CA-1 CRITICAL CARE ROTATION Medical Center Fairview (UMMC) Rotation Site Director: Dr. Martin Birch Rotation Duration: 4 weeks Introduction: Critical Care is an integral aspect of anesthesiology training. The goal of the intensive care unit (ICU) rotation is to provide residents with a suitable understanding of the critically ill patient. The rotation should provide residents with the background knowledge necessary for the care of critically ill patients, and an appreciation of management issues unique to this patient population, in the perioperative period and elsewhere. The experience in the ICU should also be sufficient to allow residents to decide if they want to pursue further training in critical care medicine. GOALS: o To train residents who are capable of providing high quality care based on principles of teamwork and collaboration for critically ill patients; o To train residents who use the bio-psychosocial model and life-long learning principles in providing high quality care including assessment and management of complex and inter-related physiologic principles that operate in a critically ill patient. Approximate Training Level Assessment Methods/Tools OBJECTIVES (by ACGME Competency) Patient Care Clinical Skills and Reasoning: o Use of clinical skills of interviewing and physical examination to perform a thorough assessment of a critically ill patient (perception to mechanism or complex overt o Formulates and discusses daily management plan for a critically ill patient (perception to mechanism or complex overt o Together with the patient and/or family/next-of-keen formulates o Direct Observation o Simulation o Chart- review o Case logs Page 1 of 7
long-term goals and objectives of management of a critically ill patient (perception to complex overt o Together with the patient and family formulates a plan that addresses end-of-life questions (perception to complex overt Technical/Device Related Skills o Masters various modes of invasive and non-invasive mechanical ventilation (perception to complex overt o Safely uses different ventilators in different environments (perception to complex overt o Uses all monitoring devices including pulmonary artery catheter and arterial wave form based cardiac output monitor with skill (perception to complex overt Patient Management o Assesses patient s respiratory status and determines the need for mechanical ventilation (perception to mechanism or complex overt o Performs airway management including standard tracheal intubation in an intensive care environment (perception to complex overt o Determines the need for and the extent of necessary hemodynamic monitoring and places arterial line, central line, pulmonary artery catheter in an intensive care environment (perception to mechanism or complex overt o Safely performs cardio-circulatory patient assessment utilizing clinical, laboratory and hemodynamic parameters and initiates appropriate medications, drips, etc.(perception to mechanism or complex overt o Uses laboratory, electrophysiologic, radiologic, echocardiographic, nuclear medicine and other diagnostic test to help with differential diagnosis and management of critically ill patients (perception to complex overt o Direct Observation o Simulation o Chart- review o Case logs Page 2 of 7
o Manages acutely decompensating patient with help of a senior resident with special emphasis on recognition of respiratory, circulatory and neurologic deterioration, familiarity with measures that allow patient stabilization and familiarity with diagnostic process in critically ill patient (perception to complex overt o Maintains orderly patient medical records (perception to complex overt o Effectively transfers care from and primary care provider and/or to a secondary provider (perception to mechanism or complex overt Medical Knowledge o Discusses hemodynamic parameters such as preload, afterload, and contractility; left and right ventricular mechanics; differential diagnosis, diagnostic approach and treatment of different shock states; mechanisms and use of vasopressors, inotropes and antihypertensive medications; diagnosis and treatment of myocardial ischemia (knowledge to application) o Discusses pulmonary physiology including control of breathing, work of breathing, lung volumes, compliance and resistance of the respiratory system, determinants of oxygenation and ventilation; differential diagnosis and treatment of respiratory failure; pathophysiology of obstructive and restrictive respiratory disease; causes, diagnosis and treatment of adult respiratory distress syndrome; physiologic effects of mechanical ventilation (knowledge to application) o Discusses determinants of renal blood flow, perfusion pressure, glomerular filtration rate; perform differential diagnosis and treatment of acute renal failure; differential diagnosis, diagnostic approach and treatment of acid-base disturbance and electrolyte disorders (knowledge to application) o Discusses surgical stress response; glucose control in the critically ill o Introductory lecture series test o Anesthesia knowledge test o Annual in-training examination o Informal oral questioning o Simulation o Oral case presentations Page 3 of 7
patients; relative adrenal insufficiency and steroid replacement in critically ill patient (knowledge to application) o Describes differential diagnosis and treatment of neurologic deficits in the ICU; differential diagnosis, diagnostic approach and treatment of ICU delirium (knowledge to application) o Discusses hepatobiliary physiology, effect of hepatic disease on other organ systems, differential diagnosis, diagnostic approach and treatment of acute and chronic pancreatitis, use of enteral and parenteral nutrition in the critically ill (knowledge to application) o Discusses the differential diagnosis, diagnostic approach and treatment of anemia and thrombocytopenia in the ICU, differential diagnosis, diagnostic approach and treatment of coagulopathies and hypercoaguable state (knowledge to application) o Discusses epidemiology, pathophysiology, and treatment of sepsis, microbiology, diagnosis, and treatment of respiratory, intraabdominal, urologic, skin and soft tissue, cardiac and CNS infection (knowledge to application) o Discusses systemic inflammatory response syndrome, manifestations of multi-organ failure syndrome (knowledge to application) Practice Based Learning and Improvement o Identify own learning deficits, develop a learning plan and carry it out (receiving to valuing) o Respond appropriately to constructive feedback (receiving to o Written essay describing an analysis of patient valuing) o Demonstrate ability to effectively search for literature (perception to management (areas of deficiencies, room for complex overt improvement) o Read, analyze and interpret the scientific literature (analysis) o Analyze own practice and determine ways in which you can improve your comprehensive anesthetic plan (analysis, valuing) o Immediate formative feedback from attending o Direct observation o Journal club Page 4 of 7
Interpersonal and Communication Skills presentations and case presentations o Use of effective listening, questioning, and explanatory skills in gathering information from patients and/or their families and in providing information to patients, families, the public, and other health care providers (receiving to valuing) o Effectively and efficiently communicates pertinent patient information to all members of the ICU team (receiving to valuing) o Skill in working as a member of a patient care team including other physicians, nurses, respiratory techs, other health care professionals, social workers, PT/OT and volunteers (receiving to valuing) o Effectively communicates with consulting physicians in a respectful manner (receiving to valuing) o Maintain timely, comprehensive, legible medical records (receiving and valuing) Professionalism o Direct observation with patient o Direct observation in simulation o 360 global rating o Learner classroom presentation o Awareness and management of his/her own values and attitudes, which might interfere with appropriate patient care specific to management of the patient (receiving to valuing) o Responsiveness to and management of issues that relate to sociocultural aspects of family life, and social adjustment related to ethnicity, religion, culture, gender or sexual preference (receiving to valuing) o Consistent compassion, honesty, integrity and respect for others in all professional activities (receiving to valuing) o Awareness and responsiveness to end-of-life issues in the ICU (receiving to valuing) o direct observation o 360 System Based Practice Page 5 of 7
o Work in inter-professional teams with nutritionist, pharmacist, social worker, physical therapist, occupational therapist to increase patient safety and quality of care (perception to complex overt o Coordinate patient care in the settings of ICU (perception to complex overt o Discuss system-based problems as they pertain to patient care at M&M conferences (knowledge to analysis) o direct observation o 360 o M&M conference presentation with system analysis Page 6 of 7
Scholarly/Research Activities Reading Requirements The resident should read the following chapters while taking the rotation: Text: CRITICAL CARE MEDICINE by Murray, 2 nd edition Journal articles and other materials are available at https://wiki.umn.edu Chapters: Assessments The resident will receive a summative written evaluation form at the end of the rotation from the Site Director, as well as verbal feedback informally throughout the rotation. The case-logs of the resident will also be evaluated periodically by the clinical competency committee for the number and type of procedures and anesthetic techniques entered to ensure they are obtaining adequate experience. Notes Page 7 of 7