code and an inservice on how to use it on the first day of your rotation. All procedures performed on patients must be entered into QS. 9. Diagnostic Imaging: All diagnostic images are digital and are stored and viewed via the PACS or IMPAX system. Those who have not received training on these systems will be orientated early on in your rotation. G. Teaching activities The ICU learning environment is based on a list of objectives that can be found in Appendix 5. An extensive list of specific knowledge objectives can be found on the Department of Critical Care Medicine s internal website. These can be used to guide your reading during your rotation. (a) ICU Orientation (Crash) Course: Held on the first Monday of every block from 0800 to 1600 at the Peter Lougheed Hospital ICU Classroom. Attendance is mandatory. Residents completing two or three block rotations need only attend during their first block. (b) Formal Didactic Rounds: The core lecture series reviews the common clinical presentations that are encountered within an ICU; these lectures are mandatory for all residents in their first block of ICU. The advanced lecture series explores the core topics to a more indepth level and introduces new concepts; these lectures are mandatory for residents that have already completed one block of ICU, and are optional for those in their first block. (See Appendix 7 for a list of topics)

(c) (d) Lecture schedule: Monday: 08:00 08:30 Advanced lecture series Tuesday: 08:00 08:30 Core lecture series Wednesday: 08:30 09:30 ICU Grand Rounds Thursday: 08:00 08:30 Core lecture series Friday: 08:00 08:30 Advanced lecture series - 9 - Check the Intranet for an up to date schedule listing the topics for each day of your rotation. Morning rounds daily: During patient rounds, informal educational sessions will take place. Afternoon discussion topics: Time permitting, informal teaching sessions will be held on topics as determined by the residents and the attending physician that week. H. Evaluation Process The evaluation process has four components: 1. Resident evaluation of the rotation: At the end of their rotation, each resident is required to complete an online evaluation of the rotation. The form will be emailed to the resident. 2. Resident evaluation of the preceptors: At the end of each block, the resident is required to complete an online evaluation of each of the attending physicians and fellows with whom they worked. This form will also be emailed to the resident. Feedback provided by residents is anonymous and is considered extremely valuable in helping us improve the rotation for future residents. You are required to complete these evaluation forms prior to the end of your rotation. 3. Subjective evaluation of the resident: The goal is to provide feedback as appropriate on a day-to-day basis. At the end of each block, a formal evaluation is undertaken. (See Appendix 8) Input is sought from all Attendings who have worked with the resident and from nursing staff. The evaluations are discussed with you in person at that time. These are also meant to give you an opportunity to comment on the rotation. In between formal evaluations, please remember that you should bring any concerns to the attention of the Attending (or the Unit Director) as soon as possible. I. Clinical Trials The Attending will discuss current clinical trials with you.

J. Clinical Practice Guidelines (CPG) - 10 - Regional and unit specific guidelines have been developed to assist physicians and other health care providers in providing care, improve quality of care and/or decrease costs. These are available on the Critical Care website and can be accessed via the bedside computers. K. Organization of Resident Call Call frequency will not be more than 1 in 4. Bedside physicians are intermittently on call weeknights and weekends. Should this happen during the week, please notify the Attending and Unit Clerk as to which ICU resident will be responsible for new consults between 08:00 and 17:00. On Thursdays, residents are expected to cease clinical activities at 12:00 in order to attend their program s academic teaching activity. Coverage on Thursday afternoons will be provided by a bedside physician or the ICU Attending. For those blocks with limited resident coverage, vacation requests will be declined for patient safety and unit functioning. Time off for major life events (i.e. weddings), exams, and conferences, will usually be granted. Please submit your requests at least two months prior to the start of your rotation. Requests are considered on a first come first serve basis. Call rooms are located in the building behind the ICU. Directions as to how to locate these rooms will be given to you during your first day of the rotation. Please also notify Joan (ICU secretary; 943-3788) and the ICU attending if any STAT days are going to be taken, preferably in writing and in advance. L. Resources Intranet: The Critical Care Medicine web page can be accessed from any of the computers within Alberta Health Services-Calgary Region. (http://iweb.calgaryhealthregion.ca/clin/icu/). From here, click on Education/Research on the left-hand side of the page to link to many useful educational resources: (a) PowerPoint slides for each of the presentations in the lecture series. (b) PDF s of the landmark articles pertinent to Critical Care Medicine. (c) A link to Critical Care Medicine Tutorials. (d) A copy of the learning objectives for the rotation. (e) Videos outlining how to complete various invasive procedures. (In progress) Belongings: Belongings should be kept in call rooms to allow for a tidy workspace on the Unit.

M. Level of Care - 11 - Determination of level of care is a difficult problem and must only be done in conjunction with the ICU Attending. The patient s wishes are paramount, expressed either in written form or verbalized (as long as the patient is orientated and aware of the consequences of the decision). If the patient is not able to make a decision, then the level of care is determined by the patient s condition and expectations of a meaningful recovery after discussing the situation with the family and other consultants if necessary. The patients best interests are always kept at the forefront.

- 12 - APPENDIX 1: NURSING PRESENTATION FORMAT NURSING REPORT 1. Vital signs: temp, heart rate, and blood pressure 2. Consciousness and current sedation (including 24 hour totals) 3. Hemodynamic data: MAP, PAWP, CVP. SaO 2, SvO 2, current inotropes 4. Respiratory: further comments on RT s report 5. Nutrition and GI prophylaxis 6. DVT prophylaxis, extremity/wound care i.e. splints, special dressings 7. Fluid balance: total for 24 hours, recent urine output, current IV fluids 8. Lines: site, type, and duration 9. Family and communication concerns 10. Medications 11. Concerns RT PRESENTATION FORMAT RESPIRATORY REPORT 1. Present ventilator parameters 2. Compliance/ventilating pressures 3. Non-invasive monitoring (pulse oximetry, capnography, transcutaneous, etc) 4. Pulmonary examination 5. Arterial/mixed venous blood gases 6. Suction passes 7. Weaning parameters where appropriate 8. Problems with ventilation/oxygenation 9. Suggestions in ventilator management

APPENDIX 2: - 13 - RESPIRATORY THERAPY OVERVIEW 1. RT Resident Interaction: Communication needs to occur on an ongoing basis. A team approach optimizes efficiency, effectiveness and overall patient care. The RTs should be used as a resource for respiratory therapy. RTs will set a patient up on mechanical ventilation and will assist you with set up of parameters, e.g. F, VT, FiO 2, PEEP and mode of ventilation. RTs will provide an inservice on the ventilators and allow for residents to breathe on different modes of ventilation. Orders for ventilator and ABGs should be written in Physicians Orders by the resident. RTs can write verbal orders and will update orders at the end of their shift. If a minor change is to be made on the ventilator, then we will make the change and notify you when convenient. 2. Titration Orders: FiO 2 will be titrated according to what SaO 2 is adequate for patient (generally sats > 90%, sometimes > 85%). Write guidelines as an order. Respiratory Rate can be adjusted to maintain either a normal PaCO 2 of 35 40 mmhg or hyperventilate to PCO 2 30 mmhg, or give desired range for ph. Weaning modes should be discussed with RTs. Various options available, i.e. pressure support/cpap, T-piece, Flow-By, SIMV/pressure support, MMV. RTs will notify you if ABGs are deteriorating, or if there are any major changes in ventilation or oxygenation. 3. Codes: 4. ABGs: There are generally two RTs at codes. RTs draw ABGs throughout the institution, and we analyze all ABGs. RNs in ICU obtain ABGs from arterial lines. In AM we start at 0700 hours and are quite aggressive in obtaining weaning parameters, weaning and extubation. If this is done early, then transfers can occur promptly.

- 14 - APPENDIX 3: TRANSFER SUMMARY EXAMPLE (Code 55) Call 944-4444 to access dictation service. You will need your Alberta College of Physicians and Surgeons ID# to complete the dictation. The transfer summary is meant to give the accepting physician an overview of the patient, focusing on their ICU course. 1) Patients name/id # Site identifier: 94 The Attending you are dictating for. 2) Copies to: Intensivist Admitting and accepting physicians Any involved consultants 3) Admission/transfer dates 4) Most responsible diagnosis for ICU admission 5) Secondary diagnoses 6) Brief summary of the patient at presentation to the ICU and co-morbidities 7) Course in ICU 8) Problem list with plan for each problem this is the most important information. 9) List of medications/treatments the patient is on DISCHARGE SUMMARY EXAMPLE (code 20) Call 944-4444 to access dictation service. You will need your Alberta College of Physicians and Surgeons ID# to complete the dictation. 1) Patients name/id # Site identifier: 94 The Attending you are dictating for. 2) Copies to: Intensivist Admitting physician Any involved consultants 3) Admission/discharge dates 4) Most responsible diagnosis 5) Secondary diagnoses 6) Summary of the patients need for hospitalization and course prior to presentation to the ICU. Co-morbidities. 7) Course in ICU. For long admissions, it is helpful to organize this section in separate paragraphs for each item on the problem list. 8) List of medications/treatments the patient is on. Plan for follow up if patient is discharged from ICU.

- 15 - APPENDIX 4: CHECKLIST FOR NOTIFICATION TO MEDICAL EXAMINER 1. Unexplained deaths 2. Unexplained deaths when the deceased was in apparent good health or death when not expected under the care of a physician. 3. Deaths as a result of violence, accident, suicide or poisoning 4. Deaths as a result of improper or negligent treatment 5. Deaths that occur within 10 days of an operative procedure or while under or during recovery from anaesthesia 6. Deaths while in custody of any person 7. Deaths resulting from any disease, ill health, injury or toxic substance arising from a person s occupation at any time. 8. Death of a formal patient of any mental health facility or any other institution defined in regulations under this act. 9. Death of a young person under child welfare custody 10. Organ donation Telephone (403) 297-8123

APPENDIX 5: - 16 - Faculty of Medicine Critical Care Medicine Goals: Intensive Care Unit Rotating Resident Curriculum By the end of their rotation in the Intensive Care Unit, every resident will be able to: 1. Rapidly identify an unstable or critically ill patient, and subsequently initiate resuscitation and investigations. 2. Define and describe the ten common clinical presentations as outlined in the Learning Objectives. 3. Discuss end-of-life issues and demonstrate methods to help family members of critically ill patients cope. 4. Work effectively in a multidisciplinary team environment. 5. Demonstrate effective and ethical decision-making skills. Learning Objectives: Medical expert: Given the large number of potential medical and surgical clinical problems that a resident may be exposed to in the intensive care unit, educational efforts are focused on ten of the most common and life-threatening clinical presentations. This is by no means an exhaustive list, and therefore, it is the responsibility of the resident to demonstrate effective adult learning strategies when faced with a patient presenting with a clinical problem not directly covered by this curriculum. Ten Clinical Presentations: 1. Acute Respiratory failure 2. Shock 3. Cardiac dysrhythmias 4. Cardiac arrest 5. Derangements of serum electrolytes and osmolality 6. Acid/base disorders 7. Decreased level of consciousness and seizures 8. Drug intoxication and withdrawal 9. Sepsis 10. Traumatic injury

- 17 - For each of the ten clinical presentations listed above, by the end of their ICU rotation, each resident will be able to: 1. Describe the epidemiology and etiology of the presentation. 2. Describe the physiology and pathophysiology that is clinically relevant to the presentation. 3. Describe, and in the relevant clinical setting demonstrate, the appropriate initial and ongoing investigations pertinent to the presentation. 4. Demonstrate successful completion of any of the skills listed in Part 2 that may be applicable to the presentation. In addition, the resident will need to demonstrate effective interpretation of any relevant results that are obtained from these procedures. 5. Describe, and in the relevant clinical setting demonstrate, the appropriate initial and ongoing management required for the presentation. In addition, interpret and act on the patient's response to these therapeutic interventions. 6. Describe the potential complications associated both with the clinical presentations and with the therapies that are typically used in each setting. 7. Describe prognosis, taking into consideration patient co-morbidities. Communicator: By the end of their ICU rotation, each resident will be able to: 1. Demonstrate the ability to succinctly, coherently and accurately communicate information to the members of the entire health care team, patients and their families via both written (chart/consult notes) and verbal (daily rounds, patient presentations and family meetings) methods. 2. During interactions with the patient and their families, create a relationship based on trust, honesty and openness through effective listening and communication skills. 3. Develop an appreciation for different methods of obtaining code level status, withdrawal of care and end-of-life issues by attending and participating in family conferences with different critical care medicine attending physicians. Scholar: By the end of their ICU rotation, each resident will be able to: 1. Demonstrate the principles of life-long learning by actively reading around patients' clinical issues, attending all scheduled educational activities and participating actively in daily bedside rounds. 2. Incorporate the principles of evidence-based medicine into their patient management strategy.

Manager: - 18 - By the end of their ICU rotation, each resident will be able to: 1. Demonstrate the ability to use their time effectively by appropriately prioritizing tasks, delegating as required and ensuring adequate time for extracurricular activities is maintained. 2. Recognize the finite nature of health care resources and, in the setting of patient-centered care, will prioritize investigations and treatments appropriately. Collaborator: By the end of their ICU rotation, each resident will be able to: 1. Demonstrate respect for and interact effectively with all members of the health care team. Health Advocate: By the end of their ICU rotation, each resident will be able to: 1. Demonstrate clinical decisions and professional attitudes that are consistent with the patient's best interests. Professional: By the end of their ICU rotation, each resident will be able to: 1. Demonstrate the principles of ethical decision making and maintain a professional demeanor in all interactions with patients, their families and members of the health care team. Procedural Objectives: By the end of the rotation, the resident will have gained experience with and be able to perform the following procedures, either independently or with minimal supervision: 1. Bag-mask ventilation 2. Endotracheal intubation 3. ECG and rhythm strip interpretation 4. Central venous catheter insertion

- 19 - In addition, when the opportunity arises, the resident will be expected to undertake the following procedures, either with supervision or independently: 1. Arterial line insertion 2. Pulmonary artery catheter insertion and hemodynamic monitoring 3. Chest tube insertion 4. Thoracentesis 5. Paracentesis 6. Joint aspiration 7. Interpretation of simple spirometry 8. Lumbar puncture 9. Bone marrow biopsy and aspiration 10. Pericardiocentesis In regards to the skills listed above, by the end of the rotation the resident will be able to: a. List indications, contraindications and potential complications for each procedure. b. Confirm appropriate placement of catheters and tubes when presented with a post-procedure chest x-ray.