Pediatric Critical Care Residency Training Program

Pediatric Critical Care Residency Training Program McMaster University Overall Goals and Objectives of Training

Preamble

Pediatric critical care medicine is a specialty concerned with the recognition and management of acutely ill infants, children and adolescents with life threatening disease or illness. Through the provision of immediate and ongoing observation and treatment, pediatric critical care medicine aims to preserve life, restore health and prevent complications. The pediatric critical care physician is competent in all aspects of identifying and treating life-threatening illness in pediatric patients.

General Objectives of Training

The Pediatric Critical Care Residency Training Program at McMaster University will provide residents with the knowledge, skills, experience and attitudes necessary to function as competent and ethical specialists in pediatric critical care medicine.

The overall objectives of our residency training program outlined below are provided in the CanMEDS format. The CanMEDS roles for physicians (and trainees) define wide range knowledge, attitudes and skills required in order to be an effective, competent, knowledgeable and professional physician.

The following paragraphs outline the components of the CanMEDS roles, methods by which the objectives of such roles can be met and methods that will be used for evaluation. Detailed objectives are provided thereafter and you are asked to familiarize yourself with them as well.

The Royal College Objectives of training for Pediatric Critical Care Medicine are also provided. These objectives are given to trainees entering the program and the trainee is referred to these documents for further information on expected competencies when presenting for certification examinations.

of 24 General Objectives of Training

1. MEDICAL EXPERT/CLINICAL DECISION MAKER

General Requirements:

The pediatric critical care medicine resident must demonstrate: i) diagnostic and therapeutic skills for ethical and effective care of the critically ill patient ii) the ability to effectively and efficiently access and apply relevant information to the care of the critically ill patient iii) effective and professional consultative ability with respect to patient care, education and legal opinions

A) Knowledge

This area comprises the factual knowledge base that the consultant must have in order to properly evaluate and manage acutely ill pediatric patients. In addition to general knowledge of pediatric disorders, specific areas of knowledge include physiology of each of the major organ systems and an understanding of clinical physiology, pathophysiology and homeostasis as it applies to treating single or multiple organ failure. In addition, knowledge of the various monitoring and therapeutic technologies pertinent to the care of the critically ill patient is required.

Such knowledge can be acquired in several ways including PCCU bedside rounds, seminars, didactic teaching rounds, conferences, academic half-day /small group learning sessions, simulation, as well as individual study. Residents are advised to consult relevant critical care journals, purchase appropriate pediatric critical care texts or use online resources in consultation with staff and more senior residents and to make use of the excellent library facilities available at McMaster University both online and real text books.

Knowledge base will be assessed in 5 main ways:

1) Case review with attending staff gives the staff insight into the depth of knowledge acquired by the resident related to clinical cases as well as scientific knowledge when specifically tested.

2) Discussions and presentations in academic half day / small group learning will allow residents to evaluate their own progress and allow evaluation from their peers and tutor.

3) Simulated resuscitations observed by staff demonstrate the residents’ ability to apply knowledge in the acute setting

4) Objective structured clinical exams (OSCES) and written practice exams provide the opportunity to objectively assess depth of knowledge across various areas

of 24 5) Direct observation and evaluation of resident performance by faculty on Entrustable Professional Activities (EPAs) will assess the resident’s ability to integrate their knowledge in the every day practice of pediatric critical care

B) Clinical Skills

Clinical skills comprise the acts of obtaining a history, performing a comprehensive general and a focused, system oriented exam, formulating a differential diagnosis, devising an investigation plan and planning therapy. These skills are best taught by the attending staff physician on the clinical service during bedside rounds or new patient assessments. Likewise these skills are best assessed through direct observation of the resident by staff physician in the clinical setting and specifically on EPAs. The OSCE exams provide an additional forum for formally assessing clinical skills.

C) Technical Skills

Technical skills required for a pediatric critical care physician consist of knowledge and skill in noninvasive and invasive airway and breathing management, conventional and nonconventional ventilator management, insertion of peripheral and central venous catheters and arterial catheters, application and interpretation of noninvasive and invasive cardiorespiratory and central nervous system monitoring, ECG interpretation, cardioversion, defibrillation and temporary transcutaneous cardiac pacing, emergent pericardiocentesis, naso/orogastric tube insertion, thoracentesis and thoracostomy tube placement, bladder catheterization, intraabdominal pressure monitoring, peritoneal tap, continuous renal replacement therapy, LPs, and bedside ultrasound. Technical skills are taught in the clinical setting under direct supervision of staff physicians or more senior resident trainees. In addition, instruction takes place using high fidelity simulation and OSCE exams. Resident competence is assessed through direct observation by staff physicians in the clinical setting and during mock resuscitations and OSCE exams.

2. COMMUNICATOR

Communication skills refer to the ability to communicate effectively with patients and their families around diagnosis, investigations needed, treatment plan, prevention and prognosis, and breaking bad news. Communication skills are also needed to effectively interact with other members of the interprofessional health care team and to provide colleagues with the results of clinical assessments including recommendations. Communication skills are taught in the clinical setting by staff physicians and during formal didactic sessions, practice with simulated patients, mock resuscitations and OSCE exams. Residents’ abilities as a communicator are assessed by direct observation of the resident by the staff physician in the clinical setting, performance on EPAs, and during OSCE exams and mock resuscitations.

of 24 3. COLLABORATOR

The care of the critically ill patient relies on contributions of an inter professional health care team. It is essential, that the resident in pediatric critical care develop skills in team leadership and collaboration. These skills are learned by residents through direct observation of staff pediatric intensivists and by formal didactic teaching in team dynamics. Resident skills as a team member are assessed by direct faculty observation in the clinical setting and by performance on EPAs.

Teaching skills are essential to a competent consultant who must be able to teach peers, residents and medical students and other disciplines and lay individuals. Teaching can be very broadly defined spanning formal lectures to informal one-on-one sessions. Teaching skills can be learned by observing others, presenting at seminars and academic half days, and by presenting at conferences. Such skills are assessed regularly and are components of the program

Supervisory skills include supervision of students and more junior residents including our medical residents on the service, management of the PCCU service and interaction with other members of the interprofessional health care team (nurses, therapists, pharmacists, social workers, dieticians etc.) both in the hospital and in the community. Resident supervisory skills are assessed by direct faculty observation and by performance on EPAs.

4. MANAGER

This role includes a variety of skills including coordination of the inter professional health care team, management of patient flow into and out of the PCCU and record keeping. Proper record keeping requires recording of history and physical exam information, diagnostic and therapeutic formulation, progress notes, discharge notes, discharge summaries and clinic letters. The manager role also encompasses the residents’ ability to prioritize demands and balance professional and personal responsibilities. Feedback by senior trainees and staff provides the best method of instruction but residents will also receive formal didactic teaching sessions. Evaluation is done by attending staff review of charts and letters, by performance on EPAs, and through the use of a multisource feedback tool.

5. HEALTH ADVOCATE

This role encompasses a variety of skills including the ability to identify the important determinants of health affecting patients. As well, one should be able to contribute effectively to improved health of patients and communities and recognize and respond to those issues where advocacy is appropriate. Residents receive formal instruction and clinical experience in child maltreatment, pediatric trauma, organ donation and end of life decision making. Evaluation will consist of direct observation by staff physician, performance on EPAs and multisource feedback.

of 24 6. SCHOLAR

The role encompasses a variety of academic skills which include understanding the principles of clinical and basic research, the ability to properly identify, read and evaluate literature, an understanding of and interest in the scientific basis for clinical practice. Critical appraisal skills are formally taught in didactic sessions in a journal club format. Independent learning of scholarly skills also occurs as trainees complete a mandatory scholarly activity during their training; this activity is formally evaluated by the faculty supervisor.

7. PROFESSIONAL

Attitudes are difficult to teach and hard to evaluate given the subjective nature of some of these topics. Included in this category are items such as sense of responsibility to patients and colleagues, respect for the patient and self-assessment capabilities. Pediatric critical care physicians are frequently faced with ethical issues related to life sustaining therapies, end of life decision making, brain death and organ donation, and substitute decision making. The resident acquires principles related to biomedical ethics from exposure to staff physicians as role models, ethics consultations by ethics specialist, bedside inter professional rounds (including social workers) and during small group case discussion. These attitudes are evaluated by direct staff observation during rounds, academic half day tutorials and in the clinical setting by performance on EPAs. The multisource feedback tool also provides a form of evaluating the professional role of the resident.

EVALUATION

The above CanMEDS roles and the objectives outlined briefly above and in more detail below form the basis of evaluation during the training program. Evaluation of each area can occur at different times and by different individuals during the program. Attitudes and skills are in general best evaluated by direct faculty observation in the clinical setting. Various tools are used by the program to evaluate resident performance including ITERs, log books, OSCEs, EPAs, Multisource Feedback, and In-training Exams. Residents receive feedback and evaluation by the staff on a regular and on-going basis following clinical encounters. ITERs are completed as a summary of all evaluation data over a 3 month period. The program director meets with the residents on a semi-annual basis to discuss evaluations and point out the strengths and weaknesses.

of 24 Objectives of Training and Training Requirements In Pediatric Critical Care

Supplement to Royal College of Physician and Surgeons of Canada Education Committee Objectives of Training and Specialty Training Requirements in Pediatric Critical Care

GENERAL OBJECTIVES:

Residents must demonstrate the knowledge, skills and attitudes relating to gender, culture and ethnicity pertinent to pediatric critical care. In addition, all residents must demonstrate an ability to incorporate gender, cultural and ethnic perspectives in research methodology, data presentation and analysis. On completion of the educational program, the graduate physician will be competent to function as a consultant pediatric critical care specialist. This requires the physician to: 1. Provide pathophysiological and evidence based, comprehensive and effective diagnosis and management plan for acutely ill pediatric patients 2. Demonstrate the diagnostic and therapeutic skills necessary for the ethical and effective care of critically ill patients 3. Communicate effectively with patients, their families and medical colleagues (particularly referring physicians), and other health care professionals. 4. Counsel families and care givers on aspects of critical illness, life sustaining therapies and end of life care, including risk factors, genetic and environmental concerns. 5. Maintain complete and accurate medical records. 6. Effectively coordinate the work of the inter professional health care team. 7. Be an effective teacher of other physicians (including medical students and residents), other health care personnel and patients and their family. 8. Demonstrate personal and professional attitudes consistent with a consultant physician role. 9. Be willing and able to appraise accurately their professional performance. 10. Be willing and able to keep his or her practice current through reading and other modes of continuing medical education. 11. Be able to access, critically assess and apply the critical care literature as it relates to patient diagnosis, investigation and management. 12. Be able to participate in clinical or basic science studies as a member of a research team.

of 24 13. Be aware of and able to integrate patient safety concepts and skills to the overall care of patients with critical illness

SPECIFIC OBJECTIVES:

At the completion of training, the resident will have acquired, along with those outlined by the Royal College of Physician and Surgeons of Canada Education Committee Objectives of Training and Specialty Training Requirements in Pediatric Critical Care, the following competencies and will function effectively in the following CanMEDS roles as:

1. Medical Expert/Clinical Decision Maker

2. Communicator

3. Collaborator

4. Manager

5. Health Advocate

6. Scholar

7. Professional

of 24 1. Medical Expert/Clinical Decision-Maker

General Requirements

 Demonstrate diagnostic and therapeutic skills for ethical and effective care of the critically ill patient

 Access and apply relevant information to the practice of critical care

 Demonstrate effective consultation services with respect to patient care, education and legal opinions.

Specific Requirements

 Demonstrate detailed knowledge of general and specialist aspects of critical illness

 Demonstrate the safe and judicious use of equipment, monitoring, and drugs with a coordinated provision of multidisciplinary care for effective organ support

 Recognize, resuscitate and stabilize patients sustaining, or at risk of, cardiopulmonary arrest or other life-threatening illness

 Demonstrate knowledge and understanding of applied clinical physiology, pathophysiology, homeostasis and pharmacology as it relates to the recognition and treatment of single or multiple organ failure

 Demonstrate an understanding of the unique aspects of physiology, psychosocial development, developmental pharmacology and age-related diseases of the developing infant, child and adolescent

Clinical Skills Demonstrate basic and applied knowledge of the following:

Respiratory Dysfunction

 Ability to determine the presence of respiratory failure, provide for its emergency support and identify a plan for subsequent investigation and management

of 24  Demonstrate knowledge of normal anatomy, physiology and developmental physiology of the respiratory system including gas exchange, respiratory mechanics, airway dynamics and the control of respiration from intrauterine life through to adulthood

 Understanding of the pathophysiologic states leading to respiratory failure and different age-related disease

 Knowledge of post-surgical respiratory problems and their management

Cardiovascular Dysfunction

 Ability to identify cardiovascular dysfunction and provide emergency life support including the methods and application of “Pediatric Advanced Life Support” (PALS) and “Neonatal Advanced Life Support” (NALS) techniques

 Knowledge and application of noninvasive and invasive hemodynamic monitoring

 Knowledge of normal anatomy, physiology, developmental physiology, and pathophysiologic states leading to cardiac failure in neonates through to adolescents and treatment strategies including pharmacologic and nonpharmacologic therapies

 Ability to recognize basic and complex cardiac arrhythmias and manage these with pharmacologic and electrical therapies

 Knowledge of the pathophysiology of shock and its treatment

 Understanding of cardiopulmonary interactions in the presence of normal anatomy and in congenital malformations of the cardiopulmonary system

 Knowledge of the problems associated with surgical interventions in children with congenital and acquired cardiac disease and application of knowledge in the preoperative and postoperative management of these patients

Neurological Dysfunction

 Ability to recognize, provide resuscitative, life-saving therapy and ongoing critical care management of central nervous system (CNS) and peripheral nervous system (PNS) and derive a differential diagnosis and appropriate diagnostic plan for these patients

 Knowledge of the etiologies, pathophysiology, diagnostic investigation, monitoring and management of altered level of consciousness, intracranial hypertension, status epilepticus

 Ability to clinically diagnose brain death and knowledge of ancillary investigations and their application

of 24  Knowledge of impact of critical illness and associated ICU admission on CNS and PNS including coordination of interprofessional resources to mitigate these effects and provide rehabilitative therapies

 Understanding of the considerations associated with long-term mechanical ventilation in patients with chronic neuromuscular disease

 Ability to provide neuroprotective therapies in diseases of the CNS including trauma and post neurosurgical states

Renal Dysfunction

 Ability to recognize, investigate and manage acute kidney injury, renal dysfunction and renal failure

 Knowledge of renal physiology and pathophysiology of renal failure including pharmacodynamics in states of altered renal function

 Understanding of the perioperative management of renal transplant patients

 Knowledge of continuous renal replacement therapy as a supportive measure in patients with renal dysfunction

Gastrointestinal Dysfunction

 Ability to recognize, investigate and manage the patient presenting with acute, life- threatening gastrointestinal illness

 Knowledge of the etiology, diagnosis and management of the acute abdomen, hollow viscous dysfunction, upper and lower GI bleeding, abdominal compartment syndrome, and intraabdominal trauma

 Perioperative management of patients requiring abdominal surgery

Hepatic Dysfunction

 Knowledge of normal hepatic physiology and ability to recognize, investigate and acutely manage the various etiologies leading to hepatic failure

 Understanding of the pathophysiology of acute and chronic liver failure, therapeutic options and transplant indications

 Knowledge of the perioperative management of liver transplant patients

of 24 Hematologic/Oncologic Disorders

 Knowledge of the pathophysiology, investigation and management of thrombocytopenia, anemia, neutropenia, haemolytic and vaso-occlusive disease, thrombosis, and bleeding diatheses

 Knowledge of the diagnosis and management of acute presentation and complications associated with solid tumor and blood borne malignancies

 Understanding of the indications and application of anticoagulant and fibrinolytic therapies

Metabolic/Endocrine Disorders

 Ability to recognize, investigate, monitor and manage acute illness related to endocrine, metabolic, fluid and electrolyte and acid-base disorders

 Knowledge of the pathophysiology, diagnosis, and treatment of endocrine emergencies and acute crisis from inborn errors of metabolism

 Knowledge of normal homeostatic control and identification, diagnosis and management of disorders of homeostasis including abnormal thermoregulation

Trauma

 Ability to manage patients with single system or multisystem trauma according to Advanced Trauma Life Support (ATLS) guidelines

 Knowledge of the acute resuscitation, diagnostic evaluation, monitoring and ongoing management of traumatized patients with regard to all body systems in the acute setting and long term follow-up

 Ability to recognize potential child maltreatment and appropriate workup of such cases

Septic Illness

 Ability to recognize, investigate, monitor, acutely resuscitate according to goal directed therapy and provide ongoing management for the patient presenting with systemic inflammatory response syndrome (SIRS), sepsis, and septic shock with and without multiple organ dysfunction syndrome (MODS)

 Knowledge of the pharmacology, indications, complications, interactions, monitoring and efficacy of usual antimicrobial agents

 Knowledge of the investigation and management specific to the immunocompromised host

of 24  Knowledge of infection control practices including hospital isolation guidelnes and indications for chemoprophylaxis

Intoxication

 Ability to recognize, investigate and manage toxic syndromes including the indications and contraindications for therapies affecting the absorption, distribution and elimination (hemodialysis, hemoperfusion) of common intoxicants

 Knowledge of pharmacokinetic and pharmacodynamic principles

 Knowledge of the psychosocial, emotional and psychiatric support required by patients and families

Burns/Electrical Injury

 Ability to provide acute resuscitative care according to ATLS guidelines to patients sustaining thermal/electrical injury and ability to subsequently diagnose the degree of cutaneous injury according to depth and location of injury and vital organ injury and institute therapy to minimize metabolic, fluid and electrolyte, infectious and organ system complications

 Knowledge of the pathophysiology, medical and surgical management of thermal and electrical injuries

Nutritional Support

 Knowledge of caloric/fluid requirements and the assessment of nutritional status and energy expenditure in critically ill patients

 Knowledge of the methods, indications, contraindications, limitations and complications of enteral and parenteral nutritional delivery

Pharmacotherapy

 Knowledge of pharmacodynamic and pharmacokinetic principles as they apply to therapeutic agents in the PCCU

 Knowledge of the indications, contraindications, risks, interactions and side effects of common therapeutic agents including but not limited to sedatives, neuromuscular blockade, antimicrobials, diuretics, and hemodynamic agents

of 24  Knowledge of indications, contraindications, complications and side effects rapid sequence induction agents

Transportation

 Knowledge of the factors peculiar to transport of critically ill patients including mode of transportation, manpower requirements, monitoring and management challenges unique to transport, communication and documentation nuances

 Knowledge of altitude physiology as it applies to air transport of critically ill patients

Transplantation

 Knowledge of the perioperative care of the transplant patient

 Knowledge in the management of the immunocompromised patient including opportunistic/nosocomial infection, rejection, graft vs host disease

 Knowledge of the diagnosis of brain death and organ preservation therapies

 Ability to describe for families the concept of brain death and discuss the option of organ donation in accordance with ethical and medical-legal considerations

End of Life Issue

 Knowledge of the ethical, medical-legal, spiritual and social considerations in decisions regarding withholding or withdrawal of life sustaining therapies

 Knowledge of legislative requirements of substitute decision makers around patient best interest and ability to manage conflict between substitute decision makers and the health care team regarding end of life decision making

 Knowledge of pain and symptom management

 Knowledge of the role of the coroner in death investigation

 Knowledge of the role of the interprofessional team in providing patients and families with emotional, psychosocial and spiritual support

Technical Skills Airway

of 24  Assessment of airway including ability to recognize potentially difficult airway

 Maintenance of airway through positioning and toileting

 Placement of oropharyngeal airway, laryngeal mask airway, orotracheal and nasotracheal intubation

 Indication for urgent surgical airways

 Indication for tracheostomy for prolonged mechanical ventilation or airway control

 Replacement of existing tracheostomy tube

Breathing

 Application of respiratory monitoring equipment including pulse oximetry, capnography, end tidal CO2 detection

 Bag mask ventilation

 Interpretation of chest radiographs

 Application and manipulation of noninvasive and invasive conventional and nonconventional positive pressure ventilation

 Delivery of inhaled pharmacotherapies and special gas admixtures (heliox, nitric oxide)

 Measurement and interpretation of pulmonary mechanics during mechanical ventilation

 Techniques for weaning mechanical ventilation

 Thoracocentesis and thorocostomy tube insertion

Circulation

 Insertion of intraosseus, peripheral venous, central venous, and peripheral arterial vascular catheters

 Mixed venous oxygen saturation measurement and interpretation

 ECG interpretation

 Defibrillation and cardioversion

 Temporary transcutaneous cardiac pacing

of 24  Bedside cardiac ultrasound assessment in hemodynamically unstable patients

 Knowledge of utilization of dual chamber temporary pacemaker

Central Nervous System (CNS)

 Declaration of brain death

 Lumbar puncture

 Insertion of vascular hemodialysis catheters

Gastrointestinal

 Naso/orogastric tube placement

 Duodenal intubation for enteral feeds

 Interpretation of abdominal radiographs

 Intra abdominal pressure monitoring

 Peritoneal tap

Nutrition

 Determination of nutritional plan

Transport

 Organization and supervision of intra and extra-mural critical care transport

 Application of techniques to treat or induce hypo/hyperthermia

2. Communicator

of 24 General Requirements The pediatric critical care resident must demonstrate an ability to:

 Establish relationships with patients and families

 Listen effectively

 Obtain and synthesize relevant history from patients/families/health care professionals

 Discuss appropriate information with patients/families and the health care team

Specific Requirements The pediatric critical care resident must be able to:

 Assess, communicate with, and support patients and families facing critical illness

 Explain life-sustaining therapies in clear and understandable and sensitive language and describe and discuss expected outcomes and goals of therapy in the context of patient and family goals, values, beliefs, and wishes including discussion of limitation, withholding or withdrawal of invasive life sustaining therapies

 Communicate effectively and minimize conflict with patients and families demonstrating aggression, anger, confusion

 Explain the concepts of brain death and organ donation

3. Collaborator General Requirements The pediatric critical care resident must demonstrate the ability to:

 Consult effectively with other physicians and health care professionals

 Contribute effectively to interdisciplinary team activities

of 24 Specific Requirements The pediatric critical care resident must demonstrate the ability to:

 Communicate and cooperate effectively with physician and nonphysician colleagues in the clinical, educational and research environment

 Prevent and resolve conflict in interactions with patients, families and members of the health care team

4. Manager General Requirements The pediatric critical care resident must demonstrate the ability to:

 Allocate finite health care resources and utilize hospital and community resources to optimize patient care

 Work effectively in a health care organization

 Balance patient care needs, learning needs and personal needs Specific Reguirements The pediatric critical care resident must demonstrate the ability to:

 Work effectively with the administrative organization of the pediatric critical care unit (PCCU), health care facility and community in order to operate a PCCU

 Manage the staffing, educational, and operational requirements of a PCCU to support the clinical, academic, and administrative functions of the unit

5. Health Advocate General Requirements The pediatric critical care resident must be able to:

 Identify important determinants of health and contribute effectively to the advancement of patient and community health Specific Requirements The pediatric critical care resident must be able to:

 Be knowledgeable of the broad determinants of health including environmental, socio- economic, and life style factors relevant to critical illness

of 24  Understand the importance of medico-legal considerations in critical illness

 Contribute to the overall advancement of childhood health and critical care medicine within the community

6. Scholar General Requirements The pediatric critical care resident must demonstrate the ability to:

 Encourage and facilitate learning of medical trainees, members of the health care team and patients and families

 Contribute to the advancement of critical care knowledge

 Develop and maintain lifelong learning skills Specific Requirements The pediatric critical resident must be able to:

 Demonstrate knowledge, skills and expertise in literature retrieval and the application of evidence based medicine in the clinical and academic setting

 apply concepts of evidence based medicine and health research methodology in the appraisal of health care research and literature

 Understand basic concepts of biostatistics, study design, research ethics requirements, protocol and manuscript preparation and research grant application

7. Professional General Requirements The pediatric critical care resident must demonstrate the ability to:

 Deliver highest quality care with integrity, honesty and compassion

 Exhibit appropriate personal and interpersonal professional behaviours

 Practice medicine and research ethically and consistent with hospital and governing body policies and procedures

Specific Requirements

of 24 The pediatric critical care resident must be able to:

 Demonstrate an awareness of the moral and ethical issues that affect patients, families and health care providers in the PCCU

 Understand the various roles and responsibilities of the critical care physician at the local, regional, national and international levels

 Demonstrate knowledge of ethical concepts including informed consent, autonomy, substitute decision making, transparency, fiduciary relationships, conflict of interest, and justice in resource allocation

 Periodically review their own personal and professional performance against national standards set for the specialty.

 Be willing to include the patient in discussions concerning appropriate diagnostic and management procedures.

 Show appropriate respect for the opinions of fellow consultants and referring physicians in the management of patient problems and be willing to provide means whereby differences of opinion can be discussed and resolved.

of 24 Pediatric Critical Care Residency Training Program McMaster University Specific Goals of Training

1. Medical Expert

Clinical Knowledge

First Year Residents

 Assessment and management of the A,B,C’s of a critically ill child  anatomy, physiology and pathophysiology of the respiratory system  the principles and theory of mechanical ventilation and other methods of respiratory support  interpretation of normal and common abnormal findings on chest radiographs  principles and interpretation of invasive and non-invasive hemodynamic monitoring  physiology and application of cardiopulmonary interactions in the PCCU  physiology and pathophysiology of shock  the pathophysiology and management of heart failure and cardiac arrhythmias across the pediatric age-groups  anatomy and physiology of patients with congenital heart disease; pre and post operatively  pathophysiology, investigation and monitoring of raised intracranial pressure  criteria required for the clinical diagnosis of brain death and indications for ancillary investigation  the major pathophysiologic entities associated with neuromuscular disease  the indications and ethical implications of long term mechanical ventilation in neuromuscular disease  the pathophysiology of renal failure and renal transplantation  the interaction between drugs and the kidney in normal and diseased states  the differential diagnosis of an acute abdomen  diagnosis of GI bleeds and the presentation of abdominal trauma  the normal function of the liver and the pathophysiology of liver failure  the physiology of a patient following liver transplantation  the complications of pediatric oncologic diseases and their treatment  differential diagnoses of thrombotic states and bleeding disorders  fluid, electrolyte and nutritional requirements of critically ill patients  transport physiology and problems associated with patient transport

Second Year Resident

of 24  pathophysiology of disease processes across stages of development of the pediatric respiratory system  advanced knowledge of congenital cardiovascular malformations and their pre- and postoperative management  management of the potential organ donor  physiologic principles, indications, and application of continuous renal replacement therapy  an advanced understanding of the management of the above disease states along with an awareness of the controversial therapies  demonstrates the ability to provide telephone advice for extramural pediatric critical care consultations

Technical Skills

First Year Residents

 application of skills from PALS, APLS and ATLS  obtain and perform measurement of all vital signs including oxygen saturations and noninvasive blood pressures  intravenous and intraarterial access in a critically ill child  ultrasound guided insertion of femoral, internal jugular and subclavian venous lines  insertion of an intraosseous needle  demonstrates proficiency and safety in the steps of rapid sequence induction for airway management  airway management including placement of oral and nasopharyngeal airways and oro- and naso-tracheal intubations,  insertion of oro and nasogastric tubes and foley catheters  insertion of hemodialysis catheters for CRRT  insertion of chest tubes and thoracentesis  performance of lumbar punctures  insertion of naso- and orogastric tubes  performance of transcutaneous synchronized cardioversion, defibrillation and pacing

Second Year Residents

 proficiency and independence in the skills listed under the requirements for first year fellows  knowledge of ultrasound assessment of: pericardial effusion, cardiac ventricular size and qualitative function, vascular volume status, pleural effusion, asicites, focused abdominal sonography in trauma (FAST)  knowledge of the technique for: fiberoptic bronchoscopy in intubated patients, emergent cricothyrotomy, pericardiocentesis

2. Communicator

First and Second Year Residents

of 24  to understand the issues involved in communicating bad news to families in stressful situations  to be able to explain complicated medical issues regarding diagnosis and prognosis in clear language to families  to develop the ability to clearly communicate with families and the medical team in tense situations or crises  demonstrate respect and understanding for the role of each member of the health care team  effectively communicate with subspecialty services during consultation requests and follow-up discussions  recognize the importance of clear documentation in patient's health care record  demonstrate conflict resolution skills when interacting with aggressive or angry family members or members of the health care team  effectively communicate appropriate positive and negative feedback on performance of junior trainees

 to perform the above skills more independently  demonstrates the ability to conduct and lead a family meeting

3. Collaborator

 to consult effectively and in a timely manner with other members of the PCCU health care team and with subspecialty services  to communicate care plans clearly and precisely to all members of the allied health teams  to demonstrate leadership and work in a collaborative manner with fellow  learners

4. Manager

 understand the demands of working in a PCCU including the personal physical and emotional stressors associated with the environment  effectively balance time and prioritize between patient care, learning needs, stress management and outside activities  utilize electronic resources to support patient care and learning needs  understand issues regarding health resource allocation and the impact on patient management

of 24  familiarity with the organizational structure of the PCCU and the manpower resources necessary to operate a PCCU  learn the practical skills necessary to effectively run the Unit  demonstrate increasing independence in decision making around patient care and bed allocation  demonstrate the ability to lead the health care team in the overall management of the PCCU  demonstrate leadership skills in identifying and addressing potential patient safety concerns in the PCCU

5. Health Advocate

 an understanding of the diverse determinants of health across patients  an awareness of the medicolegal considerations in the PCCU  awareness of societal programs available for prevention of many PICU conditions such as head injury, near drowning etc.  understand the impact of critical care on the long-term functional outcome and quality of life of patients  demonstrate proficiency with obtaining informed consent  understand the concepts of "best-interest" and "futility"  provision of caring and compassionate end-of-life care to patients and their families

6. Scholar

 learn the skills necessary to research and present critical care rounds  facilitate education of other learners in the PICU  application of evidence based medicine principles and current literature to patient management decisions on a daily basis  organize and present critical care rounds  lead formal and informal teaching sessions on basic critical care topics

 demonstrate skills of research methodology and research ethics as they apply to the design and implementation of critical care research trials  conduct and present results of a scholarly project in pediatric critical care

7. Professional

of 24 First and Second Year Residents

 exhibit appropriate personal and interpersonal professional behaviour in interactions with other health care staff and patient and family members  understand the impact of personal moral and ethical value systems on the care of individual patients and families  ensure detailed and complete follow-up and handover of all patients under the residents care  demonstrate effective conflict resolution skills and appropriate code of conduct  ensure that there is continuity of care and that all details of the patient’s care have been attended to prior to transfer to another attending