Medical Intensive Care Rotation

 

Course Director: Dr. Duncan Hite

 

Key Faculty: Drs. Arjun Chatterjee,  Peter Morris,  Duncan Hite

 

Overview:

The Medical Intensive Care Unit (MICU) specializes in the care of critically-ill medical patients. Conditions cared for in the MICU include but are not limited to: acute hypoxia, acute respiratory distress syndrome, acid-base imbalances, liver failure, renal failure, acute stroke, intracranial hemorrhage, shock, sepsis, status epilepticus, and coma. House officer rotations in the MICU are one month in length. While in the MICU, residents work closely with the Pulmonary/Critical Care Attending and Fellow on the MICU Service. The multidisciplinary team in the MICU also includes social workers, dieticians, experts in palliative care and pharmacists.

 

Principle Teaching/Learning Activities:

Direct Patient Care (DPC) each patient is admitted by a resident-intern team who remain primarily responsible for subsequent care in the ICU under the supervision of the fellow and attending physician


Daily Teaching Rounds (TR) (7:30 am to 10:30 am) with the attending and fellow.


Daily ICU Radiology Rounds (RR) (10:30-11:00 am) radiographs are reviewed by the ICU team


Daily ICU Teaching Conference (TC) (11:00 am to 12 noon). These cover a variety of critical care topics


Directly Supervised Procedures (DSP) - Residents have the opportunity to learn procedures under the direct supervision of the MICU Attending or Fellow. Included are airway management and endotracheal intubation; central venous catheter, hemodialysis catheter, arterial catheter and pulmonary artery catheter placement; chest tubes; fiberoptic bronchoscopy and thoracentesis.


Simulation Laboratory (SIM) Residents have the opportunity to practice for life threatening emergencies in the simulation laboratory, skills emphasized include the difficult airway and advanced cardiac life support


Critical Care Conference(CCC) (Fridays, 11:00 am) selected critical care topics are presented in a conference sponsored by the anesthesia critical care section

Principle Educational Goals by Relevant Competency

In the tables below, the principle educational goals for the Medical Intensive Care Unit

are listed for each of the six ACGME competencies. The second column of the table

indicates the most relevant principle teaching/learning activity for each goal, using the

legend below.
 

* Legend for Learning Activities (See above for descriptions)

DPC

Direct Patient Care

TC

Teaching Conference

RR

ICU Radiology Rounds

DSP

Directly Supervised Procedures

TR

Teaching Rounds

SIM

Simulation lab

 

1) Patient Care

Principle Educational Goals

Learning Activities

Effectively evaluate and manage patients with critical medical illness, including those on mechanical ventilation and vasopressors

DPC, TC, TR

Effectively evaluate and manage patients with critical neurological illness

DPC, TC, TR

Insert central venous lines and arterial lines with proper technique

DSP, SIM

 

 

2) Medical Knowledge

 

Principle Educational Goals

Learning Activities

Expand clinically applicable knowledge base of the basic and clinical sciences underlying the care of patients with critical medical and neurological illness

DPC, TC, TR, CCC,

 

Access and critically evaluate current medical information and scientific evidence relevant to medical and neurological critical care

DPC, TR, TC, CCC

Understand the physiologic and pathophysiologic principles of invasive hemodynamic monitoring including indications

DPC, TR, SIM, TC, CCC

Understand the physiologic and pathophysiologic principles of mechanical ventilation including indications

DPC, TR, SIM, TC, CCC

 

3) Practice-Based Learning and Improvement

 

Principle Educational Goals

Learning Activities

Identify and acknowledge gaps in personal knowledge and skills in the care of patients with critical medical and neurological illness

DPC, TC, TR

Develop real-time strategies for filling knowledge gaps that will benefit patients in the medical intensive care unit

DPC, TR, TC, CCC,

 

4) Interpersonal Skills and Communication

Principle Educational Goals

Learning Activities

Communicate effectively with patients and families in a stressful critical care environment, including discussion of end-of-life issues and limits of care

DPC, TR

Communicate effectively with physician colleagues and members of other health care professions to assure timely, comprehensive patient care

DPC, TR,

Communicate effectively with colleagues when signing out patients or turning over care to another service

DPC, TR

 

5) Professionalism

 

Principle Educational Goals

Learning Activities

Behave professionally toward towards patients, families, colleagues, and all members of the health care team

All

 

 

Principle Educational Goals Learning Activities*

6) Systems-Based Practice

Principle Educational Goals

Learning Activities

Understand and utilize the multidisciplinary resources necessary to care optimally for critically ill medical and neurological patients

DPC, TR, TC, CCC

Collaborate with other members of the health care team to assure comprehensive care for patients with critical medical and neurological illness

DPC, TR

Use evidence-based, cost-conscious strategies in the care of patients with critical medical and neurological illness

DPC, TR, CCC, TC

 

Recommended Resources

UpToDate (available online in the MICU)


MICU Manual and Syllabus: Each resident is given an overview of the MICU and orientation materials as well as goals and objectives for the rotation.

 

Medline Searching: (available online in the MICU)

 

Evaluation Methods: Residents are formally evaluated by the MICU Attending at the end of the rotation using the standard ABIM evaluation form provided by the Residency Program Office.

APPENDIX A

 

Specific Learning Objectives

  1. Respiratory:

  1. Evaluation and management of hypoxemic or hypercarbic respiratory failure

    1. Airway management

    2. Endotracheal intubation and principles of mechanical ventilation

    3. Indications for and management of non-invasive positive pressure ventilation
       

  2. Severe pneumonia: evaluation and management

    1. Community acquired lower respiratory tract infections

    2. Hospital-acquired LRTI

    3. Pneumonia in the immunocompromised host
       

  3. Massive hemoptysis

    1. Rapid stabilization and diagnosis of source

    2. Selection of definitive treatment via bronchoscopy, arterial embolization or surgery
       

  4. Severe COPD or Asthma

  1. Cardiovascular:

  1. Shock

    1. Rapid stabilization and differential diagnosis

    2. Management of the shock state including selection and titration of vasopressors
       

  2. Indications and management of invasive hemodynamic monitoring

  3. Appropriate use of echocardiography in shock diagnosis

  4. Diagnosis and management of arrhythmia

  1. Gastrointestinal:
     

    1. Massive GI bleeding

      1. Rapid stabilization and differential diagnosis

      2. Indications for endoscopic and other invasive management
         

    2. Acute liver failure

      1. Selection of patients requiring transplantation
         

    3. Exacerbations of chronic liver failure

      1. Hepatic encephalopathy

      2. Spontaneous bacterial peritonitis
         

    4. Other abdominal emergencies

      1. Peritonits and intra abdominal infection

      2. Perforated viscus

      3. Intestinal ischemia

      4. Severe pancreatitis

  1. Neurological:
     

    1. Meningitis, encephalitis and other CNS infections

    2. Acute thrombotic stroke

    3. Intracranial hemorrhage

    4. Status epilepticus

    5. Neuromuscular weakness including ALS and GBS
       

  2. Nephrology
     

    1. Differential diagnosis and management of acute renal failure

      1. Indication and management of IHD and CVVHD

      2. Diagnosis and management of urinary obstruction
         

    2. Management of serious electrolyte disturbances

    3. Differential diagnosis and management of acid-base disturbances
       

  3. Poisonings and drug overdose:
     

    1. Toxidromes