Critical Care

1. Definition: The Critical Care rotation is a one-month rotation for the CA-1 or 2 resident which will provide teaching, learning and clinical experience in the care of the critically ill patient.
2. Curriculum: The two month requirement for critical care is mandated by the ACGME RRC for Anesthesiology, and must be accomplished in units in which the majority of the patients have multisystem disease.  The requirement is divided between the medical and surgical experience.  This rotation takes place in the Surgical/Trauma Intensive Care (STICU) Unit at University Hospital.  The resident functions as a member of the STICU team which includes surgical residents, a trauma fellow, medical students, and trauma attending.  There is active involvement by Anesthesiology faculty who are experienced in the practice and teaching of critical care.  All clinical responsibilities during this month are in the STICU, including on-call.  The trauma fellow is responsible for the on-call schedule, team assignment, and assignment of patients.  The anesthesiology resident is expected to participate fully in patient care activities, morning report, teaching rounds, and STICU didactics while on this rotation. Clinical experience includes pre- and post-operative critically ill patients as well as nonoperative trauma patients.  Evaluation of residents is a shared responsibility of both surgical and anesthesia faculty.  Final credit as reported to the RRC will take all evaluations into consideration. One month in the yearly didactic schedule is dedicated to Critical Care/PACU.
3. Clinical Duties with Learning Pathways
   1. Perform and document a complete history and physical exam in the critical care setting, written with completeness and clarity. This should include full patient assessment; interpretation of laboratory, radiographic, and other pertinent studies; and an integrated critical care treatment plan
   2. The resident will present admission H&P and integrated treatment plans, as well as 24-hour summaries and up-dates on all previously admitted patients, at daily rounds.  Presentations for SICU rounds should be complete and cover all of the patients’ problems in a systematic fashion.  Presentations will begin with a summary of patient active critical care issues or problems and the previous 24 hour events.  Each organ system will be reviewed (neurologic, cardiovascular, respiratory, GI, renal/metabolic, hematologoc, infectious) as well as nutrition, DVT prophylaxis, and pain control/sedation.
   3. The resident will have mastery in his/her ability to integrate the information derived from multiple diagnostic modalities, including traditional laboratory studies and radiographic studies e.g. CXR, MRI, and CT.
   4. The resident will demonstrate mastery in ventilator management of a diverse critical care population.  This is accomplished by evaluation of the patient’s respiratory status including airway protection, and formulation of a respiratory therapy prescription.  Included in this plan are basic ventilator management and treatment of ICP, compromised airway, altered pulmonary function, and appropriate weaning modalities.  This is accomplished by the integration of physical exam, and laboratory and radiographic studies. Ventilator settings and other data such as P/F ratio (Pa02 to Fi02) and weaning parameters will be presented during rounds on all ventilated patients. 
   5. Hemodynamic management and therapy are essential modalities to be integrated by the resident into the treatment plan.  He/she will utilize complex hemodynamic modalities including continuous cardiac output catheters and demonstrate the ability to insert invasive hemodynamic lines in an appropriate and timely fashion. Supervision of line placement is by faculty/fellow.  All morbidities related to line placement are reported in accordance with the department’s Performance Improvement plan, and are tracked and discussed at the monthly QA meeting.
   6. The following procedures are routinely performed by residents under supervision at the bedside: central lines, chest tubes, arterial lines, Shileys, Swan Ganz.  Gown, mask and gloves must be utilized for these procedures.   Informed consent must be obtained, however immediate life threatening emergencies should be treated without consent if there is no time to obtain one (i.e. – pneumothorax, hemorrhage, etc).  A procedure note must be completed (pre-printed form), including diagnosis and/or indication, which the attending will countersign.  Bronchoscopy, percutaneous tracheostomy and PEG are also done at the bedside in the SICU.  The attending must be present for these procedures and informed consent must be obtained.  The nurse must be present during the procedure to monitor frequent vital signs and have necessary medications for sedation at the bedside, or alternatively the Anesthesiology resident may deliver anesthesia but only if supervised by an Anesthesiology attending.  Patients must be on 100% Fi02 and mandatory ventilation during the procedure.
   7. Triage in and out of the SICU is the responsibility of the attending or fellow.  The residents may be asked to do a consult on patients in recovery room or elsewhere in the hospital to evaluate them for admission to the SICU.  The patient should be presented to the attending, who will decide whether or not accept the patient.
   8. It is the responsibility of the resident to be a role model and mentor to the 4th year medical students.  Residents must provide supervision for all students’ clinical care, including orders, history and physical exam, and procedures.  Medical students must be supervised for all procedures and judgement exercised as to which procedures are appropriate for the level of experience of each student.
   9. The resident will epitomize professionalism at all times in the intensive care unit, demonstrating the essential attributes of compassion, integrity, dependability, and ability to work as an effective member of a team.
   10. References – Residents are expected to complete required readings from major textbooks (e.g. Miller, Barash) during the three year program.  In addition, selected journal articles will be provided during the rotation
4. Objectives – attached
5. Evaluation – All learning objectives will be evaluated as stated in section V.  Each resident will receive at the beginning of the rotation a set of cards which delineates the evaluation process for each of the objectives.  When the resident has demonstrated competency to the satisfaction of the Critical Care faculty, the card must be signed by the attending.  It is the resident’s responsibility to fulfill these responsibilities as well as to turn in the card to the Resident Education Committee (in the person of Ms. Venino).

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