Surgical Intensive Care Unit (SICU) Rotation

SICU Rotation: PGY-1 / PGY-2 Levels

PGY-1 / PGY-2 Levels

1 SICU Rotation: PGY-1 / PGY-2 Levels

Patrick J. O’Neill, PhD, MD, FACS Medical Director, Surgical Intensive Care Unit Program Director, Surgical Critical Care Residency Office: (602) 344-5637 Pager: (602) 608-0067

Tammy Kopelman, MD, FACS Vice Chair, Department of Surgery Associate Program Director, Surgical Critical Care Residency Office: (602) 344-5637 Pager: (602) 608-0071

Sydney Vail, MD, FACS Medical Director, Trauma Services Medical Director, Tactical Medicine Program Office: (602) 344-5637 Pager: (602) 608-0070

Paola Pieri, MD, FACS Associate Medical Director, Trauma Services Office: (602) 344-5637 Pager: (602) 608-0073

Noelle Rosenkrans, PA-C Office: (602) 344-5637 Pager: (602) 608-0069

Stacey Lawrence, PA-C Office: (602) 344-5637 Pager: (602) 608-0060

Michael Deeter, PA-C Office: (602) 344-5637 Pager: (602) 608-0049

Introduction

One’s first encounter with the ICU may be overwhelming. For many of you, it is the first time you are dealing with critically-ill patients, complex life support systems, potent medications, and complex ethical issues. It is no surprise that many find the ICU a confusing, intimidating and challenging place.

Comprehensive ICU management is a 24-hour a day process. The ultimate goal is to identify signs of physiologic deterioration early such that appropriate interventions may be instituted before progression to multisystem organ failure and death. In other words, it is our goal to make you into “fire preventers” rather than “fire fighters”.

ICU care is best practiced with a multidisciplinary approach. Our critical care team consists of board- certified surgical intensivists, general surgery and Ob/Gyn residents, physician assistants, and often PA students or medical students. Non-physician members of the team include ICU nurses, respiratory therapists, pharmacists, physical therapists, occupational therapists, nutritional support team members, and caseworkers. It cannot be stressed strongly enough that it is vital to work constructively and amicably with all team members. Good rapport with the staff will lead to better patient care. The

3 SICU Rotation: PGY-1 / PGY-2 Levels majority of nursing and respiratory staff are highly trained and experienced possessing sound judgment which should not be discounted. You will depend on them for accurate information, early warning of potential problems, execution of complex orders, and set up and use of multiple, complex monitoring devices.

The surgical intensive care unit (SICU) is a 13-bed unit located on the fourth floor of the hospital. The SICU provides comprehensive critical care services for surgical patients. The majority of the patients are typically trauma and neurosurgery patients, but general surgical, Obstetric / Gynecologic (Ob/Gyn), and surgical subspecialty patients are also cared for in the SICU. Patrick J O’Neill, PhD, MD, FACS, is the Medical Director of the SICU.

Organization of the Service

There are primarily four attending/teaching surgeons who provide daytime coverage in the SICU: Drs. O’Neill, Kopelman, Pieri, and Vail. Typically, the SICU attending is on service for one week at a time. Daytime coverage for this attending is from 0900 until 1700, Monday through Friday.

There are four attending/teaching surgeons who take most of the nighttime, weekend, and holiday call on the SICU service: Drs. O’Neill, Kopelman, Vail, and Pieri. Five additional attending surgeons, Drs. Caruso, Matthews, Foster, Dixon, and Miller, also take call, but less frequently. The attending/teaching surgeons take in-house call and are available from 1700 until 0900 the next morning weekdays. Weekend call (Saturday, Sunday, and holidays) is from 0800 to 0800 (24-hour shifts).

The SICU service is composed of at least two surgery residents: a PGY-2 resident and a PGY-1 resident. PGY-1’s from the Ob/Gyn Residency program join the team most of the year. Further, MS- IV medical students occasionally rotate on the service. Nighttime coverage of the SICU is provided by the PGY-2 resident.

Most of the time a mid-level provider (Physician Assistant; PA) will be present on the service. These allied health professionals are experienced, team-oriented members of the SICU service. They are a wealth of information and should be treated with respect.

MMC has an ACGME-accredited Surgical Critical Care Residency. When the position is filled, there will be a Surgical Critical Care Resident (Fellow) present in the SICU for the majority of the year. Their role is to earn an advanced surgical critical care training experience leading to board- certification. They will act as a resource to the SICU team but will not replace the members.

A simple organization chart is shown below:

SICU Attending Surgical Critical Care Resident PGY II (Fellow) Chief Physician Assistant PGY-I Resident MS -IV Med. Student

4 SICU Rotation: PGY-1 / PGY-2 Levels Schedule

A schematic schedule for the SICU service schedule is shown below.  SICU rounds should start promptly at 0900 every day except Wednesday (1000) due to conferences.  PGY-1 residents: On-duty from 0600 – 1700 (Monday through Friday).  PGY-2 residents alternate Schedule 1 and 2 each week: o Schedule 1: Monday 0600 – 0600 Wednesday 0600 – 0600 Sunday 1700 – 0600 o Schedule 2: Tuesday 0600 – 0600 Thursday 0600 – 0600 Saturday 0600 - 1700 o Remaining shifts are filled by off-service PGY-2 and PGY-3 residents  There are check out rounds at 0600 and 1700 (1800 on Wednesday).  The SICU team is expected to attend Wednesday morning conferences, as well as noon conferences on Wednesday.  There is a Multidisciplinary SICU Conference every Thursday at 0900 in the Surgery Conference Room. Bedside rounds will follow the conclusion of the conference.  There is a SICU Fellows conference scheduled for Thursday afternoon at 1400 (when we have a Fellow).

Monday Tuesday Wednesday Thursday Friday 0600 Checkout Checkout Basic Science Checkout Checkout 0630 Conference 0700 Morbidity & 0730 Mortality 0800 Grand Multidisciplinary 0830 Rounds Conference 0900 ROUNDS ROUNDS ROUNDS ROUNDS 0930 1000 ROUNDS 1030 1100 1130 1200 Jr Clinical 1230 Review Conf 1300 1330 1400 SICU Fellow 1430 Conference 1500 1530 1600 Sr Clinical 1630 Review Conf 1700 Checkout Checkout Checkout Checkout 1730 1800 Checkout

5 SICU Rotation: PGY-1 / PGY-2 Levels Expectations

Division of Labor and Specific Duties: There will be at least two residents on the SICU service (typically a PGY-1 and a PGY-2). In general, both residents will be responsible for the entire service (i.e. they will not follow individual patients). Division of labor will occur immediately after checkout rounds in the AM. The PGY-2 resident will have the right of first refusal for all procedures in the SICU. However, it is expected that the PGY-1 resident will perform at least half of the procedures with the PGY-2 resident supervising.

The SICU team will co-manage the patient in conjunction with the primary service. The SICU team will be responsible for the detailed clinical management of the patient including sedation and analgesia, ventilator management, cardiovascular support, fluid and electrolytes, nutrition, antibiotic administration, et cetera.

Specific duties of the SICU resident includes (but are not limited to):

 Be present and available in the SICU (the SICU is your only clinical responsibility) during work hours (with the exception of lunch and restroom breaks)  Gather information and discuss patient issues with the SICU team o Patients with significant past medical histories will require extra effort to find outside medical records and medication lists  Perform a COMPLETE examination on each assigned patient prior to rounds including, but not limited to: o Standard physical exam including all wounds and back/buttocks skin o Assessing the stability of the patients airway . If intubated, determine the position and security of the tube / trach o Assess the position and security of all enteral tubes (NG, OG, DHT, etc.) o Examination of all invasive catheters to assess for signs of infection o Check extremities for signs/symptoms of phlebitis or septic thrombophlebitis o Reviewing any new radiographs and obtaining the official interpretation o Review and confirm any and all culture results including speciation and antibiotic susceptibilities and log such results in the SICU Culture Book o Review all currently prescribed medications and discontinue those that are no longer needed to keep the Medication Reconciliation accurate and safe  Present at morning rounds to the Attending (and Fellow)  Write comprehensive patient notes with the above data  Perform bedside procedures under the guidance of the Attending (or Fellow) and write procedure notes immediately following the procedure.  Update patients and their families as appropriate (at least daily)  Be an active participant in checkout rounds each evening to the PGY-2 SICU resident

REMEMBER: If you always practice medicine with the thought in mind of “I want to provide the same level of care I would want for my loved ones” , you will likely be doing the right thing.

Operating Experience: The SICU residents are not expected to participate in any surgeries unless there is a critical need for their presence in the operating room. Their primary responsibilities must have been fulfilled, and they must have permission from the SICU attending to participate in surgeries. Surgeries on patients in the SICU will be the responsibility of the primary service.

Clinic: There is no specific clinic responsibility while on the SICU service.

Conferences: Mandatory conferences include Basic Science, M&M, and Grand Rounds on Wednesday morning, as well as Junior Clinical Review conference on Wednesday. The SICU- specific conferences are the Multidisciplinary Conference on Thursday mornings and the SICU Fellow Conference on Thursday afternoons (when a Fellow is rotating in the SICU).

Procedures: Maricopa residents have competency requirements that must be met prior to performing procedures (such as central venous access, arterial lines, tube thoracostomy) independently. All rotating residents must demonstrate proficiency at procedures to the satisfaction of the chief resident, mid-level, or attending prior to performing procedures independently. All procedures must be accompanied by a written procedure note placed in the chart immediately following the procedure. The attending surgeon must be notified prior to performance of bedside procedures. A word of advice: Read and understand the technical aspects and potential complications of a procedure BEFORE attempting it. Beginning a procedure without adequate preparation will result in FORFEITURE of the procedure.

PGY-2: The PGY-2 resident is considered the “Chief” for the SICU service. It is their additional responsibility to oversee the entire service and make sure all members are performing at the expected level. The PGY-2 resident must take “ownership” of the service. A successful PGY-2 SICU Chief will lead by example and encourage the members of the team to perform.

Research: We have numerous clinical and basic science research trials ongoing at any point in time. Residents will be made aware of these trials for educational purposes. Resident participation in research is strongly encouraged and vigorously supported.

Textbook: The textbook for the SICU rotation is The ICU Book by Marino. There is a posted reading list that if followed will allow the resident to complete the book in time for the end-of-rotation SICU examination.

Examination: At the completion of the SICU rotation, each resident will be expected to take and pass a written examination. A score of 70 or higher is a pass. A score of less than 60 is a failure and will result in failure of the rotation. A score of 60-69 is a marginal pass; passing the rotation will then depend on an above average clinical evaluation.

Each resident is expected to contact the Trauma Administrative Assistant, Sydney Zordani ([email protected]; 602.344.5637) to schedule the exam AT THE COMPLETION OF THE ROTATION. Taking the exam after the rotation has concluded will be approved on a case-by- case basis only and must be pre-approved. FAILURE TO TAKE THE EXAM AT THE END OF THE ROTATION WILL RESULT IN A FAILURE OF THE ROTATION.

Call: The SICU team is on for the hours listed above.

Reasons to Contact Attending/Teaching Surgeon: (an extensive list is posted in the SICU)  Death  New admission  Increase in level of care (e.g. transfer to ICU)  Need for procedural intervention (e.g. chest tube, central venous catheter)  Respiratory failure requiring intubation  Unexpected extubation  Diagnosis of shock (e.g. vasopressor need or sustained hypotension)  Unexpected cardiac dysrhythmia (e.g. new onset atrial fibrillation, ventricular tachycardia, ventricular fibrillation)

7 SICU Rotation: PGY-1 / PGY-2 Levels  Diagnosis of sepsis, or severe sepsis  Unexpected critical laboratory values  End of life issues (e.g. change in code status)  Patient or family complaints  Uncertainty regarding the plan of care  Any situation exceeding the resident’s comfort level

Evaluation: The evaluation criteria that will be used by the the mid-levels and the attending/teaching surgeons to evaluate you are listed in the objectives in the Curriculum. Additionally, each evaluator is asked to submit a subjective narrative of overall impression, areas of strength and improvement, and overall performance. You will also be asked to evaluate the SICU rotation and your attending/teaching surgeons. On or before your last day of SICU rotation, you are required to take the SICU exam. This must be scheduled in advance with Sydney Zordani via phone 344-5637 or email [email protected]

Objectives: The specific objectives for this rotation are listed in the Curriculum.