Surgical Critical Care Rotation Educational

Surgical Critical Care Rotation Educational Objectives MICU Educational Purpose: To offer the surgical critical care resident a broad range of education in critical care medicine.

Objectives: 1. To expose the trainee to the widest possible range of critical illness including acute and chronic respiratory failure, congestive heart failure, acute renal failure, liver failure, central nervous system injury (stroke, meningitis, encephalitis, seizures), shock (hypovolemic, obstructive, septic, cardiogenic), and postoperative surgery.

2. Acquire competence in theoretical and practical aspects of intubation, central and arterial catheter placement, chest tube insertion, ventilatory management, nutritional support, emergency cardioversion, renal dialysis, therapeutic bronchoscopy, cardiopulmonary resuscitation, and organ support techniques.

3. Acquire competence in theoretical and practical aspects of ICU pharmacotherapy including conscious and unconscious sedation, antiarrhythmics, thrombolytics, anticoagulants, paralytics, antibiotics, vasopressors, inotropes and vasodilators/antihypertensives.

Specific Requirements:

1. Rotate as a surgical critical care resident in the MICU with responsibility for admissions, patient management, and discharges of critically ill patients.

2. Participate in MICU rounds in conjunction with the MICU critical care staff attendings.

3. Attend and direct all cardiac arrest codes.

4. Follow-up discharged patients to ensure successful transition.

5. Attend all scheduled conferences, journal clubs, and other educational activities.

Educational Content: The educational content of this rotation includes the disease mix specified in objective 1. The patient base at MCLANO consists of the following acquired illnesses: COPD with respiratory failure, congestive heart failure, pneumonia, and sepsis as well as a tertiary/quaternary component with malignancy, chronic liver failure. Almost all patients are admitted from the emergency room or the inpatient wards.

Additional educational content for MCLANO is skewed more strongly towards HIV related disease, chronic liver failure due to alcohol abuse, and acute drug toxicities. The teaching methodology in both Intensive Care Unit’s use a combination of didactic and clinical. There is an ongoing evaluation of resident’s clinical performance by senior attending staff. Following the rotation there is a written evaluation of the surgical critical care resident by the supervising attending staff and of the program by the fellow. There is no mandatory reading list, but fellows are strongly encouraged to read around specific cases, selective chapters in standard critical care medicine textbooks are recommended.

1 SICU

Educational Purpose: The educational purpose of this rotation is to acquire core experience and essential knowledge of pre and postoperative management of critically ill surgical patients who have undergone elective or emergency surgery. In addition, the rotation will provide the surgical critical care resident the opportunity to acquire core knowledge and clinical competence in nonsurgical aspects of blunt or penetrating trauma suffered by critically ill patients.

Objectives:

Augment the resident's critical care knowledge as it pertains to the care of the critically ill surgical patient. Expose the trainee to a broad range of pre- and postoperative issues as they pertain to the management of complex surgical procedures. Pathophysiologic, pharmacologic, hemodynamic, and ethical problems as they apply to surgical patients will be emphasized.

Specific Requirements: 1. Attend surgical intensive care unit rounds in conjunction with the SICU attending staff. 2. Obtain experience in directing these rounds during the course of this rotation. 3. To present the various case conference for the service. 4. Expose the trainee to the widest possible range of traumatic illness, including penetrating and nonpenetrating trauma, crush injury, and burns, as well as their attendant complications. 5. Acquire experience with procedures germane to the trauma unit including rapid sequence induction and intubation, tube thoracostomy, diagnostic peritoneal lavage, and would management. 6. Attend all teaching conferences including the daily intake report, daily rounds in the intensive care unit, and didactic lectures on trauma and critical care. 7. Consult on all admissions to the SICU a 24-hour period including any necessary evaluations and invasive procedures, except for surgery. 8. Participate in patient assessments utilizing the METI Human Patient Simulator.

Educational Content: The resident will be exposed to a broad range of neurosurgical, cardiac, thoracic, vascular, orthopedic and general surgical patients. Residents will have the opportunity to participate in cardiac arrest situations in both the SICU and SICA with airway management skills being emphasized.

Teaching methodology will be provided in both the form of didactic and clinical instruction. Ongoing evaluations of the resident’s clinical performance by senior attending surgical ICU staff will be provided. Following the completion of this rotation a written evaluation of the resident’s performance will be provided to the faculty member’s of the Surgical Critical Care team. The resident will have the opportunity to evaluate this particular rotation with a written evaluation provided and given to the Program Director.

2 SICU for Cardiothoracic Surgery

Educational Purpose: To acquire core knowledge of pathophysiology and management of acute cardiovascular disorders and substantial experience in tube thoracostomy and fiberoptic bronchoscopy.

Objectives: 1. Exposure to the widest possible range of acute cardiovascular disorders including acute myocardial infarction, congestive heart failure, life-threatening arrhythmia, cardiogenic shock, hypertensive emergencies and urgencies.

2. Appreciation of indications for and application of thrombolytics, antiarrhythmics, pressors, inotropes, vasodilators, antihypertensives and mechanical assist devices.

3. Acquire skill in EKG analysis and rudimentary expertise in analysis of echocardiograms.

4. Acquisition of theoretical knowledge and practical experience in tube thoracostomy, management of chest tube drainage systems, and fiberoptic bronchoscopy.

While not required, the fellow is also encouraged to attend surgical thoracic procedures in the operating room in order to develop a better understanding of thoracic anatomy and potential pitfalls of central venous and pulmonary artery catheter placement.

Specific Requirements: 1. Rotation requires full responsibility for all admissions and discharges to the SICU for Cardiothoracic Care unit and the Cardiac Step-down Unit.

2. Round on all cardiothoracic patients with the senior attendings.

3. Attend clinic, assist with fiberoptic and rigid bronchoscopies and the SCC resident will be responsible for placement of chest tubes during the rotation.

4. Follow-up discharged CCU patients and the Cardiac Step-down Unit to ensure a successful transition.

5. Attend scheduled conferences and journal clubs.

Educational Content: The disease mix includes acute myocardial infarction, congestive failure, life- threatening arrhythmias, cardiogenic shock, hypertensive emergencies and urgencies, cardiomyopathy and severe pulmonary hypertension. Patient mix involves a substantial number of patients with ongoing cardiac illness, but a significant subset with acute denovo disease. All patients are admitted from the emergency or the in-hospital setting. The major strength of this rotation is that the resident is exposed to a broad range of cardiovascular pathophysiology and therapy.

The teaching methodology involves a combination of didactic and clinical instruction. There is ongoing evaluation of clinical performance of the resident by the senior attending staff. Following the rotation, there is a written evaluation of the resident by his immediate supervisor. The resident evaluates the CICU rotation and returns the evaluation to the Surgical Critical Care Program director.

3 Anesthesia /Intubation

Educational Purpose: Acquire core knowledge and clinical competence in airway management and anesthetic pharmacology.

Educational Objectives: 1. Achieve an understanding of the basic concept of the practice of anesthesiology, including pharmacology and physiology of general and regional anesthesia,

2. Learn fundamental skills of airway management.

3. Evaluate patients preoperatively so as to gain insight into risk assessment and anesthesia clearance for surgery.

Specific Requirements: 1. Assess cases preoperatively. Complexity of cases will progress during the second week if deemed appropriate by supervising staff.

2. Residents are expected to remain in the operating room during the day until relieved by supervising attending staff.

3. Attend all scheduled anesthesia conferences.

Educational Content: This rotation involves a broad disease and patient mix. All patients are seen preoperatively and are followed through surgery to the recovery room. Procedures the residents should acquire during this rotation include the essentials of orotracheal intubation and conscious sedation. The resident should also be exposed to paralytic pharmacotherapy. The resident will have exposure to inhalational anesthetic use and principles of regional and local anesthesia.

There is ongoing evaluation of the clinical performance of the resident by the assigned attending staff. Following the rotation there is a written evaluation of the resident by the supervisor and of the program rotation by the resident. Essential reading will be assigned. This rotation is meant to provide concentrated airway and sedation experience with a particular focus on orotracheal and/or nasotracheal intubation.

Since this is only a 2 week rotation and elective, additional airway management techniques are acquired utilizing the METI Human Patient Simulator. The METI Human Patient Simulator (Medical Education Technologies, Inc., Sarasota, Florida) is a realistic, hands-on simulator in which the clinical environment and the patient are represented as physical objects. A specially instrumented mannequin models the patient, and commercially available clinical equipment is used to make up the work environment.

The simulator can model either gender as young, old, healthy, or very ill. The simulator also can model some physiological aspects of pregnancy. The model driven, life-sized mannequin breathes, has pulses, and models of physiology and pharmacology that permit accurate representation of human responses. For example, the simulator reacts to intravenous drugs, CPR, defibrillation, tracheal intubation, ventilation, and a variety of other interventions. Trainees can practice assessing patients in two ways: by observing physical signs such as chest wall motion, pulses, urinary output, and heart and breath sounds or, by observing the cardiovascular variables displayed on the physiological monitor. The mannequin supports many clinical activities. Complete airway management can be practiced including mask ventilation, tracheal and bronchial intubation, cricothyrotomy and transtracheal jet

4 ventilation. The airway can be made "difficult" in several ways including changes in the neck/head alignment, incorporation of an intrapharyngeal mass, and laryngospasm. ECG leads placed at appropriate electrode locations pick up the mannequin's electrocardiogram. The mannequin's electromechanical computer controlled lungs are embedded in its chest and breathe spontaneously as well as by hand or mechanical ventilation. Lung mechanics can be adjusted by the computer in real time as appropriate. Incoming gases are detected, quantified and their concentrations transmitted to the physiologic and pharmacologic computer models. The gases ventilate the mannequin, which consumes O2 and produces CO2 (as determined by the mathematical models of metabolism and the circulation). The combination of the METI Human Patient Simulator™, and the realistic medical scenarios, provides a very plausible clinical training environment. The simulator also supports training in dealing with specific crises or events. A critical event can be set up and the trainee learns to both recognize the event and provide appropriate treatment. In addition to the assessments mentioned above, the METI Human Patient Simulator utilization includes: 6. Allow for the simulation of rarely occurring phenomena that the trainee might not otherwise observe in his or her day-to-day experience, and for the training of appropriate responses. 7. Enable repeated training of specific events or scenarios. 8. Enable hands-on refresher training, as well as instruction on new and alternative techniques. 9. Enable the reconstruction of critical events, so that the observed adverse physical reactions of the patient, and the clinician’s responses, can be analyzed. 10. Augment the present instruction of medical and nursing students, and residents. Enable a trainee to practice his or her analysis, response, and technique with no risk of death or injury to a patient.

5 Transplant ICU – Educational Purpose: To acquire core skills in the critical care management of Liver, kidney and pancres transplant patients and infections in the immunosuppressed. Objectives: Expose trainee to a wide spectrum of diseases resulting in acute and chronic liver, kidney and pancrease disease : 1. Provide an appreciation for the indications and contraindications to kidney, liver pancreas transplantation.

2. Provide experience in management of critically ill patients with newly transplanted organs.

3. Provide an introduction to pre and post transplant management including immunosuppression, infection and hemodynamics.

4. Formulate a plan of treatment of hyperlipidemia, hypertension, and diabetes in well transplant patients

5. Evaluate the potential for renal insufficiency to occur in theses patients

Specific Requirements: 1. Directly supervise the interns and residents responsible for the inpatient care of patients with transplants transplantation, and long-term liver, kidney, and pancrease transplant recipients.

2. Perform procedures including insertion of arterial lines.

3. Acquire expertise in the care of patients with end-stage renal failure.

4. Acquire expertise in the care of transplant recipients including operative techniques, immediate post-operative and long-term follow up.

5. Learn about the selection and management of patients for transplantation.

6. Participate in transplant service consultations.

7. The SCC resident will be involved in the preparation of the recipient for transplant when a donor organ becomes available and will be the primary physician in the immediate postoperative period (with supervision by the SCC attending and the transplant surgeon).

8. Participate in on-call responsibilities. SCC resident do not perform in-house call but must be available in case of transplant or emergencies. The teaching methodology involves a combination of didactic and clinical instruction. There is ongoing evaluation of the fellow's clinical performance by the primary attending staff. Following the rotation there is a written evaluation of the fellow by the supervisor and of the program by the fellow. This is a unique rotation in that it gives substantial exposure and responsibility to the fellow for the management of pre and post transplant patients. There is no mandated reading list; however, fellows are strongly encouraged to read around their cases. Selected papers and textbook chapters are recommended by the primary attending staff.

6 BURN ICU

BURN OBJECTIVES

To develop cognitive skills and competency in the critical care management of burn patients with emphasis on the fluid resuscitation and care of the burn wound. The burn unit has 12 beds 4 of which are ICU capable. The unit has over 250 admissions per year both children and adults. The SCC resident will assist with work-up’s and management of the burn patient under direct supervision of the senior burn unit attending.

The burn rotation offers an excellent opportunity to learn

1) Shock and understanding how to manage shock in burn patients

2) Resuscitation and understanding how to resuscitate burn patients

3) Fluid and electrolyte management

4) Respiratory management in burn patients

5) Nutritional care for the burn victim

6) Burn wound care and infection control

1) Medical management of the burn patient after excisional surgery and skin grafting

Didactic lectures are given weekly and small group discussion daily as well as daily teaching rounds.